Dynamics of Health Technology Diffusion in Integrated Care System (DHTDICS): A Development and Validation Study

Background: Limited diffusion and utilization of health technology have greatly halted the improvement of resource integration and healthcare outcomes. However, the dynamic mechanism of health technology diffusion in the context of the integrated care system (ICS) remained largely unknown. The purpose of this study is to develop and validate the scale on Dynamics of Health Technology Diffusion in Integrated Care System (DHTDICS) for providing instruments to investigate the health technology diffusion in the ICS. Methods: The scale with 39 items was initially designed on the basis of the proposed model developed from previous research. And it was validated in a cross-sectional questionnaire survey including 246 participants. Exploratory factor analysis was used to assess domains in the questionnaire, and analyzed correlation, factorials, internal consistency and validity of the questionnaire. In addition, structural equation modeling was performed to determine the total effects of each domain on the health technology diffusion in the ICS. Results: Reliability analysis revealed excellent internal consistency, as the value of Cronbach’s alpha greater than 0.80 for all of the four DHTDICS domains in this study. An acceptable validity was con�rmed through tests of construct validity, convergent validity and discriminant validity. With respect to the potential domains and dimensions that DHTDICS contributes, the results highlight the existence of 4 domains: personal beliefs, technical drivers, organizational readiness, and external environment. Among them, the impact on health technology diffusion is, in descending order, organizational readiness, personal beliefs, external environment, and technical drivers. Conclusions: The �ndings of this study support the validity of the DHTDICS, and will be a helpful reference for developing future intervention strategies to promote health technology diffusion in the ICS.


Background
Integrated care system (ICS) can be de ned as a health system that integrates the inputs, delivery, management of various health care services, including health promotion, disease prevention, treatment and rehabilitation [1].As the importance of ICS becoming increasingly highlighted, the growth of the integrated care system (ICS) is accelerating worldwide [2][3][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 [5].The most common collaboration between participants is technical assistance, which characterized as providing technical cooperation or support to each other.This collaboration model bene ts 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 [10].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][12][13][14].In addition to large hospitals [15,16], the role of DCP implementation has also been veri ed outside large hospitals in China [17].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 [18].
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][20][21].The interpretations of technology diffusion vary depending on the discipline.According to the Innovation Diffusion Theory (IDT) proposed by Rogers, this study de nes technology diffusion as the process in which technology is communicated between and within organizations of a social system [22].The process of technology diffusion involves ve stages: (1) knowledge, (2) persuasion, (3) decision, (4) implementation, and (5) con rmation.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 in uenced 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 [23].TAM implies perceived usefulness and perceived ease of use as two crucial factors, which focuses on the impact of technology natures [24].IDT demonstrates that the properties of technology and interpersonal communication can affect technology use [25].TOE infers that the effect of technology, organization and external environment should be considered [26].

Domains and Dimensions
Although many previous theoretical models or frameworks had focused on some stages of technology diffusion and investigated certain sets of potential in uencing factors, there were still insu cient 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 ve stages of IDT is used to access health technology diffusion.The ve progressive stages include "knowledge", "persuasion", "decision", "implementation", and "con rmation".
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 de ned as perceived ease or di culty of successfully performing a behavior.With respect to DCP test adoption and use, physicians' positive or negative attitude re ects 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][30][31].Besides, experience, expect support and potential barriers may in uence 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 [32].Innate properties of health technology can in uence behavioral tendency [33].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 re ects the overall preparedness for health technology and the preference tendency of the entire staff [36].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 [39], 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 [44].

Methods Sample and Procedure
A cross-sectional study was conducted from October to December 2018 in China.Fujian province and Jiangxi province were randomly selected from the provinces with a high and low incidence of hepatocellular carcinoma, respectively.In each province, two RMCs were randomly selected and its tertiary and secondary hospitals were included in the survey.The questionnaire and informed consent forms were sent to the physicians who work at liver disease-related departments within these hospitals.If the physicians agreed to participate in the survey, they would ll out the questionnaire at their convenience and returned directly using email or mail.

Measure
According to the proposed model in Figure 1, the scale of Dynamics of Health Technology Diffusion in Integrated Care System (DHTDICS) was initially structured with 3 parts, 39 items totally.
The rst part includes 5 items about the physicians' behavior of technology diffusion, which was adapted from the ve stages of IDT.The item of "knowledge" refers to the physicians coming into contact with the DCP test and taking the initiative to search for information about it."Persuasion" means the physicians have an understanding of the DCP test's advantages and disadvantages and develop an attitude toward it."Decision" presents the physicians decide to adopt or reject the use of DCP test, and take particular preadoption or pre-reject action.At the "implementation" stage, the DCP test is being put into practice.At the "con rmation" stage, the physicians will decide to reinforce or withdraw the use of the DCP test, like (not) recommending it to people around.Those 5 items were measured using a ve-point Liker scale ranging from "rarely" (1) through "fairly" (3) to "regularly" (5).
The third part is used to collect personal socio-demographic characteristics, including 6 items of gender, age, education, professional title, administration position, and years in practice.

