Electronic Health Records Assimilation and … et al.: Electronic Health Records Assimilation and Physician Identity Evolution Information Systems Research 23(3, Part 1 of 2), pp

Information Systems ResearchVol. 23, No. 3, Part 1 of 2, September 2012, pp. 738–760ISSN 1047-7047 (print) � ISSN 1526-5536 (online) http://dx.doi.org/10.1287/isre.1110.0407

© 2012 INFORMS

Electronic Health Records Assimilation andPhysician Identity Evolution: An Identity

Theory PerspectiveAbhay Nath Mishra

Robinson College of Business, Georgia State University, Atlanta, Georgia 30303,[email protected]

Catherine AndersonSchool for Continuing and Professional Studies, University of Virginia, Falls Church, Virginia 22043,

[email protected]

Corey M. AngstMendoza College of Business, University of Notre Dame, Notre Dame, Indiana 46556,

[email protected]

Ritu AgarwalRobert H. Smith School of Business, University of Maryland, College Park, Maryland 20742,

[email protected]

With the lack of timely and relevant patient information at the point of care increasingly being linked toadverse medical outcomes, effective management and exchange of patient data has emerged as a strategic

imperative for the healthcare industry. Healthcare informaticians have suggested that electronic health recordsystems (EHRS) can facilitate information sharing within and between healthcare stakeholders such as physicianpractices, hospitals, insurance companies, and laboratories. We examine the assimilation of EHRS in physicianpractices through a novel and understudied theoretical lens of physicians’ identities. Physician practices andthe physicians that lead them occupy a central position in the healthcare value chain and possess a numberof unique characteristics that differentiate them from other institutional contexts, including a strong sense ofaffiliation with other physicians, potent professional identities, and a desire for autonomy. We investigate twosalient physician identities, those of careprovider and physician community, grounded in the roles physiciansplay and the groups with which they affiliate. We argue that these identities and their evolution, triggered byEHRS, manifest as both identity reinforcement and deterioration, and are important drivers of EHRS assimila-tion. We use survey data from 206 physician practices, spread across the United States, to test our theoreticalmodel. Results suggest that physician community identity reinforcement and physician community identitydeterioration directly influence the assimilation of EHRS. We further find that the effects of careprovider identityreinforcement and careprovider identity deterioration on EHRS assimilation are moderated by governmentalinfluence. Theoretical and pragmatic implications of the findings are discussed.

Key words : assimilation; careprovider identity; EHR; electronic health records; health informatics; health IT;identity deterioration; identity reinforcement; identity theory; physician community identity; physicianpractices; professional identity; role identity; self-categorization theory; social identity; social identity theory

History : Anandhi Bharadwaj, Senior Editor; Radhika Santhanam, Associate Editor. This paper was received onNovember 2, 2011, and was with the authors 14 months for 4 revisions. Published online in Articles inAdvance April 18, 2012.

IntroductionIn nothing do men more nearly approach the gods thanin giving health to men.

—Cicero

The medical profession occupies a unique positionin society. For centuries, physicians have been heldin great esteem for the consequential services theyprovide and have carved a special status for them-selves because of the nature of their work—savinglives. They have also garnered substantial respect

from others by virtue of their specialized training,and endowment of esoteric skills and knowledgenot available to most. Increasing specialization of theoccupation of medicine has not only created a com-munity with strong professional bonds that is rela-tively impervious to external pressures or control butalso resulted in physicians enjoying unprecedentedlevels of autonomy and independence in the conductof their work (Freidson 1994). As a consequence oftheir close affiliation with a professional community

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Mishra et al.: Electronic Health Records Assimilation and Physician Identity EvolutionInformation Systems Research 23(3, Part 1 of 2), pp. 738–760, © 2012 INFORMS 739

and a well-defined delineation of their function insociety, physicians have developed powerful identi-ties that guide their sensemaking and enactment ofthe environment (Weick 1995). It is these identitiesand their evolution that we suggest are central tounderstanding physician decision making and behav-ior in the healthcare industry (Real et al. 2009).

Recently, in response to growing concerns about ris-ing costs and poor quality in healthcare delivery inthe United States, the independence and autonomy ofthe medical profession has been threatened, with thegovernment seeking to nudge physicians in directionsthat promise to streamline and transform healthcaredelivery by encouraging a greater use of technology.Although the healthcare profession has a longstandingtradition of using medical technologies, informationtechnology (IT) adoption and use by clinicians andcare-delivery organizations for the storage, manage-ment, and exchange of patient information is still rel-atively limited (DesRoches et al. 2008, Jha et al. 2009).Hence, there is considerable interest among U.S. pol-icymakers to use various policy levers to enhance theuse of IT for patient care. To this end, the AmericanRecovery and Reinvestment Act (ARRA) of 2009 pro-vides sizeable financial incentives for physicians whoadopt and demonstrate “meaningful use” of elec-tronic health records (ARRA 2009) and disincentivesif they fail to do so by 2015.

An electronic health record (EHR) system consti-tutes a key enabling technology that facilitates thecreation and sharing of patient information in thehealthcare delivery system. EHR systems (EHRS) arethe software platforms that physician offices and hos-pitals use to create, store, update, and maintain elec-tronic health records for patients. They represent theprimary mechanism through which the much-desiredinteroperability of health information can take placesuch that stakeholders are able to seamlessly share,exchange, and access relevant patient data (Shortliffe1999). Additionally, whereas earlier clinical informa-tion systems, such as those for laboratory results,pharmacy, and picture archiving and communica-tion, focus on specific tasks or departments within ahospital, EHRS have the potential to integrate var-ious systems and serve as a platform technology.To the degree that EHRS exhibit considerable valuepotential, and in light of the fact that EHRS assim-ilation is low in the U.S. healthcare sector (Angstet al. 2010, Audet et al. 2004, Miller et al. 2005), itis important to understand the dynamics underlyingthis phenomenon.

In this paper we investigate the assimilation ofEHRS, i.e., the extent to which EHRS use is inte-grated with the care delivery process and becomesroutinized in the activities associated with the pro-cess (Chatterjee et al. 2002) in physician practices.

