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JHOM
28,3
344
Received 15 November 2011
Revised 12 April 2012
24 August 2012
Accepted 22 November 2012
Journal of Health Organization and
Management
Vol. 28 No. 3, 2014
pp. 344-365
r Emerald Group Publishing Limited
1477-7266
DOI 10.1108/JHOM-11-2011-0118
Management attitudes and
technology adoption in
long-term care facilities
Karabi C. Bezboruah, Darla Paulson and Jason Smith
School of Urban and Public Affairs, The University of Texas at Arlington,
Arlington, Texas, USA
Abstract
Purpose – The purpose of this paper is to explore the attitudes of nursing home administrators and
key managerial staff toward health information technology (health IT).
Design/methodology/approach – This research is exploratory in nature, and applies qualitative
case-study methodology to further understand health IT adoption by nursing homes through multiple
in-depth semi-structured interviews of management, and direct observations of employee behavior at
each participating facility. A modified Technology Acceptance Model is used to examine the attitudes
and perceptions of administrators.
Findings – This study finds that there are differences in the level of health IT adoption by nursing
homes. While some administrators are aware of health IT and are implementing or updating their IT
systems in a gradual but haphazard manner, others exhibited a lack of interest in implementing
change. Overall, there is a lack of systematic planning and decision-making toward health IT adoption.
Adoption is not evidence-based, instead driven primarily by real and perceived regulatory
requirements combined with a lack of information about, or consideration of, the real costs and
benefits of implementing health IT.
Research limitations/implications – Including six in-depth case studies, the sample for this study
is small for generalizing the findings. Yet, it contributes to the literature on the slow process of health
IT adoption by nursing homes. Moreover, the findings provide guidelines for future research.
Practical implications – This study demonstrates that nursing home administrators must
systematically plan the adoption of health IT, and such decision making should be evidenced-based
and participatory so that employees can voice their opinions that could prevent future resistance.
Originality/value – This study is original and advances knowledge on the reasons for the slow
adoption of health IT in nursing homes. It finds that lack of adequate information regarding the utility
and benefits of health IT in management adoption decisions can result in haphazard implementation
or no adoption at all. This finding has significant value for policy makers’ practitioners for improving
accessibility of information regarding the use of health IT in nursing homes that could address the
health IT adoption challenge in this industry.
Keywords Decision making, Nursing homes, Organizational behaviour, Medical information systems,
Technology Accepted Model, Employee behaviour
Paper type Research paper
Introduction
The US healthcare system is currently in the midst of a push toward the widespread
adoption and use of health information technology, or health IT. In support of
this push, the Federal Government has set aside funds for health IT research
and implementation and has created the Office of the National Coordinator for
Health Information Technology. Hospitals and other settings have increased their
computerization rapidly over the past several years. Reflecting this trend, research on
the adoption, implementation, and evaluation of health IT in acute and ambulatory
settings is quickly growing (American Health Information Management Association
(AHIMA), 2005; Hamilton, 2006; Kramer et al., 2004). Long-term care facilities for the
elderly and infirm such as nursing homes, on the other hand, have been slow Management
to adopt health IT (AHIMA, 2005; Hamilton, 2006). The few studies on the adoption, attitudes
implementation, and evaluation of health IT in nursing home settings (see Poon et al.,
2006) found that this industry lagged behind others in health IT adoption significantly.
While there is ample documentation that nursing homes lag behind similar health
care industries in the adoption of health IT, it is not clear why this is occurring, and
whether it is the result of rational administrators reacting to the information available 345
regarding the costs and benefits of health IT adoption, or whether other factors are
preventing managers from adopting health IT when it would be optimal for them to do
so. This paper explores nursing home administrators’ attitudes, perceptions, and
experiences while making decisions regarding the adoption of health IT. Drawing
on the Technology Acceptance Model (TAM), we explain how the decisions to adopt
technology are dynamic and related to the specific experiences of nursing home
managers. While exploring the attitudes and perceptions of administrators, we also
examine the issues related to health IT implementation that have an impact on
adoption decisions.
The organization of the paper is as follows. It begins with a description of the
theoretical framework that assists in the examination of the adoption decisions. Then,
we discuss the relevant literature on administrative decision making pertaining to IT
adoption. This is followed by an account of the research methodology and a description
of the case studies. The findings section highlights the key themes identified from
the case analyses. This research explores management attitudes in long-term care
facilities, and identifies multiple factors associated with decision making in the case of
technology implementation and thereby, contributes to the literature on organizational
behavior. Finally, the conclusions underscore the salient scholarly contributions of the
study, and identify important implications for practitioners for future policy decisions
related to technology adoption.