Data Analysis
Internal consistency was tested using Cronbach's alpha, composite reliability (CR), and the average variance extracted (AVE).The acceptance values of Cronbach's alpha, CR, AVE are 0.7, 0.5, 0.7, respectively [45][46][47].Questionnaire optimization was in virtue of corrected item-total correlations by Cronbach's alpha, at least three or four items were used to interpret per factor.The validity was examined by construct validity, convergent validity and discriminant validity.
Exploratory factor analysis (EFA) was used to explore possible factors and factor structure in the pool of items, by principal components analysis (PCA) (the method of factor extraction).

Sample and Data Description
This study included 246 physicians in total.The corresponding sample-to-item ratios of 9.84 was greater than the threshold of 5 [50], it can be considered that sample sizes collected were acceptable.Table 1 demonstrates the demographic characteristics of the 246 participants.Data on physicians' behavior of technology diffusion and each domain are shown in Table 2 and Table 3.

Exploratory factor analysis
A PCA of all the 28 items showed KMO values of 0.920 and Bartlett's test of sphericity was strongly signi cant (P<0.001),indicating the great suitability of PCA for validity estimate.Four factors appeared with an eigenvalue greater than 1 and cumulatively explained 76.36% of the total variance.To further de ned factors included clearly, the varimax rotation method was then used.The results (Table 4) show all items in each dimension are almost loaded to four different factors, which ts well with the proposed framework and indicates acceptable construct validity.Factor 1 to factor 4 explained 26.34%, 24.32%, 14.42%, and 11.28% of the total variance, respectively.Accordingly, we named factor 1 as "Personal beliefs", factor 2 as "Organizational readiness", factor 3 as "technical drivers", and factor 4 as "external environment", respectively.Besides, factor scores of the four factors were automatically generated into the last columns of the operation interface.
To keep improving the research model, the items need to be further optimized on the basis of the corrected item-total correlation and Cronbach's alpha if deleted [51].Items would be deleted if its results satisfy both of two conditions: i) the corrected item-total correlation less than 0.6; ii) Cronbach's alpha of factor would be improved if this item deleted.As demonstrated in Table 5, all items have the corrected item-total correlation greater than 0.6, and Cronbach's alpha of the factor would not be improved if the item was deleted.Therefore, no item needs to be eliminated.
Next, we calculated Cronbach's alpha, CR, and AVE for each factor to identify reliability and validity.The Cronbach's alpha of all factors and the whole questionnaire are much higher than the recommended threshold of 0.7 (see Table 6), suggesting internal consistency is fairly well.All factor loadings of items were above the acceptability value of 0.5.Furthermore, AVE and CR values of all factors were above the recommended value of 0.5 and 0.7, which indicates a good convergent validity.
Then, we followed Fornel and Larcker's (1981) suggestion to calculate the square root of AVE [49].As shown in Table 7, the square root of AVE (reported in the diagonal of the correlation matrix) of each factor is higher than its correlation coe cients with other factors, indicating its strong discriminant validity.
Meanwhile, we show the correlations between the items and factor scores of each factor.The results are shown in Table 8.Each of the factors was separated from each other on account of having a low correlation with each other.Additionally, items of the same dimension converged on the same factor and discriminated well with other factors.
In uence of each domain on physicians' behavior of technology diffusion