Although a robust body of research in informa-tion systems (IS) has narrated, explained, and pre-dicted IT adoption and use, the healthcare indus-try exhibits unique characteristics that constrain itsability to implement technological innovations suc-cessfully, requiring greater attention to, and deepertheorizing about, how industry dynamics alter thenature of IT-related decisions, activities, and outcomes(Chiasson and Davidson 2005, Nembhard et al. 2009).Indeed, features of EHRS, when coupled with theidiosyncrasies of a health system that is character-ized by strong physician identities and a complex webof connections between physicians and other stake-holders, create a context that necessitates a refram-ing of traditional adoption models (Attewell 1992,Bharadwaj 2000).

Physician practices represent a key link in the care-delivery process because they typically have the firstencounter with a patient, maintain the relationshipfor a considerable length of time, and are responsiblefor the vast majority of care-delivery and healthcarespending, thus occupying a significant position in theU.S. healthcare system (Burns 2002, Schoen et al. 2006,Sirovich et al. 2008). The capture, storage, and man-agement of patient information through EHRS assim-ilation at the practice level is a critical prerequisite toensuring that the information can be integrated withthat of other stakeholders. Despite its importance,IT assimilation in physician practices has not beenexamined in detail in the literature (DesRoches et al.2008). We approach the focal phenomenon througha distinctive and understudied theoretical lens: thatof physician identities. Our motivation for the useof an identity lens is grounded in a rich literaturethat implicates identities as proximal and potent influ-ences on perceptions, emotions, and behavior (Stetsand Burke 2000, Swann et al. 2009), supplemented byour extensive fieldwork with physicians. Identity isfundamentally the social fact of “how an individualself-defines him- or herself” (Pratt et al. 2006, p. 236)that acts as a sensemaking filter through which theenvironment is assessed and drives the acts in whichthe individual will engage, such as the use of techno-logical innovations.

Identity theories isolate two distinctive forms ofsocial aspects of identity: role identity and social iden-tity (Hogg et al. 1995, Stets and Burke 2000). Theformer is a construal of a particular role that theindividual plays (e.g., a scholar, an advocate, a con-sultant) and entails not only performing tasks associ-ated with the role but also attempting to control theresources for which the role has responsibility. The lat-ter, social identity, involves identification with a socialcategory and acceptance of the values and norms

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Mishra et al.: Electronic Health Records Assimilation and Physician Identity Evolution740 Information Systems Research 23(3, Part 1 of 2), pp. 738–760, © 2012 INFORMS

of the group (Stets and Burke 2000). Although dis-tinct, individuals’ role and social identities are simul-taneously active and influence actions taken by them(Stets and Burke 2000).

Physicians’ role and social identities together con-stitute their professional identity, which is a reflectionof their enactment of a role and their self-definitionas a member of a profession (Chreim et al. 2007). Welabel the professional role identity of physicians as thatof a careprovider. In this identity, physicians view them-selves as central to patient treatment and considerthemselves an integral part of the physician practicewhere patients receive care (Chreim et al. 2007, Prattet al. 2006). The physician practice setting is character-ized by an established hierarchy in which the physi-cian is regarded as the source of expertise and allother members, such as nurses and technicians, deferto this expertise (Nembhard et al. 2009), further rein-forcing the careprovider role identity of the physician(Lichtenstein et al. 2004). Patients reaffirm this identitywhen they rely on their doctors to “make them better.”We call the professional social identity of physicians, inwhich they view themselves a part of the extendedcommunity consisting of physician practices, hospi-tals, and other medical professionals, as physiciancommunity identity. Years of stringent medical train-ing followed by grueling rotations typically fostera strong sense of “profession” among physicians(Freidson 1994, Pratt et al. 2006). This communityidentity consolidates their association with “referenceothers,” which represents a collective aspect of self,has a strong influence on self-definition, establishesthe value significance of the professional group, andseparates their collective from other groups (Brickson2005, Foreman and Whetten 2002).

Identity scholars have noted that role and socialidentities are malleable and can evolve. Environmentalshifts such as rapid technological changes can engen-der significant role transitions and identity modifi-cations, including both identity reinforcements anddeteriorations, and cause individuals to take actionthat promotes identity maintenance (Chreim et al.2007, Ibarra and Barbulescu 2010). Tripsas (2009)persuasively argues that although identity and itsevolution are critical to understanding organiza-tional innovation, extant research has largely ignoredtheir relationships. In the context of EHRS, althoughimpending changes have been widely discussed, nowork that we are aware of has investigated per-ceived changes to physician identity and EHRS use.However, the fact that physician identities are likelyto be affected by EHRS is implicit in the literature.Research suggests that the introduction of EHRS inthe physician practice entails a significant strategicchange that can transform clinical workflows, infor-mation availability, and doctor-patient relationships,

thereby challenging identity. Yet the ease of informa-tion access enabled by EHRS can also enable physi-cians to perform their tasks more competently andefficiently, thus reinforcing identity (DesRoches et al.2008, Fiks et al. 2011, Ford et al. 2009, Jha et al. 2009).

We consider the role and social identities of physi-cians, draw upon and extend the concepts of identityreinforcement and deterioration, and examine theirinfluence on EHRS assimilation. Despite significanttheoretical work in social identity, identity enhance-ment and threat are understudied in extant literature(Tripsas 2009), and empirical work examining identityand identification is limited (Foreman and Whetten2002). Finally, although identity theories have beenapplied in a variety of contexts, including health-care (Brewer and Gardner 1996, Dukerich et al. 2002,Johnson et al. 2006, Pratt and Foreman 2000, Real et al.2009), they have yet to be utilized to study IT-relatedphenomena. In this paper, we address these theoret-ical and empirical gaps in the literature. Groundedin identity theories, we conceptualize physician iden-tity reinforcement and deterioration and develop aresearch model that investigates EHRS assimilationthrough the lens of identity. We draw upon the medi-cal informatics literature to inform our understandingof the healthcare context. Acknowledging the highlyvisible and active role of a key stakeholder in health-care technology policy, the government, we examinethe moderating effect of governmental influence onthe relationship between the physician’s perceptionsof reinforcements and threats posed to his/her care-provider identity and EHRS assimilation. We suggestthat this powerful stakeholder is likely to conditionthe actions physicians take in response to perceivedrole identity reinforcement and deterioration, butnot social identity reinforcement and deterioration,because as members of a professional community,physicians enjoy protection from external threats notavailable to them as individuals. We empirically testour research model using physician practice-level sur-vey data obtained from key informants represent-ing 206 physician practices spread across the UnitedStates.