Theoretical framework
In order to determine how attitudes affect behavior in people, Ajzen and Fishbein
(1980) developed the Theory of Reasoned Action (TRA). With the TRA as its
theoretical base, Davis (1989) developed the TAM, that acceptance or rejection of
technology is a response that can be explained by the motivation of the users.
This motivation is influenced by external stimulus such as the features and
capabilities of the technology. TAM maps and explains how external variables
indirectly influence internal beliefs, attitudes, and intentions.
Davis (1989) further suggests that the behavioral intention to adopt technology can
be explained by two factors – perceived usefulness and the perceived ease of use.
Perceived usefulness is defined as the extent to which people’s utilitarian expectation
from technology use with respect to performance enhancement is satisfied. Perceived
ease of use is the extent to which the people believe that using the technology will be
free of effort (Davis, 1989). Furthermore, perceived ease of use influences perceived
usefulness because, other things remaining the same, an easy to use technology can
beget effective results. Moreover, studies show that higher levels of perceived ease of
use of technology can lead to a higher level of its perceived usefulness because the
energy saved from spending too much effort can be channeled elsewhere to improve
job performance (Davis et al., 1989). The modified version of TAM includes behavioral
intention because Davis et al. (1989) suggest that when a system or technology is
perceived to be useful, there is a strong behavioral intent to use it. TAM is one of the
JHOM most powerful theories that explain technology adoption or non-adoption that has
28,3 been confirmed by several studies (see Gefen and Straub, 2009 for a summary on
TAM). With extensions and several additions of variables to the original TAM
model by other researchers (Venkatesh et al., 2012; Venkatesh and Davis, 2000), this
model is most applied to explain and predict technology acceptance. We apply the
“perceived usefulness” and “perceived ease of use” factors of the TAM to explore and
346 explain volitional behavior in the context of health IT acceptance and implementation
in nursing homes.
Furthermore, we also include two constructs from Venkatesh et al.’s (2003) Unified
Theory of Acceptance and Use of Technology (UTAUT) that is a modification of the
original TAM model. Of the four key constructs of the UTAUT model (i.e. performance
expectancy, effort expectancy, social influence, and facilitating conditions) that influence
behavioral intention to use technology, this study uses “social influence” and “facilitating
conditions” in the analysis. Social Influence is defined as the extent to which an
individual’s behavior is influenced by other’s view of the use of that technology. In
mandatory settings it would mean compliance, whereas in voluntary settings, it would
mean social acceptance resulting from the use of technology. Facilitating conditions are
defined as the extent of an individual’s belief of the existence of an organizational and
technical infrastructure that will assist in technology acceptance or adoption. This
suggests the presence of resources that facilitate and are compatible with technology
adoption. The modified TAM framework applied in this analysis is drawn from the TAM
and UTAUT models, and the constructs assist in the explanation of health IT adoption in
nursing homes. Such modification is necessary as touted by Chiasson and Davidson
(2004, p. 171) who in their review of theories applied in the health care context suggest
that pre-existing “research topics, constructs, and theories need to be reshaped to deal
with these institutionally unique issues.” In other words, they suggest the development
of context specific theories to explore and examine issues that are unique to the unit of
analyses in the health care industry.
The extant study explores the adoption process through the lens of the TAM and
examines whether perceived ease of use, perceived usefulness of technology, social
influence, and facilitating conditions, derived from a modified TAM, influence nursing
home administrators’ decisions to adopt health IT. This approach to analyzing the
attitudes and behavior for technology adoption can provide some useful insights into
the acceptance of health IT in the nursing home industry. Studies show that health IT
adoption is slow in this industry, which points to the fact that within the nursing
homes that have adopted health IT, there is much diversity in the adoption and
implementation process. By exploring this issue case-by-case at several nursing homes,
this paper sheds light on context specific variations. The following section reviews the
literature on administrative decision-making for health IT adoption, and the process of
health IT adoption by long-term care facilities.

Literature review
Health IT and its impact on organizations
The impact of health IT on quality of care, cost effectiveness, efficiency, clinician
satisfaction, and other outcomes has been well documented in acute care and
ambulatory settings (Hamilton, 2006). Studies have shown that health IT has the
potential to bring major benefits to these care settings. First, health IT has the potential
to improve and streamline healthcare, help patients obtain their medications, facilitate
renewal of medication, assist in retrieving medical information during emergencies,
and ensure access to medical histories (Shekelle et al., 2006). Some researchers (e.g. Management
Armstrong, 2000; Bates and Gawande, 2003; Bates et al., 1998; Brown et al., 2005; Kaushal attitudes
et al., 2003; Koppel et al., 2005) suggest that health IT can play an important role in
reducing medical errors, which according to some estimates, are the third leading cause of
death in the USA (Starfield, 2000). Adoption of e-prescribing and computerized provider
order entry can reduce medication errors due to poor handwriting, while electronic health
records (EHR) can promote better clinical outcomes, improve medication adherence and 347
refill rates, improve member satisfaction, and lower overall healthcare expenditures
(Balfour et al., 2009; Bates, 2002; Dixon and Zafar, 2009; Kaushal and Bates, 2001; Wang
et al., 2003). Another body of literature suggests that efficiency gains are realized and cost
savings can occur when health IT is implemented (summarized by Possant et al., 2005).
Overall, the literature suggests that health IT has to potential to improve overall
healthcare quality, safety, and satisfaction while delivering some cost savings.
Most of these studies have not taken place in long-term care, and it is not clear
whether their results would translate to this setting because of the unique characteristics
of the nursing homes themselves, along with their payers and patients (Kramer et al.,
2009). The results of health IT adoption in the nursing home setting have been mixed at
best. Judge et al. (2006) studied how the addition of a decision support system to an
existing CPOE system in a large, academically affiliated long-term care facility affected
clinician response. They found that those who received an alert were only slightly more
likely to take the appropriate action. Rantz et al. (2006) used a mixed-methods approach
to evaluate the use of electronic medical records (EMR) in several skilled nursing
facilities in Missouri. The qualitative portion of their study found that staff members
thought that they were more efficient and were able to document more accurately
because of the EMRs. The quantitative portion of their study found that EMRs had
contributed to higher activities of daily living scores, but a decline in range of motion.
Additionally, Rochon et al. (2005) studied the impact of CPOE on clinician time utilization
in a long-term care setting and found that CPOE had little impact.

“Perceived usefulness” and “perceived ease of use”

While much work has been conducted regarding the efficacy of health IT, it is not clear
the extent to which nursing home administrators have information regarding the costs
and benefits of health IT, or the conditions that have been found to facilitate the
implementation process in nursing homes. Limited information leads to perceptions of
the “perceived usefulness” and “perceived ease of use” that may differ from reality.
Furthermore, research has found that these factors differ substantially in the view
of managers as compared to their employees who use the technology (Lyons et al.,
2005). When the administrator’s perceptions of the costs and benefits of health IT are
incomplete or inaccurate, sub-optimal, or even harmful, choices may be made regarding
the mix of technology to adopt. When they are unable to convey the “perceived
usefulness” of health IT to nurses and nursing assistants due to differing perceptions
or values, the latter may resist health IT innovation, thwarting its eventual efficacy.
When managers fail to consider employee perceptions regarding the ease of use of
important features, unexpected training costs could interfere with the cost-effectiveness of
the technologies utilized or employees could resist utilization of the technologies due to the
initial effort required to become acquainted with the new system. This is corroborated by
recent research finding that the primary barriers to successful health IT adoption
included costs, training, and the organization culture change required (Cherry and Owen,
2008), and that an important reason some organizations realize positive outcomes and
JHOM some organizations fail to obtain any cost savings or is the employee relations climate
28,3 (Lipsky et al., 2009). We explore these factors in more detail in our study.

