Open International Journal of Informatics (OIJI) Vol. 9 No.

2 (2021)

A Conceptual Framework to Investigate Health Article history

Professionals’ Blockchain Technology Adoption Received:
Readiness in Malaysia 12th October 2021

Received in revised
form:
Fariha Anjum Hira*1, Haliyana Khalid2, Siti Zaleha Abdul 18th October 2021
Rasid3, Md Moshiul Alam4 Accepted:
1,2,3 28th October 2021
Azman Hashim International Business School, Universiti
Teknologi Malaysia, Kuala Lumpur 54100, Malaysia Published online:
3
11th November 2021
University of Business and Technology, Jeddah, Saudi Arabia
4 *Corresponding
Razak Faculty of Technology and Informatics, Universiti author
Teknologi Malaysia, 54100 Kuala Lumpur, Malaysia [email protected]
1
[email protected], [email protected],
3
[email protected], [email protected]

Abstract

Malaysia's healthcare industry has historically been slow to embrace health information technology.
By enhancing the efficiency of electronic health records, blockchain technology can help eliminate
medical errors and data breaches while also facilitating the exchange of health information. Before
deploying blockchain, building a conceptual framework for assessing health professionals'
readiness as the primary user can aid policymakers in planning technology and strategy
development. In comparison to the number of studies on the acceptability of health technology, there
is a shortage of research on the adoption of blockchain technology. A readiness assessment
framework is currently absent from the blackchin-based health information technology literature.
The current study explores the factors influencing health professionals' willingness to embrace
blockchain technology in Malaysian public hospitals to overcome this gap. Additionally, this study
develops a conceptual model that combines the Unified Theory of Acceptance and Use of Technology
(UTAUT), the Norm Activation Model (NAM), and initial mediator trust. The suggested conceptual
framework will be practically evaluated and validated in the future.

Keywords: Blockchain technology, Electronic Health Records, Health Information Technology,

Malaysia, Technology adoption

1. Introduction
The use of blockchain technology (BcT) as the underlying mechanism for
Electronic Health Records (EHR) is a viable solution to overcome the limitation and
issues of existing EHRs in Malaysia like medical error, health data breaches.
Additionally, there is a lag in horizontal innovation regarding patient identification
and information blockage, which can be aided by using BcT as an underlying
mechanism of EHR [1]. However, low Health Information Technology (HIT)
adoption is a concerning issue that will likely hinder any technology adoption in the
country, such as BcT. Despite Malaysia's aspiration to be a developed nation with
a single health information system, adopting technologies in healthcare has been
low. While comparing the progress with developing even other developed counties
that began HIT initiatives like Malaysia, the rate shows that Malaysia is visibly
lagging in technology adoption. EHR coverage in developed countries is 60%, and
above, high-income developing countries Botswana and China have EHR coverage

_________________________________________________________
* Corresponding author. [email protected]
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Open International Journal of Informatics (OIJI) Vol. 9 No. 2 (2021)

of 60% and 50%, respectively [2]. However, although EHR has a significant impact
on improving quality of care and quality of life, the healthcare industry of
developing countries is suffering due to the lack of EHR adoption. Malaysia is one
of them. Figure 1 demonstrates that Malaysia has the lowest EHR coverage among
the countries on the chart. In the case of Malaysia, the low adoption is concerning
because the government is actively involved in digitalizing countries' healthcare
sector. Malaysia has only about 25% EHR coverage in the country, which raises
concern over the adoption of BcT.

Figure 1. EHR coverage in developing and developed countries

One of the main reasons behind this is the lack of health professionals' readiness
to adopt HIT. HIT projects involve a high risk of failure. Worldwide, half of the
HIT (EMR) projects failed before achieving the targeted rate [2]. Even if it survives,
the progress remains below expectation. In both cases, the goal of the project
remains unaccomplished. Therefore, the reason behind HIT failure and slow
adoption has been studied before. Therefore, assessing health professionals'
readiness in the pre-implementation phase is recommended for swift technology
adoption and diffusion. Although there is no formula to guarantee the success of the
HIT initiatives, knowing the issues that can influence the uptake of HIT can increase
the possibility of success and reduce the risk of failure [3]. Therefore, before the
system implementation, users' readiness assessment must identify influential factors
to overcome the BcT adoption barrier; furthermore, the lower the barrier, the better
the speedy technology innovation diffusion. Therefore, HIT diffusion is the
policymakers' prime priority [4]. The BcT is still in its infancy and is relatively
unfamiliar to health professionals.
Consequently, before introducing the BcT to the Malaysian healthcare industry,
it is critical to understand the factors contributing to BcT adoption from the health
professional's perception. Furthermore, there is a clear gap between qualitative
novel architecture-based system development studies to BcT adoption studies [5];