Theoretical BackgroundTechnology adoption and use has attracted signifi-cant attention from the academic community and hasbeen studied from a variety of theoretical perspec-tives, such as diffusion of innovations (Premkumaret al. 1994), the technology acceptance model and itsextensions (Davis 1989, Kim 2009, Ortiz de Guineaand Markus 2009, Venkatesh and Davis 2000),learning (Attewell 1992), institutional theory (Teoet al. 2003), social exchange theory (Hart andSaunders 1997), knowledge- and resource-based views

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(Armstrong and Sambamurthy 1999), rational eco-nomics (Brynjolfsson and Kemerer 1996) and powerand politics (Markus 1983). Some of these theoreti-cal lenses have been applied in the past decade toinvestigate various aspects of health IT adoption anduse, the majority of which has appeared in healthinformatics journals. We briefly review the existingstate of research on health IT adoption in IS and themedical informatics literatures. This is followed bya discussion of identity theories and their applica-tion to unique aspects of the healthcare context. Wethen describe our research model and develop specificresearch hypotheses.

Healthcare IT Adoption and UseIS and organizational science research involvinghealth IT has typically examined use in a case studycontext. For example, examining computerized physi-cian order entry at an acute care hospital, Davidsonand Chismar (2007) found that institutional and tech-nology changes triggered processes facilitating theeffective use of IT. Investigating the implementationof two clinical information systems in three Canadianhospitals, Lapointe and Rivard (2005) found thatphysician resistance to IT increased as the perceivedthreat shifted from one involving solely individual-level conditions to one involving group-level initialconditions, providing evidence for physician “clan”culture. The resistance exhibited by physicians whena threat was perceived to be an individual-levelcondition was essentially uncoordinated, but resis-tance among physicians converged once a group-level condition materialized (Lapointe and Rivard2005). The presence of a clan culture was also high-lighted by Kohli and Kettinger (2004), who studiedthe implementation of a physician profiling systemin a community hospital in the United States. Theysuggest that informating the clan becomes legitimizedthrough both internal and external influences. In sub-sequent work, Lapointe and Rivard (2007) arguedfor the need to explore alternative yet complemen-tary models of implementation, which may operateat different levels; focus on more than one key phe-nomenon; and examine a variety of antecedents tocompensate for the limitations of existing researchthat focuses on a single level, a unitary phenomenon,and one set of antecedents. Collectively, althoughconducted in settings other than physician practices,these studies provide insights into IT adoption anduse in the healthcare industry and underscore theimportance of physician perceptions, technologicalcharacteristics, and the external environment.

In contrast to the IS literature where investigationsat the level of the physician practice setting are lim-ited, the medical informatics literature reports sev-eral case studies and surveys addressing barriers and

facilitators of EHRS adoption and use (e.g., Milleret al. 2005, Ventres et al. 2006). The majority of infor-matics research comprises large-scale, survey-baseddescriptive studies that examine the effects of variousfactors on adoption decisions (e.g., DesRoches et al.2008, Miller and Sim 2004, Simon et al. 2007b) orthe functions for which the EHRS are used (Hsiaoet al. 2008). Findings suggest that larger practicesand those located within a hospital are more likelyto adopt (Simon et al. 2007b). Commonly cited bar-riers to adoption include high financial costs, per-ceived losses in productivity, and physician attitudetoward technology (Miller and Sim 2004, Simon et al.2007b). Although informative, these studies are nev-ertheless not theoretically grounded, nor do theyexplore the complex determinants that are likely toexist in a dynamic professional, environmental, andorganizational setting (Angst et al. 2010, Kazley andOzcan 2007).

Our review reveals that although prior researchhas examined IT adoption and use in considerablebreadth and depth, important opportunities exist forextending it in the context of the healthcare industry.In particular, examining the ambiguities and uncer-tainties inherent in a transformational technologysuch as EHRS, the consequent sensemaking physiciandecision makers need to engage in, and their per-ceptions about how their careprovider and physiciancommunity identities may evolve as a result of EHRSoffer a rich opportunity to extend the literature.

Identity Theories and Physicians’ IdentitiesThe psychology literature defines identity as a cog-nitive construct of the self, which answers the ques-tion, “Who am I?” (Hogg 2001, Kreiner et al. 2006).Personal identity focuses primarily on the individu-ated self or characteristics of an individual that sep-arate him/her from others. Researchers have notedthat in the contemporary world, however, when indi-viduals define themselves based on their membershipin various collectives such as organizations and pro-fessional groups and attach a significant importanceto these associations (Dukerich et al. 2002), such a sin-gular focus on individuals is frequently at odds withobserved behavior in collectives (Turner and Onorato1999). Accordingly, researchers in social psychologyhave conceptualized social identity as “what definesus?” to examine the individual as a member of a col-lective and to explain actions and behaviors by suchcollectives (Tajfel and Turner 1979).

Extant literature discusses two manifestations of thesocial aspects of self—role identities and social iden-tities (Hogg et al. 1995, Stets and Burke 2000). Roleidentities refer to specific roles people perform, dis-tinguish a particular role from others, and providemeaning for self. Roles do not exist in isolation; rather,

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others respond to them and reinforce the basis forself-definition (Hogg et al. 1995). Role identities com-prise meanings that emerge in the form of expecta-tions regarding people’s own and others’ behavior(Stets and Burke 2000). Social identities, in contrast,are derived from the social categories or collectivesto which one belongs (Hogg and Terry 2000, Tajfeland Turner 1979). Such associations provide membersan avenue to establish relationships with similar oth-ers, to differentiate between in-group and out-groupmembers, and to derive their sense of social worth(Ashforth and Mael 1989). Role and social identitiesexist and operate concurrently, i.e., people such asphysicians simultaneously occupy roles and partici-pate in professional groups, and both identities influ-ence perceptions and behavior (Stets and Burke 2000).