“Social factors” and “facilitating conditions”

Social factors are important in technological implementation, but some administrators fail
to consider them initially. For example, Rodriguez and Pozzebon (2011) explore the pre-
348 implementation behavior of a clinical information system by two university multi-hospital
centers in Canada. They found that management actions and decisions were seemingly
driven by financial concerns and power struggles between the groups associated with the
implementation. Furthermore, during the pre-adoption and pre-implementation phase, the
technological aspects were overemphasized with little reference to these organizational
and political issues that impede successful implementation. Indeed, the attitudes and
behaviors of the administration during the initial phases of technology implementation
can have a significant impact on the way technology is accepted by the organization and
its stakeholders, including any positive or negative consequences that emanate from the
chain of events succeeding adoption (Pozzebon and Pinsonneault, 2005; Abdinnour-Helm
et al., 2003; Herold et al., 1995).
Because studies of the effect of health IT on organizational outcomes has been mixed, it
is important to consider the conditions which facilitate successful implementation, which
may shed light on the factors that lead to the successful implementation of health IT, and
the environments in which health IT leads to positive outcomes. These best practices and
contingency data are necessary for managers to make optimal decisions. A case study of
the implementation process of EMRs at a hospital suggests the importance of a proactive
stance among the key actors who are well aware of potential problems and challenges
(Pare et al., 1997). In addition, Pare et al. (1997) found that health administrators and IT
managers should adopt implementation practices that are contingent upon the project.
Given the distinctiveness of each project, the implementation tactic should be tailored to
the project. Customization works better when complemented by key actor’s characteristics
such as their experience, skills, and credibility (Pare et al., 1997). Studies examining the
response of health professionals and managers to EHR implementation found poor
organizational management practices such as top-down leadership approaches, poor
timing of implementation, and the provision of inadequate resources to support health IT
implementation as barriers to effective implementation (McGinn et al., 2011). The same
group of respondents, however, considered reflexive management approaches, proactive
nature of the management team, and voluntariness as facilitators to EHR implementation.
Since most of these studies occurred in the hospital industry, however, it is unclear the
extent to which they will extend to nursing homes.
Few studies exist that consider the facilitating conditions for implementing health
IT in nursing homes. Cherry and Owen (2008) found that the facilitators to health IT
adoption included the availability of initial and continuing training programs,
thorough implementation plans, government assistance with costs, evidence that
health IT will bring improvements, and support from state regulatory agencies. Lipsky
et al. (2009) found that employee empowerment and administrator motives for
adopting health IT influenced its successful implementation. The existing literature
provides a good basis to our study for advancing understanding of the impact of
perceived ease of use, perceived usefulness, social factors, and facilitating conditions
on the decisions to adopt health IT in nursing home settings. This framework assists
us in indentifying additional factors in the decision to adopt health IT that contributes
to the literature on nursing home management.
Research methodology Management
Design attitudes
This study applies a qualitative methodology to explore the process of health IT adoption
in six nursing homes in the Dallas-Fort Worth-Arlington metropolitan area. These
nursing homes represent a mix of for-profit and nonprofit nursing facilities that cater to
general as well as specialized care of elderly persons. The primary sources of qualitative
data are the administrators of the nursing homes that participated in this study. 349
We complement our interviews with careful observations recorded during our visits to
these nursing homes. This exploratory study first analyzes each case on its individual
strengths and then makes comparisons among the cases (Maxwell, 2005; Yin, 1994).
The research team e-mailed and called 75 nursing homes in the Dallas-Fort Worth-
Arlington metropolitan area beginning June 2010, requesting them to participate in this
research. Of the 75 nursing homes, 14 declined to participate because of lack of time
and/or non-adoption of health IT, and 55 did not respond to the call for participation
despite multiple reminder e-mails and phone calls. Six nursing homes agreed to
participate in this study after several waves of follow-up requests via telephone and
e-mail. The participating nursing homes ranged from large to small in size, and served
different categories of clients. The research team visited each nursing home over
a period of a year and conducted in-depth interviews with the administrators on
the process of health IT adoption in their respective homes. When appropriate, in
addition to the administrator, the team interviewed the Directors of Nursing (DONs),
case managers, nursing staff, kitchen staff, and administrative interns to get a holistic
view of the process of health IT adoption. The interviews lasted between 60 and
120 minutes, with some respondents interviewed multiple times, in order to obtain
supplemental or clarifying information. In total, 42 people were interviewed.
An interview guide consisting of semi-structured questions was prepared based on
the literature on health IT implementation in health care facilities. The research team
carefully evaluated the questions and items on the guide before administering it to the
participants. In addition, modifications to the guide were made based on interviews,
the responses of the participants, and the type of nursing home. The list below depicts
the interview guide prepared for the research participants. Since most of the interviews
were conversational in style, this guide assisted in keeping the interviews on track
while garnering as much information as possible from the interviewees:
Perceived usefulness:
. What is your primary focus for implementing IT?
. What types of HIT are being used currently?
. Does your office have plans for purchasing/upgrading its information
technology?
. Benefits experienced.
. Organization’s “readiness” to adopt health IT in terms of leadership initiative.
. Pre and/or post-adoption cost-benefit analyses.
Perceived ease of use:
. Does your practice use any clinical or administrative databases or programs that
were developed or made in-house?
. Any challenges to health IT adoption and implementation. How are they addressed?
JHOM . Description of the functions (administrative and clinical) that relies on health IT.
28,3 . The extent to which staff members use health IT.
. The duration of training.
Social influence:

350
. How would you describe the position that you hold at your organization?
. Are you a member of the organization’s executive committee (the senior
leadership team that drives overall organization strategy and direction)?
. Strategy use in the adoption of health IT.
. If a competing nursing home has adopted health IT, would that lead to health IT
adoption in your facility?
Facilitation conditions:
. The primary source of your institution’s IT spending.
. The extent to which Information Technology (IT) is integrated into your
organization’s strategic operating, clinical and capital plans.
. Do you feel that your existing computer or IT capabilities (including access to
online resources) are adequate to support the goals of your organization?
. Organizations’ short-term (one to three years) and long-term (three to five years)
plans for health IT acquisition.
The research team supplemented this with skilled observer notes on the aesthetics of the
nursing homes including the physical layout, presentation for potential residents and their
families, and external appearances of the facilities such as cleanliness. Furthermore, we
observed employee dynamics pertaining to the discussion on health IT, their appreciation
of such technology and/or apprehension toward new things, and the overall interest in
implementing change and modernizing their operations. In addition to observing the
physical layout and administrator interests and motivation to acquire new technology, we
also observed the living conditions of the residents in order to understand if they were
predictors of technology adoption. It is important to note that none of the nursing homes
that participated in this study had implemented the full suite of the health IT system
that includes integrated financial, clinical, and administrative software technologies for
efficient patient care. Most of the nursing homes have adopted some types of health IT
from the full suite, and were in the process of upgrading and implementing them. The
others, however, did not show much enthusiasm about modernizing their facilities. This
study included both the adopters and non-adopters of health IT in order to understand
and advance knowledge on the factors that facilitated adoption or non-adoption decisions.
Table I summarizes the organizational characteristics of the health IT (HIT in the table
title) adopters and non-adopters participating in this study.
The interviews with the nursing home personnel were recorded and transcribed
verbatim. The research team read the transcripts individually and identified emerging
themes that were common across all the nursing homes studied. In addition to the
interview transcripts, observations from the nursing home visits, employee and
administrative behavior related to health IT queries also contributed to the theme
identification. The individual identification of themes assisted in the triangulation of
data by the investigating team. In cases where the research team could not arrive at a
 Adopters Non-adopters
Management
n 4 2 attitudes
Age in years (mean, median) 32.75, 19.5 59.5, 59.5
Ownership status
For-profit (n) 1 1
Non-profit (n) 3 1 351
Public (n) 0 0
Chain status
Chain (n) 2 2
Non-chain (n) 2 0
Setting
Urban (n) 3 1
Suburban (n) 1 1
Rural (n) 0 0
Type of care
General (n) 3 2
Specialized (n) 1 0
Medicare/Medicaid
Medicare only (n) 1 0
Medicaid only (n) 0 0
Both (n) 2 1 Table I.
Neither (n) 1 1 Summary organizational
Operating revenue (mean) $12,630,000 $5,880,000 characteristics of HIT
No. beds (mean) 105.5 90 adopters and non-adopters

consensus over certain themes, the data were revisited and deliberated upon until there
was agreement within the group. From these themes, key concepts are drawn that are
based on the nursing home administrators’ perspectives on health IT, and the process
of health IT implementation by the adopters that involved, in some cases, significant
organizational changes.

Research sites
We analyze six nursing homes in the Dallas-Fort Worth-Arlington Metropolitan Statistical
Area. Table II depicts the profiles and characteristics of the participating organizations.
The participating nursing homes were primarily generalist service providers, with
one specialist home focussing on Alzheimer’s and dementia. Size ranged from large
chain-affiliated facilities to small community-based organizations serving the wealthy
and the poor.

Findings
While several commonalities exist among the nursing homes regarding health
IT adoption, this study uncovered an overall theme relating to the lack of a systematic
process followed by nursing home administrators in decision-making regarding
technology adoption. This study focusses on four related themes that emerged across
several sites, all relating to this common finding. First, the study finds that the decision
to implement health IT was usually not evidence-based, instead driven primarily by
real and perceived regulatory requirements combined with a lack of information about,
or consideration of, the real costs and benefits of implementing health IT. Other themes
that emerged regarding the implementation decision were a lack of awareness about
health IT types (information asymmetry) and incomplete communication among
 28,3

352
JHOM

Table II.

organizations
Profile of participating
Site A Site B Site C Site D Site E Site F

Have HIT other than for No Yes Yes Yes No Yes

admin purpose
Year first adopted n/a 2009 2008 2007 n/a n/a
Degree of HIT n/a Medium High Low n/a Low
sophistication
Future plans Yes – initial Yes – greater Yes – greater Yes – greater No Yes – greater
adoption sophistication sophistication sophistication sophistication
Established 1976 1993 2008 1922 1907 1990
Ownership For-Profit Non-Profit For-Profit Non-Profit Non-Profit Non-Profit
Chain No No Yes No No Yes
Setting Sub. Urban Sub. Urban Urban Urban
Type of care General Dementia General General General General
Medicare/Medicaid Yes/Yes No/No Yes/Yes Yes/Yes No/No Yes/No
Operating rev. (millions 3.75 6.5 10.5 19.0 8.0 14.5
of dollars)
No. employees n/a 117 n/a 464 90 142
No. beds 120 100 128 134 60 60
No. residents typical 57 85 106 n/a n/a 50
organizational stakeholders regarding the benefits and costs of health IT. In reference Management
to the implementation process, key findings converge around a trial-and-error, rather attitudes
than evidence-based, approach to implementing health IT and a lack of formal
planning to guide technological innovations. Administrators who did not implement
health IT similarly did not make this decision consciously, but were more likely to refer
to limited information or reluctance to change. An outline of the four important themes
identified in the analyses and their explanations is presented in Figure 1. Moreover, 353
each theme identified from the analysis is explored in more detail below.