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thus, a BcT adoption framework is unavailable. Therefore, this study intends to

unearth the most influential factors of BcT enabled EHR adoption among health
professionals in Malaysian public hospitals. Besides, the study aims to propose a
BcT adoption framework that can be validated in the future.
The most crucial aspect for successful HIT adoption is the socio-technical factors,
not the technical ones [6]. Because the end-users are concerned about self-interest,
they look for the benefit of using the technology to make their day-to-day work
more convenient. The better fit between technology with the user from the users'
perspective is the greater chance of evolving for the HIT to be implemented
successfully. Thus, the lack of understanding of individuals' (users') requirements
will lead the HIT initiative towards failure. Therefore, to mitigate the risk of failure
or slow implementation, it is necessary to understand the health professionals'
intention to adopt BcT for EHR as part of their day-to-day work because they are
the primary users of any HIT. Researchers further emphasize developing a socio-
technical framework to understand users' technology adoption intention [6], [7].
However, the literature lacks a framework regarding the health professional's
adoption of BcT for EHR to the author's best knowledge.

2. Literature Review

2.1. Theoretical Underpinning

Based on the literature review of relevant theories, the Unified Theory of
Acceptance and Use of Technology (UTAUT) and norm activation model (NAM)
has been chosen to support the proposed BcT adoption framework.

2.1.1. UTAUT: Figure 2 shoed the Unified Theory of Acceptance and Use of
Technology (UTAUT), a well-known and widely used theory to assess individual-
level technology adoption, thus appropriate for this study. This study eliminates the
moderators (age, gender, experience, voluntariness of use).

Figure 2. The UTAUT Model

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2.1.2. NAM: The norm activation model (NAM), as in Figure 3, is mainly used to
explain pro-environmental behavior. However, pro-environmental behavior is pro-
social behavior since health professionals serve the community beyond duty, thus
likely to behave pro-socially.

Figure 3. The NAM Model

2.2. Hypothesis Development

This study develops a hypothesis and conceptual model considering the
UTAUT, NAM, and initial trust. The hypothesis and proposed model are
presented below in the forthcoming sections.

2.2.1. Performance Expectancy: Performance Expectancy (PE) means the extent

to which technological usage gives users efficiency in carrying out activities [8]. In
this study, PE refers to the extent to which BcT is useful in performing healthcare
professionals' tasks and service delivery at the workplace. Thus, PE denotes the
degree to which medical professionals think technology can improve their
healthcare service delivery efficiency. Therefore, PE is hypothesized to positively
influence the user's behavioral intention towards accepting the BcT technology.
Based on the discussion, the below hypothesis is formulated.

H1 Performance expectancy positively impacts the adaption intention.

2.2.2. Effort Expectancy: Effort Expectancy (EE) means the degree of ease related
to using the system" [8]. The importance of EE is it works as a tool to develop a
sense of the usefulness of a particular technology. Therefore, the users tend to
consider technology for easy task accomplishment [9]. Moreover, in BcT enabled
EHR, EE is linked to the users' perception that the BcT will not require much effort
(easy to use) be more beneficial for health service delivery outcomes. The
description of EE for this study is, the easier it is to utilize BcT, the more likely
health professionals are to use it. Consequently, the following hypothesis is
developed.

H2 Effort Expectancy positively impacts the adoption intention.