The notion of role-based identity draws upon thecore foundation of identity theory (Stryker 1980, Stetsand Burke 2000) that conceptualizes identity as theclassification of self as an occupant of a role, with theattendant meanings and expectations of the role andits performance. These meanings and expectationsconstitute a standard that guides behavior. A beliefthat one is enacting a role competently reinforces feel-ings of self-esteem and role-related behavior, whereasperceptions of poor role performance cause distressand diminish role-related behavior (Hogg et al. 1995).Role identity focuses on the match between individ-ual meaning ascribed to occupying a role and thebehavior that the individual enacts in that role whileinteracting with others. The assumption of a role iden-tity is accompanied by the adoption of self-meaningsand expectations to accompany the role as it relatesto others and a desire to preserve these meanings andexpectations (Stets and Burke 2000).

Social identities are theoretically anchored insocial identity theory and self-categorization theory(Foreman and Whetten 2002, Hogg 2001, Johnson et al.2006, Scott and Lane 2000) that explore how individ-uals view themselves in relation to social groups andwhether they are likely to adopt the identities of var-ious collectives (Kreiner and Ashforth 2004). Peoplecreate these associations based on perceived overlapbetween self and collectives. The larger the overlap,the more people prefer the membership of a collec-tive, and the higher the emotional and value signifi-cance of these associations. Social identities representinternalization of the identities of the collectives aspart of the self and result in psychological accep-tance of the values and norms of the collective (Scottand Lane 2000). Members evaluate such collectives,also called in-group, more positively than others andexpend efforts to establish positive distinctness forthem (Hogg 2001).

As discussed, the dual self-construals of physi-cians, i.e., their role and social identities, are fostered

by selection, education, training, and communicationprocesses (Apker and Eggly 2004). In their role as acareprovider—the most consequential and focal playerin the physician practice—physicians view themselvesas the orchestrator of care delivery and view otherssuch as nurses, pharmacists, and technicians as aidsthat follow instructions. The roles performed by otherprofessionals are called counter-roles in identity the-ory. The interactions and negotiations between rolesand counter-roles contribute to role identity creationand sustenance.

As a part of the extended physician community,physicians identify with their medical specialty, otherphysicians, and medical professionals as a whole(Johnson et al. 2006). In his in-depth analysis of themedical profession, Freidson (1994) characterized itas highly autonomous and controlling of the condi-tions and content of medical work. Clinicians place ahigh value on autonomy in decision making and set-ting the standards of clinical performance (Ford et al.2009) and, acknowledging the deep knowledge andexpertise required for the practice of medicine, soci-ety has typically granted this autonomy (West andBarron 1999). Moreover, the physician community’sculture is very close-knit and views external attemptsat instituting controls as an assault on its autonomy(Friedson 1994; Ford et al. 2006, 2009; Pont 2000). Thecommunity feeling is central to the organization andexperience of professional work (Adler et al. 2008).Indeed, the medical profession has been portrayed asa clan (Kohli and Kettinger 2004) where the physiciancommunity and group culture are identified as prox-imal influences of behavior. The practice of medicinealso involves a high degree of uncertainty and ambi-guity which leads physicians to rely extensively onone another and their social networks (Mano-Negrinand Mittman 2001, West and Barron 1999). In thepresence of greater uncertainty surrounding a behav-ior, attitudes and behaviors tend to be more stronglyinfluenced by peers (Bandura 1986). In the medicalfield, such peer influence has previously been foundto be an effective means of enacting changes in physi-cian clinical behavior (Lomas et al. 1991).

Both identity theory and social identity theoryexamine the social aspect of the self, with the formercasting behavior in terms of roles and the latter interms of group membership and joint norms and val-ues. Although the two theories differ in their focus—roles versus groups—and the dynamics of identityformation, to the degree that they share a commongoal of explaining social behavior, it has been rec-ommended that they be applied together in stud-ies of social behavior (e.g., Hogg et al. 1995, Stetsand Burke 2000). Such integration, however, is lack-ing in the literature. Our work addresses this gap.We note that our expectation that identity is likely to

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drive physician decision making about new informa-tion technologies in healthcare is supported not onlyby theories of social behavior but also in our extensivefieldwork that often highlighted the significance ofphysician identity in their attitudes and choices.1

Identity Reinforcement and DeteriorationAlthough identities doubtless influence behavior, theyare not immutable. Both the roles individuals per-form as well as the salience of the groups they asso-ciate and identify with are vulnerable to evolutionand change (Abdelal et al. 2006, Stets and Burke 2000).Environmental, contextual, and circumstantial shocksmay modify people’s evaluative schema, changetaken-for-granted views that are used to make senseof the world, and necessitate modifications of iden-tity and image (Elsbach 2003). These modificationscan take two forms—identities are either reinforcedor they are threatened as a result of environmentalchanges, including technological shifts (Chreim et al.2007, Tripsas 2009). Technological changes, in par-ticular, can result in fundamental modifications inworkflows, relationships, balance of power, controldynamics and current modes of cognition, and requiredifferent modes for getting tasks accomplished (Ibarraand Barbulescu 2010, Tripsas 2009). In this process, ifa person’s role or standing in the in-group is compro-mised, downgraded, or attacked, people experience athreat to their identity because such changes are con-sidered a regression or a nuisance or a discomfort,resulting in loss of status and prestige, which maynot be socially desirable (Bartel 2001). To illustrate, inan interview, commenting about the use of a palm-sized electronic prescribing device, a doctor notes, “IfI feel uncomfortable with the device—it’s too small orI don’t like where the buttons are—I’m going to beconcerned and not use it when I’m with a patient.”In this instance the use of the electronic device, in themind of the treating physician, implicitly threatenedhis role identity of careprovider because he does notknow how to use it.