Institutional pressures
This analysis suggests the existence of certain types of pressures in the decision to
adopt or not-adopt health IT, and thereby supports the social influence construct
of the modified TAM. Pressures from the government to maintain accountability by
submitting quarterly patient reports via computerized systems have led nursing home
administrators to submit the Long-Term Care Minimum Data Set (MDS). The MDS is
a standardized, primary screening and assessment tool of health status that forms the
foundation of the comprehensive assessment for all residents of long-term care
facilities certified to participate in Medicare or Medicaid. The MDS plays a key role in
the Medicare and Medicaid reimbursement system and in monitoring the quality of
care provided to nursing facility residents. Because this is mandatory, the nursing
homes that accepted Medicare and/or Medicaid had no option but to submit reports
through the computerized system.
In addition to the real regulatory constraints placed on nursing homes that forced
the adoption of IT in administrative functions, administrators also anticipated
potential increases in regulatory requirements regarding health IT use, so these
institutional pressures influenced the adoption of other forms of health IT as well. In
particular, administrators feared that governmental agencies such as the Centers for
Medicare and Medicaid Services (CMS) and Health and Human Services might make
adoption of other forms of health IT mandatory in nursing homes. Nursing home
leaders also responded to CMS incentives for adopting “meaningful use” of health IT
by which health care providers must demonstrate technology’s impact on health
outcomes. Some administrators anticipated that these “incentives” signaled future
regulatory requirements, so as a response, they adopted health IT without systematic
planning of its costs and benefits, or adaptability to their institution.
To remain competitive, nursing home administrators often engage in benchmarking,
where they seek to imitate the process of automation and adoption of health IT used by
their successful counterparts. This is often done based on the perception that health IT
has lead to the success in this other nursing home, and an assumption that what works
in this other nursing home will similarly work in one’s own nursing home, without
systematic evidence to either point. Apart from using computers for MDS reporting,
some nursing homes did not adopt any forms of health IT, and instead continued to use
traditional methods for taking notes and writing prescriptions. They reported that until
governments mandate the adoption of health IT, they have no plans to adopt it and no
measures in place to systematically explore whether health IT implementation will
improve their care quality and efficiency outcomes.
The importance of institutional pressures, such as regulations and competition,
when combined with the lack of data-driven decision making, suggests that nursing
homes have been largely reactive in their decision-making regarding health IT
adoption. Since this type of reactive decision making is not based on the real costs and
 28,3

354

Themes
JHOM

Figure 1.
Management action based on competition; institutional pressures; & perceived need
Institutional Pressures

Management will not act unless forced to act

Adoption in a piece-meal and experimental fashion

Experimental and Tentative

Costs of adoption, upgrades, and maintenance has resulted in tentative approach

Lack of complete knowledge about the forms of health IT available

Information Asymmetry
Incomplete information about the usage and benefits of health IT

Lack of understanding and difference in meaning has hurt adoption

Incomplete information on HIT resulted in fragmented communication

Incomplete Communication
Levels of government and nursing facilities are on different pages on health IT

Expected benefits may not kick in for a long time if adoptions are haphazard
benefits of health IT to the organization, it possibly results in sub-optimal quality of Management
care and efficiency outcomes for those that adopt health IT. This is because there is no attitudes
evidence that they are adopting the type of health IT that will maximize quality
outcomes while minimizing expenses. The following examples from two organizations
(an adopter and a non-adopter) shed more light into this process. In Site E, the nurses
who actually used the health IT system found it to be overly technical and
disconnected from the field of medicine and nursing. Furthermore, the administrator 355
said that the decisions on health IT systems are taken at the corporate office and
implemented by the regional nursing homes in a standard fashion. Therefore, the
systems are not customized to each facility’s requirements. The nurses further stated
that they have not experienced a reduction in paper usage, and because of the new
system, they feel that their workload has doubled.
The administrator at Site F, that had implemented MDS, but not any other health IT
systems, stated that there was little discussion prior to the decision and that the board
was largely accepting of the proposal to acquire the MDS system. Moreover, the MDS
system was acquired because of state mandates and therefore, there was no analysis of
real costs and benefits. In addition, the social worker mentioned that more time was
spent in administrative activities like fighting the flaws of the automated reporting
system, resulting in less time with patients. The administrator further stated that they
had no plans for implementing additional IT systems unless the government mandates
it because the systems involve high acquisition and maintenance costs with additional
costs of training of personnel.
In summary, we conclude that the social factors that influence managerial decision
making, particularly the actions of other nursing homes, are very strong. Given the
expense involved with health IT, however, we recommend that managers utilize resources
up front to ensure that they invest in the right type of health IT, rather than follow the lead
of other organizations, whom our research suggests also probably did not make optimal
decisions. Evidence of this fact is the request made by some administrators of nursing
homes to the lead researcher for the names and contact information of other nursing
homes that have seemingly better health IT systems in place, so that they could acquire
the same system to replace their existing system. Further, we suggest that while using
anticipation of future regulations should be a contributing factor to the decision to
implement health IT, it should not be relied upon to the exclusion of a more nuanced study
of the relative benefits of certain types of health IT.