2.2.3. Social Influence: Social Influence (SI) is defined as the extent to which a
person sees the importance of peer opinions on whether they should utilize the
technology [8]. The view of the affiliated others will influence an individuals'
behavior towards technology. The influence can be positive or negative. However,
the SI will affect an individual's decision to adopt a technology. In BcT–based EHR,
the SI is predicted to impact health professionals' adoption intention positively.
Furthermore, it is essential to note that social and psychological frameworks

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encompass social and personal norms (PN). PN (in NAM) is not the same as social
norms [10]. Maity et al. [11] assert that SI (or subjective norm) influences an
Individual's attitudes and beliefs [8], and in their study context, PN is an attitude.
Thus, they further anticipated that SI shapes PNs regardless of whether they are
normative (green information technology) or non-normative (digital piracy). They
hypothesized that a high SI would result in this more positive PN. The findings for
both cases, green information technology, and digital piracy, were positive and
significant. In line with their study, the following hypothesis has been developed.

H3 Social Influence positively impacts adaption intention.

H4 Social Influence positively impacts personal norms.

2.2.4. Personal Norm: Personal norm (PN) is "feelings of moral obligation to

perform or refrain from specific actions" [12]. Feelings morally obliged towards
society play an essential role in reflecting individuals' pro-social behavior [13].
Empirical studies that tested NAM in the realm of pro-environmental behavior (e.g.,
Vining and Ebreo [14]) indicate it can explain individuals' pro-social behavior. PNs
can affect pro-social behavior. Health professionals behave pro-socially due to their
job nature. As a result, the following hypothesis is developed.

H5 Personal norm positively impacts the adaption intention.

2.2.5. Ascription of Responsibility: Ascription of responsibility (AR) is also called

outcome efficacy. AR is one of the three factors of NAM that influences individuals'
pro-social behavior. AR or outcome efficacy is a concept that describes a sense of
responsibility while conducting a particular task [10]. Consistent with the NAM, it
is anticipated that if health professionals accept the duty to act in mitigating medical
data management related issues (i.e., medical error, data breach risk reduction), they
will have a greater desire to embrace BcT-based EHR and will also feel more
obligated to behave pro-socially. Consequently, the following hypothesis is
developed.

H6 Ascription of responsibility positively impacts adaption intention.

H7 Ascription of responsibility positively impacts personal norms.

2.2.6. Awareness of Consequence: Awareness of consequence (AC) means being

conscious that engaging in (or refraining from engaging) a particular act can result
in specific outcomes [10]. According to this definition, if the health professionals
understand that BcT adoption has positive effects such as reducing medical error,
effective data management, and improved quality of patient care, they will adopt
the technology. Also, this AC will activate their AR. According to Maity et al. [11],
considerable research that already has utilized NAM in various pro-social scenarios
shows that users' awareness of their actions has distinct effects that affect their sense
of accountability and moral duty for that activity. These studies indicate that AC
positively influences PN, a relationship that we expect in our research. According
to the researcher, using BcT-based EHR is a socially desirable activity. The user is
also aware of the implications, which could lead to the establishment of PN. As a
result, BcT is expected to have a favorable effect on PN. Individuals' PN are also

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engaged when perceiving that a specific event constitutes harm to others [15].
Therefore, AC (problem awareness) should activate a PN or a "perceived moral"
need to preserve the patient's health and wellbeing. As mentioned by Dalvi-Esfahani
et al., [16], according to Nordlund and Garvill (2003; p. 341), individuals who are
conscious about the harmful impact of their act on environmental damage develop
moral obligation thus, behave environmentally friendly. Similarly, health
professionals aware of the adverse effects of lack of medical data availability are
more likely to create a moral imperative to act pro-socially. In BcT-based EHR, the
more health professionals are obliged to behave pro-socially and the more they
intend to adopt BcT. Therefore, the following hypothesis is developed.

H8 awareness of consequence positively impacts adaption intention.