Alternatively, technological developments andenvironmental changes may serve to reinforce identi-ties (Stets and Burke 2000, Tripsas 2009). When tech-nological changes enhance people’s roles and theirrelative position in a social group, and allow themto use the same cognitive schema they have used inthe past for behaviors, such modifications result inidentity reinforcement. In another interview a doc-tor noted that electronic health records are “defi-nitely much quicker. I love it 0 0 0 can’t imagine lifewithout it. It may not make me a better doctor butit can definitely cut down on errors 0 0 0handwriting,

1 The vignettes in this document were extracted from a qualitativestudy including interviews, focus groups, and onsite observations.

alerts 0 0 0 [pause] maybe it does make me a bet-ter doctor?” In our focus groups with physicians,even doctors who were unwilling to concede to theimmediate value of electronic systems acknowledgedin the presence of their peers that IT was the futureof medicine and sustained resistance was futile.

As may be expected, identity reinforcement anddeterioration yield different responses, such as iden-tity endurance and identity change, to adapt to theneeds and demands of internal and external stake-holders (Abdelal et al. 2006, Scott and Lane 2000).When there is no explicit threat or an imminentneed for self-protection, the current cognitive schemais preserved and reinforced. By contrast, when con-fronted with a threat, people use cognitive tactics tomaintain positive perceptions of their identities andtake actions to thwart or slow down the change toidentity (Elsbach and Kramer 1996). When the collec-tive identity is under threat, people selectively high-light traits and characteristics from their identitiesthat portray them and the collective in a positive light.They may also resort to highlighting another identityor to reframing the threat so it is consistent with theidentity, obviating the need for change (Tripsas 2009).

Physicians and Physician PracticesAfter social identification has occurred, either throughroles or collectives or both, there is a transition fromindividual to social identity, and although the potencyof social identity varies, it is generally more pow-erful than individual identity (Hogg and McGarty1990). Such identities are particularly strong for topmanagers and owners of organizations (Johnson et al.2006, Scott and Lane 2000). In an organizational con-text, top managers’ identities tend to overlap sig-nificantly with the organizations they lead (Prattand Foreman 2000). This is especially true for own-ers of small organizations where the owners iden-tify almost entirely with their organization (Johnsonet al. 2006). Thus, it is entirely possible for peopleto ignore external changes and take steps to reducethe perceived threat to the identity because of vestedpower interests, biased cognition, inertia, and a pref-erence for dominance and autonomy (Abdelal et al.2006, Scott and Lane 2000). Additionally, during peri-ods of change and turbulence, which are charac-terized by uncertainty, ambiguity, and reservationsabout the appropriate action, top management per-forms the critical task of sensegiving (Fiss and Zajac2006). Organizational “elites” routinely play the cen-tral role in managing identity by shaping the beliefsof the entire organization (Pratt and Foreman 2000),as evocatively illustrated during a field visit to a urol-ogy practice in a midwestern U.S. town. Commentingon the physician practice-owner and his perception ofEHRS, a certified medical assistant observed, “It’s not

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more work, it’s just ‘different work’ [pause] 0 0 0but heis the boss,” suggesting that the view of the physicianis likely to prevail at the level of the practice.

In physician practice settings, physicians are con-sidered the authoritative source of knowledge that iscritical to providing better care to patients; they arethe key actors in these knowledge-intensive organi-zations. Healthcare organizations such as physicianpractices are prototypical professional bureaucracieswherein much decision-making power and auton-omy is granted to the operating core—the physicians(Lapointe and Rivard 2007). Others employed in thepractice, such as staff assistants, nurses, and tech-nicians, simply complement the physician’s perfor-mance; they do not generate direct revenues (Adleret al. 2008). To the degree that physicians’ roles inpatient care are dominant to the counter-roles playedby nurses, technicians, and administrators, they areuniquely positioned to exert a significant amount ofinfluence on the practice. Additionally, because of thehierarchical structure of physician practices, the opin-ions of physicians and physician owners carry signif-icant weight (Johnson et al. 2006), suggesting that thecognitive schema and identity of the physicians arelikely to be represented in the actions and behaviorsof the physician practice. Furthermore, in comparisonto the sporadic nature of interactions that occur in

Figure 1 Identity Model of EHRS Assimilation in a Physician Practice

Careprovider identity

Physician communityidentity

Perceivedcareprovider

identityreinforcement

Perceivedphysician

community identityreinforcement

EHRSassimilation

ControlsPosition, gender, age,number of physicians, staff skill,IT infrastructure, patient techsavvy, cost concerns

Perceivedphysician

community identitydeterioration

Perceivedcareprovider

identitydeterioration

H4: –

H3: +

–

H2: –H1: –

+

Perceivedgovernment

influence

larger hospitals between various medical profession-als, the interactions between physicians and nurses,technicians, and other support staff, through complexworkflows, are more frequent, intimate, and intense,providing numerous opportunities for physicians toinfluence the opinions of others. These exchangesfacilitate the coalescence of perspectives toward theone held by the physician.

In summary, our synthesis of extant research sug-gests that EHRS assimilation in physician practicesis likely to be determined by physicians’ assessmentof how EHRS will change the care-delivery pro-cess and the characteristics and attributes consideredimportant for the in-group of medical professionals.Physician sensemaking about whether such changesreinforce or threaten their social and role identitiesthen serve as key drivers of technology use behaviors.

Research Model and HypothesesOur research model is illustrated in Figure 1.The model depicts the relationship between EHRSassimilation in physician practices, the evolution inphysicians’ role and social identities, and govern-mental influence. Consistent with the recommenda-tions of researchers in organization theory and ISthat the implementation aspects of new practices andinnovations be studied rather than simply adoption,

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(Ansari et al. 2010, Jasperson et al. 2005), the focaloutcome of interest is EHRS assimilation in physi-cian practices. Notably, we examine how physicianpractices that adopt an EHR system assimilate it toaccomplish various clinical tasks. We conceptualizethe antecedents of assimilation as perceived reinforce-ments and deteriorations to the two focal identi-ties, careprovider and physician community, evokedby EHRS. Additionally, we examine the moderatingrole of governmental influence on the relationshipbetween careprovider identity constructs and EHRSassimilation. We develop specific hypotheses in thenext section.