Experimental and tentative processes

The interviews suggested that the administrators, owners and managers were aware of
health IT systems available for nursing homes to a certain extent. Pre-adoption
discussion of the perception of ease of use of health IT was not as evident as the
perception of the usefulness of technology adoption. Five of the administrators were
cognizant of some of the potential benefits of health IT. Their perception of usefulness
and potential benefits of health IT led them to champion for its acquisition. However,
the implementation attitude of these administrators was tentative and experimental.
Several factors contributed to this attitude. First, the price of the health IT system and
the subsequent upgrades to the facilities’ computers and the perception of staff
resistance to change and/or staff training costs resulted in a reluctance to consider the
opportunities presented by health IT. Second, prevalence of traditional management
practices resulted in a lack of strategic planning, evaluation, and cost-benefit analysis
that prevented nursing home leadership from understanding the benefits of health IT
JHOM adoption in their particular facility, resulting in risk aversion. Finally, an indifferent
28,3 attitude toward health IT by some administrators in the absence of regulatory
pressures and evidence of successful measurable administrative and clinical outcomes
resulted in a reluctance to spend the time to explore the opportunities presented by
health IT, due to a satisfaction with current processes. Administrators were also
reluctant to implement because they were apprehensive of the ease of use of new
356 technology for some of the older nurses who had never worked with computers and
were scared of ruining company property as evident from Sites B and F.
As a result of failing to strategically plan for technology administration and a focus
on technology costs, many nursing homes had built their health IT system in a piece-
meal way by acquiring their health IT system from multiple vendors. Integration
issues were a concern for these nursing homes, and one that prevented them from fully
realizing the potential benefits of such a system. Lack of integration among individual
parts led to frequent duplication and an inability to utilize all features of the system.
One nursing home (Site B) installed a fully integrated administrative and clinical
system at the outset that was customized to the needs of the facility. This facility did
not experience any of the issues that non-integrated facilities did. This facility
experienced less paper usage and minimal duplication of documentation, suggesting
that cost savings were more substantial compared to other nursing homes. Despite the
integration problems, the other facilities that had implemented some types of health
IT remained optimistic about future gains and had plans to build systems that are more
sophisticated in the future. Management expressed the belief that natural kinks in the
system would be worked out over time. The perception that the health IT technology
could be gradually tailored to fit each organization suggests a reactive rather than a
proactive approach to customization. The administrators held the belief that users of
the systems would become more familiar with regular usage and will be more receptive
to new technologies.
Because of the haphazard process by which technology implementation occurred in
several organizations, which appears to have resulted primarily from a lack of up-front
systematic planning, health IT in nursing homes is probably not being optimally
utilized. Usefulness (at least in the perception of managers) is considered generally, but
not considered carefully when multiple systems are required to interact. Administrator
optimism suggests more of an ideological belief in health IT than a careful analysis of
how health IT can best produce desirable outcomes in their facility. In addition to
careful up-front planning, which can lead to fewer inter-operability problems down the
road, it is important for administrators to carefully review the outcomes produced by
their health IT systems and be willing to change course when data indicate that current
technology is not producing optimal results.

Information asymmetry
Prior to adoption, most administrators lacked important information on the utility and
usefulness of the various health IT software available. Although the perception of the
usefulness of health IT was evident from the discussions with the administrators, the
ones that had adopted were not completely convinced of the systems ease of use or
usefulness. This is possibly because the adoptions were recent and these facilities had
yet to realize the usefulness of the system. In general, administrators had concerns
about choosing the right vendors, customization of the software to the specific setting,
and functionality. Interview results pointed to a lack of knowledge on administrative
and clinical health IT, their potential utilization in the facility, or their regular
maintenance. Those who adopted health IT and were using technology became aware Management
of the existence and benefits of such systems from peers and vendors at workshops attitudes
and conferences. Making decisions based on the recommendation of peers, however,
could be problematic since positive outcomes in one organization may not transfer
to another organization due to unique customer bases and requirements and organizational
strategies. In addition, few health IT vendors were capable of such customization in
systems and training, reducing the probability that their systems will optimally serve 357
nursing homes. This suggests that perhaps policies that require nursing home technology
utilization, but do not consider current vendor offerings, are short sighted. Encouraging
innovation on the part of technology providers may be a better use of societal resources.
Staff behavior in the event of new technology adoption is another critical concern of
most administrators. New technology adoption would mean scheduling training
sessions for both the management and staff of the nursing homes, and this means
additional work hours. Most administrators confirmed that staff was reluctant to learn
and work with new technology as it slows their work pace, and makes them more
prone to mistakes during the initial phases. Since management often does not
have complete information on health IT systems, their functionalities, and their
effective applications, they struggle to adequately convey the systems’ utilities to the
nursing staff. This gap in information dissemination results in misunderstandings and
frustration among the nursing staff, many of whom react to such changes in operations
by actively or passively resisting technology usage. As found in Site D, which adopted
some applications of clinical health IT in 2007, resistance was experienced initially.
Most nurses complained about the slow response time of the health IT system
that made their work inefficient. The reasons for the adoption were not adequately
explained to the clinical staff who assumed that the new technology is another whim
imposed on them by management. They exhibited their opposition by pulling the cable
out of the socket, turning off the system, and so forth so that management would need
to call in technical assistance for addressing apparent technology issues. This suggests
that the staff did not perceive the usefulness of systems, and so they were actively
undermining its success.

Incomplete communication
Not only was the perceived usefulness of the system among the staff inadequate, but
ease of use was not adequately considered by administrators, who also lacked
knowledge of the health IT’s benefits, challenges, and adoption issues. This finding is
corroborated by the haphazard manner of health IT implementation witnessed in this
study. The issue of incomplete information about health IT systems and their usage
on the part of the administrators resulted in flawed communication with the staff.
Consequently, staff experienced technical issues that disrupted their workflow, and
caused frustrations from the use of the new systems.
Based on the interviews with administrators, the research team found that
communication of incomplete information on health IT translated into fragmented
realization of benefits. For example, site B, with the fully integrated health IT system,
could not communicate the full benefits and security features of the health IT system
with their staff and with their external regulators. Therefore, they experienced
an increase in the use of computers as well as paper records because staff would
maintain duplicate records in computers and papers for fear of “messing up,” and the
administrator had to submit patient information in duplicates. Even with a relatively
more customized health IT system than most other facilities, this facility could not
JHOM realize the full potential and benefits of the system. In addition to communication
28,3 problems, administrators reported problems with the software supplied by the
vendors, perhaps due in part to the inability of vendors to personalize service.
Problems reported include slow response time and the need to duplicate the input of
information. These issues reduced the efficiency of staff.
To reduce communication problems with key staff, this study suggests that staff
358 should be included in the decision-making process regarding health IT. By allowing
staff a voice in the process, not only will their resistance to change be lower, but they
will also be more likely to understand the product when it arrives. Furthermore, the
health IT adoption process would be more effective with an increase in the amount of
time vendor representatives are available on site for questions and for training the staff
at each facility that implements the automation systems.
The above-discussed themes were identified from the interviews with the
administrators and staff of the nursing homes that participated in this study. Table III
highlights the key quotes of the administrators that were recorded from the personal
interviews. These quotes point to the specific themes identified from the analysis. They
are consistent with three of the constructs of the modified TAM applied here. For
example, the quotes in Table III reflect the perceived usefulness of health IT, and are in
line with the social influences and facilitating conditions constructs. The perceived
ease of use construct, however, is not consistent with the major themes derived from
the discussions with the administrators. This suggests the perceived ease of use
of the health IT systems might have been excluded during the decision-making
process. While discussing the acceptance and resistance to new technology with the
administrator at Site D, the administrator jokingly said that if nursing staff resisted or
opposed working with the new system, then they would lose their jobs. The DON
clarified that staff that had problems working with technology receive technological
assistance from co-workers. This suggests that ease of use of new technology was
undermined in the decisions to adopt. According to our findings, however, this is a very
important variable in the decisions to adopt, which when neglected, could result in
ineffective and inefficient application and usage of health IT.