Discussion
Limited diffusion and utilization of health technology have greatly halted the improvement of resource integration and healthcare outcomes [52,53].This issue has become even more severe and prominent especially under the background of continuous ICS growth worldwide.To bridge the research gap that few are known on the dynamic mechanism of health technology diffusion in the ICS, this study took the DCP test as an example and developed an instrument to measure and evaluate the dynamics of health technology diffusion in the integrated care system (DHTDICS).It will be provided as a scienti c tool for investigating the mechanism and further promote health technology diffusion in the ICS.
By conducting EFA, analyzing the internal consistency, validity and dimensionality of the DHTDICS, the reliability and validity of this instrument have been con rmed.Results of reliability analysis revealed excellent internal consistency, as the value of Cronbach's alpha all greater than 0.80 for four of the domains in this study.Regarding the validity test, EFA results showed all items in each dimension were loaded to four different factors, which ts well with the proposed framework and indicates good construct validity.AVE and CR values of all factors were above the recommended value of 0.5 and 0.7, which indicates an acceptable convergent validity.Additionally, it demonstrated items of the same dimension converged on the same factor, and discriminate well with other factors.
With respect to the potential domains and dimensions that DHTDICS contributes, the EFA results highlight the de nite existence of 4 domains and 8 dimensions: domain of personal beliefs (the effect of individuals' perceptions and impressions on subjective and interpersonal predisposition, including dimensions of attitude, subjective norm and perceived behavioral control), domain of technical drivers (the effect of characteristics of health technology on hardware predisposition, including dimensions of ease of use and price rationality), domain of organizational readiness (the effect of context preparedness in spiritual level, including dimensions of organizational culture, technology absorptive willingness and technology sharing willingness) and domain of external environment (the effect of forces that can exert in uence on physicians from the outside of the hospitals, including dimension of industry competition pressure), which were in line with assumption of scale design and also consistent with the ndings of previous research on health technology utilization [54][55][56].This result reminds us that successful technology diffusion doesn't depend solely on the technology itself, on individual practitioners, on the promotion of organizations, or on the external environment, but is the outcome of the joint efforts or effects of all the aspects mentioned above.It emphasizes the importance of taking concrete measures from a multi-dimensional perspective to integrate the efforts of all involved parties while promoting health technology diffusion in the context of ICS.
Among multiple domains having an impact on the health technology diffusion, domains of personal beliefs and organizational readiness were illustrated as two of the most powerful domains in the DHTDICS in this study, which implied that more attention should be paid to these two aspects.For instance, the domain of personal beliefs, namely Factor 1 in this study, revealed that positive attitudes, strong subjective norms, and perceived behavioral control would facilitate health technology diffusion.
Similarly, the domain of organizational readiness, namely Factor 2 in this research, consisting of organizational culture, willingness of technology absorptive, and technology sharing, highlighted the importance of developing an organizational atmosphere that advocates technology innovation and promotes inter-organizational technology exchange and cooperation.Thus, to promote the diffusion of some appropriate health technology in RMC, it is recommended to uptake some continuing education and training to raise the awareness of certain health technology and the importance of expanding its use.Besides, the positive role of subjective norm also highlighted the impact of peer and organization as mentioned above.Additionally, as con rmed by previous researches, organizational norms and values control the way individuals interact with each other within or outside the boundaries of the organization, which also directly impacts the health technology diffusion [28,34].Apart from these factors, domains of technical drivers and external environment are also signi cant dynamics components that cannot be ignored in health technology diffusion in RMC.
Known to us, there is a dearth of empirical study related to the dynamic mechanism of technology diffusion in the context of ICS.To bridge the research gap, this study develops and validates an instrument for measuring DHTDICS, which will be helpful for identifying the dynamics of health technology diffusion in ICS.The results of this study will not only guide the real practice of promoting the utilization of DCP test for hepatocellular carcinoma screening but also provide clues or inspirations for the diffusion of other health technologies in RMC, given that the important dynamics of health technology diffusion determined in this study had been generalized to the setting of the ICS.However, there are also some limitations to this study.Firstly, owing to the social desirability bias [57], although we emphasized that all responses were con dential and solely for academic research when lling out the questionnaire, the physicians enrolled may not tend to voice negative assessment on the actual performance of themselves and the hospitals, which probably lead to overestimation of their attitude and utilization of DCP test.Secondly, this study is also limited by its cross-sectional design, and future research may collect cross-sectional data at different time points to form panel data, which will be more robust in investigating the determinants of DHTDICS.Thirdly, owing to time and funding constraints, the DHTDICS has only been validated with a speci c technology, the DCP test.The generalizability of this instrument needs to be further validated with other technologies.Also, test-retest reliability has not been assessed as the second wave of data collection was not conducted

Conclusions
This study contributed to the knowledge of health technology diffusion by developing and validating the scale of Dynamics of Health Technology Diffusion in the Integrated Care System (DHTDICS), which comprehensively comprised multiple aspects as personal beliefs, technical drivers, organizational readiness and external environment.The scale will be provided as a robust tool for measuring and evaluating the dynamics of health technology diffusion in RMC, which will be also helpful in developing future intervention strategies to promote health technology diffusion in the ICS.As this study is an exploratory survey, the comprehensive understanding of DHTDICS can be further validated by assessing other technologies or conducting interviews with hospital managers and physicians in the future.

Tables
Kaiser-Meyer-Olkin (KMO) values, Bartlett's test of sphericity, factor loadings, eigenvalues, the correlation matrices and the squared multiple correlations were used to verify the factorability.The recommended threshold of KMO values and factor loadings are 0.7 and 0.5, respectively [48,49].Factors with eigenvalues greater than 1 in the factor extraction were determined.Structural equation modeling was performed to determine the in uence of each domain on the physician's behavior of technology diffusion.
Data analyses were performed using IBM SPSS software (SPSS, Inc., Chicago, IL, USA) and Amos 17.0 software.Statistical signi cance was set at P<0.05.Ethical ConsiderationsEthical permission was granted for this study from the Ethics Committee of Fujian Medical University(No.2017-17).Participation in the survey was voluntary.All potential participants of the survey had been given informed consent forms and all responses were anonymous in this study.If the participants completed and returned the questionnaire, it was considered informed consent.

Table 2 .
Items of physicians' behavior of technology diffusion.

Table 3 .
Items of perceptions on diffusion.

Table 4 .
Exploratory factor analysis.Table Results of reliability and convergent validity analyses.
Table Items' item-total correlation and Cronbach's alpha if deleted.

Table 9 .
Total of each domain on the physicians' of technology diffusion.