Careprovider IdentityPerceived Careprovider Identity ReinforcementPerceived careprovider identity reinforcement repre-sents the belief among physicians that the imple-mentation of EHRS will enable them to retain andstrengthen their autonomy and dominant role in thecare-provision process. Physicians, in general, con-sider themselves to be knowledgeable and compe-tent (Chreim et al. 2007, Pratt et al. 2006) andbelieve that they are central to many of the accom-plishments taking place in the physician practice.Additionally, because of their unique and complexknowledge and almost complete autonomy in patienttreatment regimens, they drive a significant propor-tion of healthcare decisions and stake a claim onpatient outcomes. Thus, to the extent that an EHRsystem is believed to augment physician roles, pro-tect resources vital for these roles, enhance their self-perception of competence, and complement physicianknowledge, physician practices are likely to be moti-vated to assimilate EHRS.

In the process of providing patient care, physiciansperform two key activities—information retrievaland information synthesis and diagnosis (Claytonet al. 2005). Because of their unique knowledge andskills, physicians’ time is a highly valued and scarceresource and indeed is priced as such in the market.The optimal use of a physician’s human capital isin the delivery of care. In traditional paper-basedsettings, a considerable amount of time is wastedon information retrieval from disparate systems andpaper documents. EHRS enable physicians to accessall the medical information about patients efficientlyat one place, thereby enabling them not only toretain control of information resources but also touse their time more effectively for synthesizing thisinformation, diagnosing patient problems, and deter-mining treatment regimens for them. Additionally,by relinquishing routine components of their roleand delegating patient education activities to otherprofessionals such as nurses and technicians, physi-

cians can use the released time to undertake complexproblems that provide opportunities for professionalgrowth and where their expertise is most needed(Ibarra and Barbulescu 2010), thereby augmenting thecareprovider role.

From the perspective of patients, the physician isstill the source of information—it is the physician whoexplains to the patients what different disease condi-tions entail, what test results mean, what medicinesthey need to take, and what precautions are neces-sary for them. From the perspective of nurses, tech-nicians, and pharmacists, it is still the physician whodrives decisions regarding tests, medicines, and surg-eries. To the extent that the use of an EHR systemmay make the physicians less dependent on nursesand administrative staff for information retrieval andprovide them with additional time to enable the pro-vision of more effective and efficient care to patients,their image and identity of being a competent, knowl-edgeable, and autonomous careprovider should beenhanced. As noted in identity theory, individualsseek to maintain and preserve role identity and willengage in actions that enable this. Thus we expectperceived careprovider identity reinforcement to bepositively related to EHRS assimilation.

Perceived Careprovider Identity DeteriorationPerceived careprovider identity deterioration is reflec-tive of the belief among physicians that the imple-mentation of EHRS will compromise their autonomyand dominant role in the care-provision process.According to Elsbach and Kramer (1996), individualsmay feel threatened when the central and distinctivedimensions of their roles or perceived positional sta-tus is devalued. When the status quo is changed dras-tically, individuals experience anxiety and identityconflict. The dissonance may arise not only from hav-ing to learn new ways to perform tasks but also fromrelinquishing certain desirable features of the old role.However, when a person’s identity is threatened, hisor her primary self-defensive goal is to affirm theintegrity of the self rather than seek ways to resolvethe particular threat (Elsbach 2003). Bartel (2001) sug-gests that in such circumstances, people are likelyto activate a prevention focus and engage in con-certed efforts to preserve the desirable features of theidentity.

A change that assaults the very fabric on whichphysicians base their identity—autonomy andcompetence—and questions or modifies their role inthe care-delivery process is likely to induce substantialidentity threat. Many researchers have suggested thatthe introduction of an EHR system entails significantclinical and administrative changes in physicianpractices and transformations in the way care deliverywould take place (DesRoches et al. 2008, Ford et al.

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2009, Jha et al. 2009), signaling to physicians that theirrole identity may be altered significantly. There hasalso been speculation that because physicians wouldneed to use a handheld device or a computer toenter and access information, they would not be ableto focus on the patient and discuss their problemsand treatment options, resulting in adverse patientreactions, including dissatisfaction (DesRoches et al.2008, Ford et al. 2009, Jha et al. 2009). One physiciannoted, “I still write a lot of paper scripts. When I’min an exam room, I write things on paper. I don’twant the device in the room. I’m very old-fashioned.I walk out of the exam and enter a script and thengive it to my assistant to enter. I don’t want mypatients waiting for me.” Another doctor stated, “Mypatients are used to it. But sometimes patients stoptalking when I’m working on the computer in theexam.”

Finally, there may be some fear among physiciansthat the introduction of a technology that can accesspatient data and match it with the latest treatmentoptions available threatens the very foundation onwhich their identity is predicated—the exclusive own-ership of valued knowledge and skills—and mayrender them obsolete. These changes may appear tocompromise physician-patient relationships and chal-lenge the control physicians have over patient treat-ment, thereby adversely impacting their careprovideridentity. Dissatisfaction with a role leads professionalsto redefine it and to take proactive measures to mod-ify the role and circumstances to preserve identity.As discussed earlier, when confronted with threats,physicians are likely to reject activities perceived asdetracting from their careprovider identity, thus pre-serving the status quo and safeguarding their auton-omy and source of power. We therefore expect thatperceived careprovider identity deterioration will benegatively related to EHRS assimilation.

The Moderating Effect of Governmental InfluenceOne of the limitations of identity theory is thatalthough it acknowledges the importance of othersin identity formation and subsequent behavior, itunderplays the influence of the immediate larger con-text (Chreim et al. 2007, Hogg et al. 1995), attribut-ing identity evolutions predominantly to changes inrole positions. Identity theory pays relatively lim-ited attention to the roles, identities, and behav-iors of external stakeholders (Stets and Burke 2000).We believe that in the context of healthcare pro-vision in the United States, one particular externalstakeholder—the government—may have a signifi-cant influence on the possible options available tophysician practices and their subsequent behaviors.