Implications and conclusions

The findings from the case studies point to the variances in the adoption of health IT
by nursing homes in the Dallas-Fort Worth-Arlington MSA. The themes suggest that
adoption of health IT is still in a nascent stage in nursing homes particularly because
of the fragmented nature of health IT adoption and the indifferent attitude of
management toward health IT. Furthermore, most nursing homes that have adopted
health IT are yet to realize the full potential benefits that health IT systems have to
offer, and many features that have already been purchased and could be activated
to improve processes remain unutilized. As suggested by the theoretical constructs,
nursing homes that have adopted technology have done so because of social and
institutional pressures from real or anticipated regulations or from the perceived
usefulness of the health IT systems. In addition, our study finds that the costs involved
in the acquisition, maintenance, and upgrades of the health IT systems, along with the
costs of training, act as a deterrent in pre-adoption decisions. This suggests that of the
four constructs applied here, namely, perceived usefulness, perceived ease of use, social
influence, and facilitating conditions, administrators are more likely to act on the
perceived usefulness of health IT systems, yet conditions facilitating such decisions
are not present in all nursing homes. For example, in Site A, the administrator and
Theme
Institutional pressures
Information asymmetry
Experimental and tentative
nature of the process
Incomplete communication
Notes: aAdopted HIT other than for administrative purposes; bhas not adopted HIT other than for
administrative purposes
Participant quotations
Management
attitudes
“You know, CMS has come out with a guideline that they want you to
have implemented this by a certain time. That guideline’s going to
turn into a requirement before long”a
“They all want, you know, they want streamlined information as fast
as they can get it, whereas ten years ago it wasn’t that way. And so 359
it’s all moving towards that realm”b
“It is state mandated that is the only reason we have to do it”b
“It’s federally mandated by 2015 we all have to have electronic
medical records so it’s going to have to be an integral part regardless
whether they want it to be or not”a
“I think it would be beneficial to us, because we do spend
a lot of time just going in a kind of roaming around to figure
things out”a
“I’ve almost decided that, with the technology, we’ve got a whole new
set of problems that we keep working through all the time”a
“The one key thing that people have to understand with the system
is that, making sure you understand how customizable it is”a
“But it’s trying to, it’s trying to convince the owner of the building to
sink thirty-five thousand dollars into a building that’s not
necessarily performing the way he wants is impossible”b
“We are doing it gradually”a
“When you look at the time frame, it wasn’t intended to happen that
way, because we did have it more spread out, but because of like the
pharmacy selling and all that, things have gone a little differently
than we planned”a
“And it’s definitely getting to be a significant cost factor, cause
obviously, every program has some maintenance fee with it. And we
have a lot of different software programs that we’re currently using”a
“And the problem there now, everybody’s having to piece these
things together, so you’re having to build bridges so these two
systems can talk and it’s amazing that they all work, with as many
bridges as there are out there”a
“The old strategic plan still has some things out there, but quite
honestly I don’t – I don’t really recall much IT in that plan, which
may be why we’re piecing things together now”a
“You are looking at one of the oldest professions in the world and
putting a new concept on it”b
“I think they’re getting better, from what I hear. They’re getting a
little bit better about adjusting to the electronic environment”a
“When a surveyor comes in, we provide them with a laptop and
instructions and we orientate them a little bit to the computer, but
then – You know, some of them are good on it, some of them aren’t”a
“I guess one of the barriers is that Texas is not recognizing electronic
signatures for physicians yet and that’s a big thing right there”a
“It was very frustrating and very time-consuming, because of all the
changes with the legislature, all the time with the state of Texas,
so I constantly have to stay on top of things and make sure you’re
doing things correctly and what not”a
Table III.
Illustrative quotes of
main themes identified
JHOM managerial staff were ready for health IT uptake, yet the owners of the nursing home
28,3 were reluctant due to the exorbitant costs of such systems. The findings do not support
the presence of the “perceived ease of use” pertaining to health IT systems during
management discussions on adoption. As evident from Sites B, D, and F, which were at
various stages of implementation, “ease of use” was not a criterion in the decision to
adopt and implement health IT. It is clear that some administrators thought about this
360 issue especially when the organization employs clinical staff who are not comfortable
working with computers, but they concluded that the issue is not serious enough to
garner action. They believed that health IT usage could be made easier through
training and peer support. In fact, the difficulty of working with the new system and
the length of time required for learning to operate it resulted in staff hostility and
resistance. The staff felt that new systems were imposed on them and considered
health IT a burden that added to their workload.
The constructs, perceived usefulness and social influence, were more evident in the
pre-adoption discussions with the administrators. The construct, facilitating
conditions, was present in a lesser degree in the adoption and implementation of
health IT. From the case analyses, we found that administrators believed that the lack
of facilitating conditions was the main reason for not adopting health IT. In the case of
the adopters of health IT, facilitating conditions were present where health IT was a
part of the operations from the time of establishment of the nursing home as in Site C.
The other adopters such as Sites B, D, and F attempted to create facilitating conditions
that would result in effective application of health IT. Facilitating conditions ranged
from regular training, transparent decision making, management accessibility, and so
forth. These initiatives resulted in mild to moderate success rates in the transition to a
new system. Yet, when the corporate headquarters of Site F decided to change to
another new IT system that would be standardized across all the nursing homes that
belonged to their chain, there was much ambiguousness and disappointment among
the administrators and management. The administrators felt that the new system was
unnecessary and not tailored to local operations. Therefore, it is apparent that the
facilitating conditions are very context specific to the organizational culture.
In sum, we observe the marked presence of the three constructs of the modified
TAM – perceived usefulness, social conditions, and facilitating conditions, in the
nursing homes. The fourth variable – perceived ease of use, however, is not discernible
among administrator pre-implementation discussions in any of the cases. In order for
