This study is one of the scarce studies that measure users’ acceptance of EPPs and validate the TAM theoretical model in an Arab country. Given that different cultures react differently to the use of EPP and given the rise in its use, it was important to examine the intention to use to provide decision-makers with an empirical tool that would potentially enhance the actual use. Globally, portal developers, researchers, and practitioners would also benefit from the findings when targeting patients from different cultural backgrounds (71).
We found that providers (physicians and nurses) valued the usefulness of EPP (82%). Our providers were overly optimistic about the perceived usefulness of EPP as compared to a study by Kelly et al. (71), who found that 53% of health care providers valued EPP as a tool to improve patient quality of care. It is possible that this is partially due to the Lebanese culture, which is often rather quick to adopt a positive attitude toward innovation in general (72) and is a novelty-seeking culture, especially among individuals with higher educational attainment (73). This finding has yet to be tested in actual use as intention and actual use may not be concordant. In fact, in a study conducted by Makarem and Antoun (74) in the same setting, 87.2% of physicians indicated that email was useful for communication, yet only 5.1% used email to communicate with their patients. As for perceived ease of use, 77% of our providers indicated that EPP would be easy to use. This ease of use of EPP and the ability to learn new technology easily by providers can be an important determinant of the actual use (20). However, further studies are needed to confirm those expectations. Due to the small sample size of providers, we were not able to conduct SEM. Al-Adwan (75) used the TAM model to explore determinants of physician’s adoption of ET in hospitals in Jordan showed that the model explained 64.5% of variance in physician’s behavioral intention.
The intention to use among patients was 52%, lower than 69% (76) and 84.1% (77) reported in the literature. To our knowledge, this is the first study to explore the intention to use the EPP among patients in an Arab region. The lower intention to use is concerning because we expect that actual use will be even less. In a study conducted in Saudi Arabia among diabetic patients, Belcher,Vess, and Johnson (78) explored the use of EPP among diabetic patients and shed light on various limitations associated with actual use among the Arab population. Basic factors such as Internet access, language, and material content may be principal factors for suboptimal use. While the Internet is widely proliferated in most Arab countries, some sub-group of the population may still not have access to the Internet (79). Patient portal communication is often in English and not all patients may be well versed in the English language (78). Even among those that are well versed, some may have difficulties understanding medical terms. Wang et al.(80) showed that even top-rated materials often use a language that exceeds the average reading ability. Thus, investing in simplifying messages and tailoring them to the patient’s situation need to be carefully considered during implementation.
We examined the reliability and validity of the TAM model. Taylor and Tod (1995) indicate that a robust model should be able to explain a reasonable proportion of the variance in behavioral intention or use (45). In this study, we found that the TAM had excellent reliability (Cronbach Alpha of .91). The validity test (EFA) showed that three components explained 73.48% of the variance, which means that the constructs of the TAM model have a considerably large explanatory power to predict intention to use in an Arab country. However, other models need to be validated in this region such as the Unified Theory of Acceptance and Use of Technology (UTAUT). Further, more contextual factors need to be added to existing models. to explain why technology is accepted or rejected in this specific population.
We found that the perceived usefulness of EPP mostly drives the intent to use. Such a finding is echoed in other studies using the TAM model (81-83). To bolster EPP use, individuals need to be able to understand the purpose of the technology, which is to provide information when and where it is needed to improve outcomes and patient safety. Hence, organizational efforts focusing not only on promoting the acquisition of the technology but also on marketing the added value of this technology is needed. For example, in our study, patients valued the importance of EPP in controlling their health conditions, promoting their healthy living, and saving them time. Thus, displaying posters in waiting and exam rooms showing patients the usefulness of EPP in facilitating appointment taking, medication refill, and communicating with their physicians can encourage them to use the EPP needs to be considered (84).
We found the perceived ease of use indirectly influenced perceived usefulness. Naturally, When the system is user-friendly and simple, it will likely be successfully used. The human interface with technology matters (85, 86). For instance, if access to the content of EPP is aesthetically simple, clear and follows a logical process for navigating the system, patients are more likely to use it (87). Hence, every effort needs to simplify the process of utilization, including training, coaching, and providing continuous support (88, 89).
The digital divide by age and education among our patients were also common observations in studies done in developed countries. For example, in a study carried out on diabetic veterans in North Carolina, USA, lower age, and some college education were more interested in learning how to use EPP (90). Special considerations need to be taken while addressing older age individuals or those with less educational attainment such as posting educational materials sufficient for a grade 6 reading level, larger fonts, more illustrations, and fewer words can make the EPP more accessible (91-93). Furthermore, providers need to be proactive by encouraging patients to constantly check their EPP, as this will increase use(94).
Several weaknesses need to be disclosed. We conducted this study with available patients at the AUBMC-FMC, which is a highly recognized organization in Lebanon, capturing patients from higher socioeconomic status or those working in the organization, thus limiting its generalizability to the overall population of Lebanon. Survey completion was voluntary; it is possible that those interested in the topic were more likely to accept our invitation thus possible selection bias. The available small sample of providers prevented us from conducting SEM.
When this study was conducted, the EPP was still under construction. Currently, the system has been launched. Looking forward, longitudinal studies focusing on actual EPP use will be needed. Greenhalgh et al. (95) pointed that likely the optimistic view on the perceived usefulness will be tapered upon the use of the portal, or the perceived ease of use will be influenced with how friendly the system is to patients.