The healthcare industry is among the most reg-ulated sectors in the United States. Different orga-nizations with varied jurisdictions, missions, and

affiliations wield influence and often chart the futurecourse of the healthcare industry. For example, fed-eral, state, and local governments regulate variousplayers in the industry to facilitate access to health-care, such as requiring emergency departments inhospitals to accept patients regardless of insurancecoverage. Efforts by regulatory bodies to coerce physi-cians’ decisions are often treated contemptuously asphysicians resolutely guard their autonomy and inde-pendence and are satisfied with their competence(Chreim et al. 2007, Ford et al. 2009). However,because governments have the power to legislate,governmental edicts may cause fundamental changesin the healthcare industry and compel physician prac-tices to alter the way they provide care.

Health information digitization and EHRS haverecently received a significant amount of attentionin the press. In 2004, President Bush issued execu-tive orders to promote the movement toward paper-less health records and issued a directive that by2014, a majority of U.S. citizens would have electronichealth records (Bush 2004). President Obama and thecurrent administration have repeatedly emphasizedthe role of IT. Such deadlines, surveillance, and eval-uations trigger a change in perceived locus of controlfrom internal to external. In addition, there are fre-quent and alarming reports about medical errors thatcould have been prevented with better use of technol-ogy. All of this attention serves to create a sense ofenvironmental pressure and threat around the EHRSadoption and use issue.

As shown in Figure 1, we suggest that governmen-tal influence will be salient to physicians because itrelates to their careprovider role identity but not totheir perception of the physician community identity.The existence of a role identity implies acting to meetspecific expectations of the role with respect to othersand is more directly related to day-to-day actions andbehaviors. Changes in the environment potentiallyhave a more immediate influence on the behaviorsrequired to maintain and shape role identity at thelevel of physicians because they translate to changesin work processes (see ARRA 2009, “Meaningful Use”criteria, HITECH Act). For example, a policy man-date that would compensate physicians for electronic“Web visits” in the same way as for a face-to-faceconsultation with the patient could have profoundimplications for the way in which patients and physi-cians interact and consequently for the care providerrole identity. Furthermore, as noted by Ethier andDeaux (1994), although severe threats can challengethe existence of an identity or the meanings and val-ues associated with it, threats can be managed bycontrolling one’s association with the social collective.Thus, government mandates can impact a physician’srole as a careprovider, but only the physician controls

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the extent to which s/he identifies with the broaderphysician community.

It is also true that as members of a collective, indi-viduals are better insulated from external shifts bythe power of the group that can serve as an advo-cate for its members (Chreim et al. 2007). To illus-trate, recently the Center for Medicare and MedicaidServices announced that it would require physiciansto report quality measures to the public (PQR 2011).To proactively shape how these quality measures aredefined, the American Medical Association has takena vocal advocacy role and is guiding the discoursearound quality measurement (AMA 2011). Thus, weposit that governmental influence will alter the rela-tionship between careprovider identity constructs andEHRS assimilation.

In the presence of governmental influence, the pos-itive effects of careprovider identity reinforcementwill be diminished and the negative effects of care-provider identity deterioration further accentuated. Inthe case of careprovider identity deterioration, physi-cians may feel that they have to learn new ways toprovide care to patients because of the need to con-form to the edicts of the government, thereby causingeven greater changes in their roles. In other words,the loss of autonomy and independence may arisenot only from clinical and administrative changesbut also from governmental mandates. Furthermore,physician practices will be required to perform oner-ous tasks and submit extensive documentation to thefederal and state government bodies to demonstratethat they are using EHRS meaningfully. The strictand nonnegotiable timeline set for meaningful usestages 1 through 3 under the HITECH Act and thespecific goals imposed regarding electronic documen-tation, e-prescribing, and patient information captureand sharing, although beneficial for the greater good,may be perceived as forced by the government andthus be resented by physicians. We saw instances ofthese perceptions during our field work. A urologyphysician commented, “I am doing more ‘secretarialwork.’ When I had this [referring to a paper scriptpad] I didn’t care what pharmacy they [patients] wentto, to get it filled. Now I have to look it up. You knowthere are three CVSs on [route XYZ] in [medium-sizedMidwestern city?].” In addition, a few physicians feltas though EHRS and electronic prescribing opened upthe possibility that federal and state agencies couldmonitor their practices’ behavior. One doctor noted,“[electronic prescribing] is a sensitive issue 0 0 0will webe profiled?”

To an extent, several of these issues are rele-vant for physicians who believe that EHRS reinforcetheir careprovider role identity. Although these physi-cians believe in the value of EHRS, they are notlikely to welcome government mandates and edicts

because such attempts are viewed as coercive andthreatening to their autonomy. Although it couldbe argued that government mandates surroundingEHRS use institutionalize and legitimize the initiative,physicians traditionally have not responded well to“heavy-handed” approaches that threaten autonomybut rather have attempted to circumvent mandatesby various means (Pont 2000). In addition, govern-ment mandates have the potential to increase infor-mation privacy concerns among patients because ofthe fear that their medical data could be used inunauthorized ways by third parties, ultimately creat-ing backlash for practice owners. It is important toremember that physicians desire to remain the sourceof all knowledge and the orchestrator of care provi-sion, not a middleman between a powerful externalentity and the patient, with the former mandating thatthey use technology more extensively. Finally, eventhose physicians who believe in the inherent potentialof EHRS may be skeptical of government intentions,believing that the end goal of meddlesome interven-tion may be a reduction in reimbursement rates in thefuture. There is a deep-seated distrust of the govern-ment among medical professionals. Following thesearguments, we hypothesize:

Hypothesis 1 (H1). Government influence diminishesthe positive relationship between perceived careprovideridentity reinforcement and EHRS assimilation in a physi-cian practice. Thus, the original positive relationship isweaker at higher levels of government influence.

Hypothesis 2 (H2). Government influence exacerbatesthe negative relationship between perceived careprovideridentity deterioration and EHRS assimilation in a physi-cian practice. Thus, the original negative relationship ismore negative at higher levels of government influence.

