Study design
A cross-sectional quantitative study.
Data collection
Data were collected using a questionnaire consisting of four parts. The questionnaire had two versions with content that differed only in the background data section, where one was addressed to patients and the second to nurses (see Supplementary material: Questionnaire for patients and nurses). The required sample size was obtained by means of the G*power program [17]. The sample size required for achieving power of 0.90 and α of .05 was 138 participants in each of the two groups nurses and patients. Data were collected from a convenience sample consisting of 482 participants. Inclusion criteria for patients was having a chronic disease that was treated by their general physician in the community, being hospitalized for at least 48 hours and being fluent in Hebrew. The sampled population included 312 inpatients with a chronic illness who were hospitalized in internal medicine departments of two hospitals in central Israel, and 110 nurses working in these departments. An additional 55 contact nurses working in a large HMO were also included.
Research Tool
The first part of the survey examined the background variables of the participants, including age, gender, marital status, education, and degree of religiosity. In addition, the questionnaire designed for the nurses included questions about job position, seniority in nursing, and professional education. Two additional items addressed the awareness of the intention to implement HIE in Israel and queried the source of this knowledge. The second part of the questionnaire examined knowledge, attitudes, readiness to use HIE, and intention to use the system.
Knowledge was measured by 19 items examining knowledge about computerized HIE. The construction of this section was based on the literature [15,18] and the Ministry of Health administrative circular [10]. The questionnaire presented items that examined knowledge regarding the operation of and the domains to be included in the HIE. Participants were asked to indicate whether each item was correct or incorrect, or to record that they did not know the answer. The sum of the correct answers was calculated, with a higher score indicating a higher level of knowledge. The possible scores ranged between 0-19.
Attitudes towards the HIE. The construction of this part was based on the literature [2,3,16]. and on a validated tool that examines attitudes towards HIE [18]. The questionnaire was face validated by four head nurses working either in internal wards or at an HMO. The judges were asked to indicate whether the items in the questionnaire examined attitudes towards HIE. Only items approved by all the judges were included in the questionnaire. The final questionnaire included 12 statements examining attitudes towards the impact of the HIE on treatment. For each statement, the participants were asked to indicate their agreement on a five point scale ranging from 1 (do not agree at all) to 5 (completely agree). An average score of all items was calculated. Cronbach’s Alpha of the scale was 0.849.
Readiness to share medical information through HIE. In this part, the respondents were asked to indicate their readiness to share their medical information through HIE with a list of 14 medical and medical agents not involved in direct care. This list was compiled according to the guidelines of the Israeli Ministry of Health [10]. Factor analysis using Varimax rotation revealed two constructs. The first was a readiness to share personal medical information with medical healthcare providers represented by seven agents: community clinics, other hospitals, private physicians, physicians from a different hospital, clinic nurses, nurses from another hospital, and other health professionals (physical therapist, social worker occupation therapist, dietitians). The second was a readiness to share personal medical information with medical agents not involved in direct care. These were represented by eight agents, including psychologists, pharmacists, genetic counsellors, risk management units at the hospital, laboratory managers, and medical researchers. The Cronbach’s Alpha of the first construct was 0.887, and of the second, 0.865.
Intention to use HIE. At the end of the questionnaire, there was one general question asking nurses how much they would use the computerized HIE and the patients to what extent they agreed that information about them could be used as part of the HIE. This was answered on a scale of 1 (not at all) to 10 (absolute agreement).
Procedure
Prior to data collection, the research team held meetings with the departmental managers and head nurses to explain the purpose of the research. All participants gave their approval to the research. In the internal wards, questionnaires were distributed by four research assistants to patients with chronic diseases hospitalized for at least 48 hours and to nurses working on the same wards. In the HMO, questionnaires were distributed by email to contact nurses who work as nurse coordinators between hospitalized patients and the community. Before completing the questionnaire, participants received a brief explanation of the study objectives. The research assistants were available to answer questions and collected the completed questionnaires.
Data Analysis
Data were analyzed using IBM® SPSS® English version 25.0 software (SPSS Inc., Chicago, IL, USA). Participants’ characteristics were presented using means and frequencies. Differences between the groups were analyzed using one way analysis of variance (ANOVA). Scheffe tests were performed post hoc in order to reveal the source of any differences. Multiple linear regressions were performed to assess the associations between knowledge, attitudes, and socio-demographics, and both the readiness to share information on HIE, and intention to use HIE. Factor analysis with Varimax rotation was performed to confirm clusters of agents with whom there was a readiness to share personal medical information on HIE.