H9 awareness of consequence positively impacts ascription of responsibility

2.2.7. Initial Trust: Trust has been vital in developing relationships among
individuals or organizations [17]. However, technology trust is different from those
(individual to Individual or Individual to organizational) trust as it is between
individuals and technology. This study's focus is trust between individuals and
technology. There are two types of technology trust, namely, initial trust and
continuance trust. Also, trust formation has three stages: initial trust-building, trust
maintaining, and trust recession. BcT is still at a nascent stage of development,
likely to face difficulty in initial trust-building [18]. Initial technology trust develops
before interacting with it. In other words, Initial trust is created before first-hand
contact with the technology. At this point, the technology trust begins at zero [19].
User's trust in the initial phage goes through stages, and based on Initial trust later,
they determine whether they want to use the technology [20]. There is a pre-
conceived principle in the case of technology trust - "no trust, no use" [21]. That
means the potential users will only adopt the technology (in this case, BcT based
EHR) when they have a positive initial trust in the technology [22]. The Initial trust
develops the desire to rely on variables that cause an individual to accept the risk
and uncertainty associated with the technology adoption [19]. Health professionals'
concern about patients' privacy may cause a delay in technology uptake and
diffusion, particularly for BcT as it will be directly involved with patients'
information. Therefore, initial trust in BcT-based EHR may play a vital role in
health professionals' BcT adoption intention. These study hypotheses are mentioned
below.

H10 Initial trust has a positive effect on adoption intention

H11 Initial trust mediates the relationship between self-interest factors and
adoption intention
H11a Initial trust mediates the relationship between performance expectancy
and adoption intention
H11b Initial trust mediates the relationship between effort expectancy and
adoption intention
H11c Initial trust mediates the relationship between social influence and
adoption intention
H12 Initial trust mediates the relationship between normative factors and
adoption intention

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H12a Initial trust mediates the relationship between personal norm and adoption
intention
H12b Initial trust mediates the relationship between ascription of responsibility
and adoption intention
H12c Initial trust mediates the relationship between awareness of consequence
and adoption intention

This study's objective is to propose the research framework depicted in Figure 4.

The UTAUT and NAM have endorsed the framework.

Figure 4. Conceptual Framework

3. Methodology and Data Analysis

The study will follow the quantitative research methodology to reach the research
aim. Ideally, a quantitative analysis offers objective data and is undertaken to
incorporate programs in an aspect-oriented manner. Also, this analysis method
guarantees the authenticity of conclusions supported with robust mechanisms of
justification and definition. The proposed model will be empirically tested using the
collected from a questionnaire survey. Health professionals from 145 public
hospitals in Malaysia will respond to this individual-level study to generalize the
finding. According to Krejcie and Morgan's [23] table, the sample size should be
384. It is unlikely that all distributed questionnaires will be usable; therefore, an
additional 10 percent of questionnaires will be distributed for 422. The fundamental
research will be conducted following the phases as illustrated in Figure 5.

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Figure 5. Research Phases from Data Collection to Recommendation

4. Conclusion
Technology adoption studies have been conducted for the last three decades. The
more we are getting into technologies, the more technology adoption is gaining
importance. The technology ought to be accepted by the end-users to be successfully
implemented; thus, assessing users' readiness is a crucial undertaking. This study
proposes a conceptual model that will be further empirically tested to assess health
professionals' readiness to adopt BcT technology for EHR, which is lacking in the
literature.
The conceptual model incorporates self-interest and normative factors, initial
trust to investigate clinical and non-clinical medical professionals' intention to adopt
BcT technology in Malaysian public hospitals. UTAUT and NAM theory has been
used to develop the proposed model. The contribution to the knowledge of this study
is the use of NAM theory that remained unexplored in the HIT adoption study
context. This study is expected to bring substantial benefits for the future
sustainability of the Healthcare System through improved efficiency of resources.
It provides a foundation for further research. This study is expected to bring
meaningful insight to support the ministry of health, public hospital management in
decision-making and planning BcT intervention in the public hospitals of Malaysia.
BcT technology implementation has the potential to establish a sustainable, safer,
and patient-centric healthcare delivery system. User readiness to adopt this
technology is one of the primary concerns that may hinder this novel technology's
implementation and diffusion. Therefore, pre-implementation phase user readiness
assessment is advisable to mitigate the risk of project failure, low adoption, or slow
implementation of BcT technology in the Malaysian healthcare industry.

Acknowledgments
This work was supported by the Universiti Teknologi Malaysia under Grant
Q.K130000.3555.05G72. The authors convey their heartfelt appreciation and
gratitude to the Azman Hashim International Business School, the Razak Faculty of
Technology and Informatics, and the Universiti Teknologi Malaysia (UTM).

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