Integrated care system (ICS) can be defined as a health system that integrates the inputs, delivery, management of various health care services, including health promotion, disease prevention, treatment and rehabilitation . As the importance of ICS becoming increasingly highlighted, the growth of the integrated care system (ICS) is accelerating worldwide [2-4]. In China, regional medical consortiums (RMC) is an important manifestation and carrier of the ICS, the participants in RMC mainly involve leading hospitals in local or cross-regional (they are usually public tertiary hospitals), county hospitals and community health institutions . The most common collaboration between participants is technical assistance, which characterized as providing technical cooperation or support to each other. This collaboration model benefits promoting communication and collaboration between different levels of health institutions [6,7]. Meanwhile, it also puts forward higher requirements on the integration ability of health resources and the service quality [8,9]. Although some achievements have been made in the integration of health resources in the RMC, the problem of under-utilization of health technology still exists in practice, and the value of many health technologies have not been given full play . Taking des-gamma-carboxy prothrombin (DCP) for example, DCP is a tumor marker of primary hepatocellular carcinoma (PHCC), and the security, effectiveness and economy of DCP test in early detection of PHCC have been reported in many clinical practices and studies [11-14]. In addition to large hospitals [15,16], the role of DCP implementation has also been verified outside large hospitals in China . However, in terms of coverage even in the context of RMC, the use of DCP in China is far behind Japan, which also has a high incidence of liver cancer but with DCP widely and routinely used to screen for liver cancer . Since the dynamic mechanism of health technology diffusion in the ICS remained largely unknown, to provide theoretical guidance and supporting tool for promoting effective integration of health technology, this study aims to take DCP test as an example to develop a scale for measuring the dynamics of health technology diffusion in the context of the integrated care system.
Theories in Technology Diffusion
A lot of researches on technology diffusion have carried out in the disciplines of sociology, behavior, psychology, and so on [19-21]. The interpretations of technology diffusion vary depending on the discipline. According to the Innovation Diffusion Theory (IDT) proposed by Rogers, this study defines technology diffusion as the process in which technology is communicated between and within organizations of a social system . The process of technology diffusion involves five stages: (1) knowledge, (2) persuasion, (3) decision, (4) implementation, and (5) confirmation. Among these, stages of decision and implementation refer to adoption and full use of a technology, which had been stressed more importance. In addition to the IDT, there are many other classical theories have been proposed to guide the adoption practices by exploring the effects of different sets of factors on technology diffusion, such as the Theory of Planned Behavior (TPB), Technology Acceptance Model (TAM), and Technology-Organization-Environment framework (TOE). Among these theories, TPB suggests an individual’s behavior is ultimately influenced by behavioral intention, which is a function of attitude toward behavior, subjective norms, and perception of the ease with the behavior that can be performed . TAM implies perceived usefulness and perceived ease of use as two crucial factors, which focuses on the impact of technology natures . IDT demonstrates that the properties of technology and interpersonal communication can affect technology use . TOE infers that the effect of technology, organization and external environment should be considered .
Domains and Dimensions
Although many previous theoretical models or frameworks had focused on some stages of technology diffusion and investigated certain sets of potential influencing factors, there were still insufficient explanations in terms of health technology diffusion from different perspectives and facets. Therefore, we integrated these theories to provide a comprehensive insight of health technology diffusion and explore the dynamics of health technology diffusion in the ICS from four domains, namely the domain of personal beliefs, technical drivers, organizational readiness, and external environment (Figure 1).
As shown in Figure 1, physicians’ behavior of technology diffusion evolving from the five stages of IDT is used to access health technology diffusion. The five progressive stages include “knowledge”, “persuasion”, “decision”, “implementation”, and “confirmation”.
In this study, personal beliefs refer to the physicians’ perceptions of the DCP test and its use. It is one of the domains strongly associated with health technology diffusion, which mainly depends upon three major factors: attitudes, subjective norms and perceived behavioral control. Attitude has been perceived as one of the most powerful predictors in technology adoption and use, while subjective norms are kind of perceived criteria and pressures from important individuals’ judgments. And perceived behavioral control is often defined as perceived ease or difficulty of successfully performing a behavior. With respect to DCP test adoption and use, physicians’ positive or negative attitude reflects different predispositions [27,28]. And for the physicians working in a clear hierarchy system such as the RMC, opinions on DCP test from leaders, supervisors and colleagues are forces to be reckoned with [29-31]. Besides, experience, expect support and potential barriers may influence their perception of whether the adoption of the DCP test would be successful or not.
The technical drivers, which involve the nature of technology including ease of use and price rationality, acts as an indispensable domain concerned with diffusion dynamics of health technology . Innate properties of health technology can influence behavioral tendency . Taking the DCP test, for instance, ease of use is a degree to which the physicians expect the DCP test can be performed with ease, while price rationality is an underlying important source of motivation [34,35]. These are of vital importance for county hospitals and community health institutions within the RMC. Because of limited funding support and human resource, these organizations tend to adopt technologies easier to perform with price rationality.
Moreover, studies have mentioned the importance of the domain of organizational readiness, which reflects the overall preparedness for health technology and the preference tendency of the entire staff . Particularly in the emphasis of technology diffusion between organizations, the role of organizational-level factors is critical. For this paper, organizational readiness consists of three factors: organizational culture, technology absorptive willingness and technology sharing willingness. Organizational culture is the ensemble of values, norms, beliefs, language patterns and operating behaviors shared by individuals or groups within an organization, such as RMC or a hospital within it [37,38]. Technology absorptive willingness shows the willingness and readiness situations of introducing a new health technology into the organization , while technology sharing willingness is a degree of sharing knowledge with the other organizations [40,41].
The domain of external environment is generally considered as an important factor affecting health technology diffusion, which usually focuses on industry competition pressure [42,43]. In the context of RMC with good integration of health service delivery, in most cases, competition still occurs among hospitals of the same type and grade. Even in some conditions for soliciting more patients, there are some intense competitions among different levels of medical institutions within RMC. Both the trend in the market and the tendency of business partners are the main concerns of the hospital managers while deciding on whether adopting certain technology .