New technologies are frequently being adopted by healthcare organizations in order to try to improve the quality and efficiency of healthcare [1
]. The picture archiving and communication system (PACS) is an example of such a technology. A PACS is a medical image management information system which manages medical images and integrates equipment through a network. Such a system allows digital images to be stored in a database and retrieved using a file management server, to be transmitted using computer networks, to be displayed at various resolutions to users with different requirements, and to be analyzed and processed as a reference for medical treatment. It is now common for a PACS to be integrated as a module within a wider Radiology Information System (RIS) or Hospital Information System (HIS) [1
]. Users of a PACS include technologists, image library personnel, radiologists, physicians/clinicians, and nurses.
The tangible benefits of a PACS (cf. film-based systems) are well established and numerous, and include ([1
]): improving the operational efficiency and productivity of the medical image service; allowing the availability of images anytime and anywhere; reducing waiting times for image retrieval and turn-around times of clinical reports; attaching scans to patients’ electronic health records; scheduling the use of radiology equipment more efficiently; facilitating long-distance consultations; providing auxiliary tools to support image diagnosis; and improving hospital workflow, with subsequent benefits for patient care. Intangible benefits include increased satisfaction with the service on the part of radiology staff and referring physicians, and increased satisfaction of patients with their care [5
Overall, the advent of PACSs has resulted in a dramatic simplification of image management for host health organizations. However, PACS implementation and adoption, like many other healthcare IT implementations [2
], represents a major change in a healthcare organization and has proved to be a substantial challenge to many such healthcare organizations [3
]. Managing change to overcome clinician resistance and increase acceptance may pose a significant obstacle to any successful IT adoption, including that of a PACS [3
]. The best and most expensive IT system will be ineffective if it is resisted by its users. Given the anticipated expanded application of IT systems in healthcare and the increasingly large financial and other resources being allocated to them [1
], then human factors, including user acceptance, become even more important. Or, as Ward et al. [11
] put it, “the factors which influence staff attitudes towards [the IT systems] become increasingly significant if the investment is to be worthwhile” (p.93). In the case of PACSs, the global market is forecast to increase from $2.8 billion in 2012 to $5.4 billion in 2017 [12
]. The Middle-East market for PACSs-RISs was estimated at $86 million in 2009 and could grow to $140 million by 2014 [13
]. The number of hospitals with PACSs or RISs in the Middle-East was 984 in 2010 and is set to increase to 1680 by 2014. In 2009, one-third of PACS installations in the region took place in Saudi Arabia.
Given the levels of investment associated with the adoption of PACSs, and the need to gain as much benefit from the systems as possible, the importance of user acceptance to the success of PACS implementations in health organizations is clear. Various studies have investigated the determinants of behavioral intention (acceptance) with respect to IT implementation [11
]. Several different types of model have been developed to study IT acceptance, including the Technology Acceptance Model (TAM), the Diffusion of Innovation model, the Information Systems Success model, the Social-Cognitive Theory model, and the Task-Technology Fit model [17
]. This study uses a variant of the TAM of Davis [21
] to assess the behavior (acceptance) of staff with respect to the host PACS in King Abdulaziz Medical City (KAMC), a hospital in Riyadh, Saudi Arabia. The TAM (and its variants and extensions) has been shown to be appropriate for evaluating user acceptance behavior toward IT systems, including in the healthcare setting [14
]. Holden and Karsh’s review [22
] found 16 datasets in more than 20 studies where the TAM (or a variant or extension thereof) has been applied to clinician use of health IT.
Despite the importance of PACSs for healthcare organizations, the large financial investments involved, and the increasingly widespread use of these systems, there have been surprisingly few investigations into users’ acceptance of this healthcare technology. Published studies of aspects of PACS acceptance include those of Pare and Trudel [3
], Duyck et al. [6
], Hurlen et al. [7
], Bramson and Bramson [10
], Duyck et al. [23
], Pare et al. [24
], Pynoo et al. [25
], and Duyck et al. [26
]. However, of those, only five studies ([6
]) used a model of technology acceptance to quantitatively investigate PACS acceptance, and as three of the studies ([6
]) used the same questionnaire survey database, just three unique databases are represented in the literature prior to this study. The number of studies of PACS acceptance therefore is remarkably small compared with the widespread, and increasing, use of the system. This study additionally represents the first investigation of PACS acceptance using a TAM (or variant/extension thereof) to be performed in a hospital in an Arab country.
The technology acceptance model (TAM)
Derived in its original form from the theory of reasoned action (TRA) [27
], the TAM explains how users accept and use a technology (Figure ). Developed by Davis [21
], the model regards two acceptance measures as the primary determinants of behavioral intention to use technology: (1) Perceived usefulness (PU), defined as "the degree to which a person believes that using a particular system would enhance his or her job performance”; and (2) Perceived ease of use (PEU), defined as "the degree to which a person believes that using a particular system would be free from effort" ([21
], p.985). The model proposes that PEU has a causal effect on PU, and that each of these has an influence on the user’s attitude towards use; both PU and attitude toward use influence behavioral intention (acceptance), which in turn influences usage [17
The technology acceptance model (TAM) of Davis .
The original TAM was extended (to create TAM2) [28
] by adding some additional drivers of PU and PEU, including theoretical constructs of social influence processes and cognitive instrumental processes. There have also been attempts to enhance the explanatory power of the TAM [15
] by adding antecedent, mediating, and moderating variables to explain acceptance behavior in different settings. Lee et al. [16
], in their review of the TAM, found that more than 20 different factors have been introduced into various versions of the model, including constructs representing education level, computer expertise, voluntariness, fit between user and system design features, management support, and socio-demographic variables. A later extension of the TAM was formulated by Venkatesh et al. [19
] as the Unified Theory of Acceptance and Use of Technology (UTAUT). The UTAUT incorporates four direct determinants of behavioral intention (acceptance), which are performance expectancy (equivalent to PU), effort expectancy (equivalent to PEU), social influence, and facilitating conditions. The model also contains four moderating variables (experience, voluntariness, gender, and age) that have been found to be significant in some studies of technology acceptance.
Specific to the healthcare context, Holden and Karsh [22
] found in their overview of healthcare-related TAM studies that almost all such studies had added variables to the basic TAM in an effort to better understand the antecedents of health IT acceptance or usage behavior. These variations have been added “to account for the complexity of healthcare’s socio-technical systems” ([22
], p.166). Topics in healthcare have included the acceptance of telemedicine, electronic health records systems, computerized physician order entry systems, mobile healthcare systems, and PACSs [15
This study uses a variant of the TAM of Davis [21
] to assess the acceptance of the host PACS by radiology staff at KAMC, Riyadh, Saudi Arabia. The specific objectives of the study are: 1) To assess radiology user acceptance (behavior) regarding the PACS in the radiology department at KAMC, in Riyadh, Saudi Arabia; 2) To determine the extent to which three constructs (perceived usefulness, perceived ease of use, and change) influence user acceptance; and 3) To determine whether user acceptance is explained by socio-demographic variables.