successful implementation of health IT in nursing homes, there needs to be a good
balance between the important aspects of change, that is, the people involved in the
implementation, the technology implemented, and the process of implementation. Our
research highlights the perspectives of the key people involved in the health IT
adoption decisions, and finds that the processes of implementation of health IT in
nursing homes are inadequate. More focus was on the “perceived usefulness” and
benefits to the nursing home, and less on the “perceived ease of use of technology.”
One important contribution of this study is the apparent behavior and attitude of
the majority of the nursing home administrators toward health IT. In general, an
apathetic attitude toward change and innovation prevailed among nursing homes
without health IT. Such administrators will not take any initiative unless forced to do
so. These administrators were not actively seeking information about health IT, nor
had they conducted any cost-benefit analysis prior to making decisions on adoption.
Even nursing homes who did implement health IT generally did so in a haphazard
method that lacked coherent planning. Institutional and competitive pressures
combined with the perception that adopting health IT would result in improved care as Management
well as look good to stakeholders resulted in the adoption. One problem may be that attitudes
obtaining information is costly or difficult for administrators, which suggests that
policies that focus on information dissemination may be more effective than policies
that mandate health IT use to obtain public health goals. This is especially likely given
that nursing homes who implement technology often do so without pertinent information,
and most likely therefore make satisficing decisions rather than optimizing decisions, 361
which reduces the potential effectiveness of health IT in their facilities.
The apparent absence of information symmetry on health technologies may
influence the perception of its usefulness. As evident from some of the adopters
described in this study, belief of peers’ and competitors’ successful implementation of
health IT led to their implementation with little regard to the system’s perceived use or
adaptability. As a consequence, these nursing homes are yet to realize the outcomes of
their investments. This study also suggests that nursing homes are a different facet in
the health care industry and serve a different clientele, so the results of health IT
studies in other industries may not carry over to the nursing home setting. Moreover,
the variations of care services within this industry could inhibit the full potential of
health IT. A policy approach that includes the encouragement of customized software
development could improve health IT outcomes in this industry.
While it is difficult to generalize the findings from six cases, it can be suggested that
overall, there is lack of entrepreneurship and risk-taking within this industry. This
may be because the nursing profession includes employees and administrators whose
focus is on the care of their clients, not innovation. Furthermore, since long-term
care facilities serve old or frail vulnerable adults who cannot care for themselves, the
human element in care provisions is more important than the use of technology.
While technology can make facets of care giving efficient, for instance, record
maintenance and response to accidents, the effectiveness component is yet to be
realized in long-term care facilities. The expectation that health IT will result in
streamlining of paper-based processes, and the transformation to a wholly technology
assisted process is not fulfilled. We also found that paper usage after implementation
of health IT has not decreased. Rather, certain functions such as nurse’s notes were
often duplicated in paper due to fear of machine problems.
Overall, the administrators demonstrated a sanguine view of the health IT systems
in nursing facilities. There is much hope that initiatives in some nursing homes will
assist in experiencing the full potential of the health IT systems because the safety and
accountability features are beneficial in some organizations. This hope, however, may
be misplaced since it is not accompanied with a systematic plan to action to address the
limitations of current systems and base future implementation systems on objective
data. It instead appears to be based on an almost ideological belief in the superiority
of electronic systems with inadequate attention to considering optimal systems.
Systems were implemented for improving the efficiencies of the administrative and
clinical functions, with insufficient attention to some critical aspects of the process of
implementation that includes assessing the ease of use of the technology by the actual
users and its operability with the facility’s existing technology. In other nursing homes,
a dogmatic belief in the futility of health IT appears to hamper even the consideration
of practical innovations. As indicated by TAM, the perceived usefulness of the
technology systems is playing a large role in whether the systems are being used, but
the perceived usefulness of the system in the perception of the person making the
adoption decisions (the administrator) often appears disconnected from the perceived
JHOM usefulness of the system in the eyes of its actual users. This disconnectedness was
28,3 apparent in several instances and is attributable to the absence of information
symmetry between the decision makers and the actual users. In addition, the ease of
use of the system is rarely factored in to the decisions on adoption, which when ignored
could lead inefficiencies and ineffectiveness in organizations.
Future comparative and evaluative studies on the nursing homes that implement
362 advanced health IT might shed light on the actual benefits, and thereby provide
scholars and practitioners with evidence-based knowledge on health IT utilization.
Also important is the access to information in real time and subsequent control by the
administrators. Future research might also explore the concept of information
symmetry in greater depth. This concept has been relatively under-researched in the
past, which is surprising, considering its potential impact on adoption and use. The
findings from this exploratory study suggest that little information on health IT is
available to decision makers. Undoubtedly, this will influence perceived benefits of the
health ITs that will overcome the challenges of system integration and slow usage
issues, and ultimately, acceptance and adoption.
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About the authors

Dr Karabi C. Bezboruah is an Assistant Professor, and has research interests in organizational
changes, decision-making, resource generation, and general management of public organizations.
Her research in health organizations and heath care includes exploring ideas and issues using Management
rigorous multi-step qualitative methodologies. Dr Karabi C. Bezboruah is the corresponding author
and can be contacted at: bezborua@uta.edu
attitudes
Dr Darla Paulson is an Assistant Professor with research interests in micro and macro human
resources management. Most of her prior research focusses on the health care industry and the
public and nonprofit sectors.
Jason Smith is a Graduate Student with research interests in organization theory and information 365
technology management.

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