The primary objective of the study was to measure user acceptance of HIE and analyse it by use level and setting through the administration of a survey utilising the UTAUT framework. The UTAUT has been frequently used across a variety of technologies and has shown to explain variance in use behaviour and intentions among end-users (12, 13). A secondary objective was to explore barriers and facilitators to HIE uptake using the NPT, which has been shown to be a valid and reliable method to assess implementation processes in a variety of contexts (14).
The findings show that most users perceived HIE useful, easy to use and relevant to their role. Most respondents showed a clear intention to use HIE in the future, with some also being keen to increase its use. However, the survey also revealed some gaps in the implementation strategy which may have impeded adoption. There were also significant differences in user acceptance between user groups, indicating an association between technology acceptance and use of technology.
Habitual use showed the largest statistically significant difference amongst user groups. Habit as a UTAUT construct has shown to be largely influenced by other factors such as importance to job, satisfaction, and experience with IT (15). Given this, the difference in relevance between user groups that was also identified may be feeding into the lack of habit development observed in lower-lever user groups. Habitual usage amongst end-users is important to establish as it has shown to increase the uptake and use of digital technology (16).
Interviewees also indicated that HIE use was not embedded into their practice and expressed the need for further awareness, reminders about the product, and tools for its use to improve adoption. HIE organisations should develop communication strategies to ensure that all end-users are aware of the product, see the value in using it, and have the resources they need to optimise its use in specific contexts.
Subjective norm was also significantly different across user groups, with lower-level users experiencing significantly lower subjective normalisation of the use of HIE among their peers than high-level users. Subjective norm relates to social proof theory, or the idea of individuals looking to others within their environment for confirmation of behaviour, which has been well-established and applied to a variety of contexts, including digital technology and healthcare (17, 18). The establishment of social proof is widely used as a marketing tool for companies and organisations, and should similarly be applied within HIE implementation strategy plans to increase acceptance and uptake (19). The use of HIE ambassadors could promote subjective normalisation of HIE and further increase user acceptance and adoption.
There was also agreement across all user groups that training was inadequate. Similarly, all interviewees indicated that they received little to no training and that, while classroom-style teaching was not necessary, in situ training videos or resource manuals on how to use the product would be beneficial. The need for appropriate digital literacy was also highlighted, with high-level users indicating they have the knowledge necessary to use HIE significantly more than lower-level users. It is therefore important to provide users from different health facilities with training and support to increase their knowledge and confidence in using HIE and improve their attitudes towards using the system (20, 21).
Social care services exhibited lower levels of perceived usefulness and social influence. Social and community care services also indicated issues with training and support. Training to use HIE was inadequate, and social care also noted they lacked the resources to properly use the system. The variations seen in user acceptance across care settings may be reflective of a lack of consideration of the profound differences between traditional and non-traditional care settings. Social and community care settings historically existed within silos separate from other NHS services; however, the demand for holistic care models has increased their integration with traditional NHS services (22). As HIE was primarily designed to be used in acute and primary care settings, considerations for services provided outside those settings were not made when designing the system. In fact, participants within social and community care services indicated issues with the user interface and with embedding the solution within their practices and noted that HIE did not look familiar to other systems used in those contexts. Therefore, it is important to tailor the design of HIE to those settings and provide users with resources and tools to learn how to use HIE effectively.
In line with findings from previous studies (3), use of HIE was found to result in time and cost savings, increased informed decision making, and collaborative care design. Several barriers were identified, including poor communication strategies and user awareness, inadequate training and resource provision, lack of stakeholder engagement, and privacy concerns. In developing implementation strategies, the consideration of all stakeholders must be addressed. Participants indicated that end users were not involved pre- or post-implementation, and that system introduction was handled by IT and change teams. Engaging end users early in the process but also post-implementation could result in higher levels of system awareness, approval, and utilisation(23). As HIE expands, implementation strategies should be developed with collaborative end users in order to minimise several barriers identified within this study and increase uptake and adoption.
Although the survey was distributed to a diverse range of HIE users, gender was not equally represented in the survey sample, which can be due to the fact that 77% of the NHS workforce is female (24). In addition, participation to the survey was low due to the extreme pressures the NHS workforce was experiencing at the time of the study as a result of the COVID-19 pandemic. Also, most respondents were high adopters, which may have introduced some response bias due to the small representation of lower-level users in the study. Moreover, while the UTAUT framework was helpful for the design and understanding of the survey portion of the study, it may have oversimplified the relationships of the different constructs that feed into uptake and use of digital technology. Finally, the results of this study are not meant to be generalisable as service evaluations are primarily designed to assess current care standards and assist decision-making in particular settings, although they can be useful to others who are considering implementing a HIE solution.
Future studies should attempt to gain a larger sample size and generate findings that are more generalisable. Further investigation into the findings of this study surrounding inadequate training methods and limited support mechanisms for users would also be beneficial as this has shown to have a large impact on adoption and uptake of technologies (25). The development and testing of new implementation plans for HIE to identify the most appropriate methodology for application on a national scale should also be addressed. An analysis of the policies that currently exist regarding how data is shared on HIE may also be beneficial to understanding privacy concerns that may be a barrier to widespread use.