Physician Community IdentityPerceived Physician CommunityIdentity ReinforcementPerceived physician community identity reinforce-ment refers to the belief among physicians that theimplementation of EHRS will enable them to adhereto the norms established by their reference group—the physician community, comprising of other physi-cians and organizations engaged in the practice ofmedicine—and continue their membership in thesocial collective. As discussed earlier, physicians iden-tify closely with other physicians and their professionand value their links and connections because of theneed to collaborate frequently during the provisionof patient care. The complex and highly specializednature of medicine frequently requires multiple physi-cian practices to cooperate with one another. Forexample, in treating a particular patient, a pulmonary

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specialty practice may share information with oncol-ogy, radiology, and cardiology practices as well aswith other local hospitals. Physician practices typi-cally hold admitting rights to one or more local hospi-tals to support the acute care needs of their patients.Because of repeated interactions with other physicianpractices and hospitals, the actions of these entitiesmay influence the focal practice because they serveas signals of what referent others value and haveaccepted as important. Perceptions that change isbeing embraced from within the referent group can bea powerful motivation for change because it enablesthe physician to simultaneously maintain control andautonomy and amplify affiliation with the in-group(Chreim et al. 2007, Kohli and Kettinger 2004).

The availability of standardized electronic informa-tion using EHRS can enhance cooperation betweenphysicians and augment their knowledge aboutpatients and the care provided to them by otherphysicians. The extent to which other practices andhospitals have already assimilated EHRS provides animpetus to the focal practice as a result of the sharedvalues within the peer group (Gagne and Deci 2005).We note that such behavior is unlikely to be viewedas externally imposed and non-volitional; physicianswill experience significant autonomy because thebehavior is congruent with the values of the peergroup into which they have self-selected and becausethe changes are not forced upon the focal practice byother practices or hospitals. Physicians self-determineand elect to take this action because they believe thatit enables them to remain a part of the in-group andto maintain their desired self-image. If other collab-orators have already assimilated EHRS and the focalpractice has not, it may be motivated to assimilate inorder to strengthen its professional identity by keep-ing pace with its peers and the broader professionalcommunity.

Furthermore, through its connections to other prac-tices and hospitals using EHRS, the focal practice canlearn about EHRS and associated costs and benefits.The actions of others within a professional commu-nity characterized by a strong identity are importantsignals of the value of the action and improve thelikelihood of change within the focal practice (Chreimet al. 2007, Kohli and Kettinger 2004). In summary,physician practices working in an environment inwhich other practices, medical professionals, and hos-pitals with which they interact have already adoptedEHRS will be more likely to assimilate because it iscongruent with their professional goals and affirmstheir community identity.

Hypothesis 3 (H3). Perceived physician communityidentity reinforcement associated with EHRS is positivelyrelated to EHRS assimilation in a physician practice.

Perceived Physician CommunityIdentity DeteriorationIn the process of care provision to patients, physicianpractices interact with a variety of non-governmentalstakeholders such as technology vendors, insurancecompanies, and pharmaceutical companies. Althoughthese organizations are vital components of thehealthcare ecosystem because of the inputs and ser-vices they provide, from a physician’s perspective,these entities are not a part of the physician com-munity because they are not directly responsiblefor the provision of patient care. Consequently, aphysician engaged in social comparison would con-sider these entities to be out-group. In their effortto streamline business processes and increase rev-enues, these non-governmental stakeholder entitiesmay exhort care providers to share information withthem electronically. For instance, insurance compa-nies may require documents to be submitted elec-tronically and pharmaceutical companies may wantaccess to patient data for segmentation and targeting.However, because these entities are not consideredto be a part of the physician community in-group,their requests are unlikely to be received in thesame manner as those from the in-group. There isevidence that the development of favoritism for thein-group is generally accompanied with greater hos-tility for the out-group (Stets and Burke 2000, Swannet al. 2009) because individuals seek to accentuate dif-ferences between the in- and out-groups. Perceivedphysician community identity deterioration refers tothe belief among physicians that their identity maybe threatened by the imposition of EHRS by non-governmental entities that represent the out-groupand the result is resistance to, or suspicion of, suchefforts. During a physician focus group study, onedoctor angrily exclaimed, “Now we get a packet froman insurance company that says, ‘we don’t want them[the patients] on Statins,’ and that bothers me!”

Demands from these stakeholders exert pressureon physician practices and interfere with the auton-omy with which physicians treat patients. Althoughphysicians have an element of discretion in how muchimportance and salience to attach to such demandsbecause this set of stakeholders does not have thesame level of authority to mandate as does the gov-ernment, they may nevertheless believe that theiridentity is threatened by virtue of decreased auton-omy and power that would result over their practiceof medicine.

As discussed earlier, physicians “fiercely” valuetheir autonomy and react adversely to attempts toregulate their behavior by the out-group (Ford et al.2009). Studies of physician decision making in ahealthcare setting find internal influences to be morepersuasive than those that are externally imposed

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(Ford et al. 2006, Kohli and Kettinger 2004). Theunderlying rationale is that influences such as pres-sure and evaluation can be detrimental to physicians’identity, creativity, and problem-solving behavior.Thus, when faced with externally imposed influencesfrom out-group stakeholders to adopt and use EHRS,physician practices may perceive such demands asdetracting from their community identity and resistsuch exhortations in order to maintain their commu-nity identity. Thus:

Hypothesis 4 (H4). Perceived physician communityidentity deterioration associated with EHRS is negativelyrelated to EHRS assimilation in a physician practice.

Research MethodsSample and Data CollectionPhysician practices across the United States servedas the research setting for this study. To test ourresearch model, we collected survey data from asample of these practices. We developed the sur-vey instrument based on a thorough literature reviewand interviews with physicians, administrators, andstaff at a multifacility family health clinic in a south-ern state in the United States Based on subsequentfeedback from healthcare informaticians and physi-cians actively involved in health IT implementations,we refined the preliminary survey instrument. Thesesteps ensured face and content validity of the sur-vey. We pilot tested this survey with the mem-bers of the Center for Practice Innovation (CPI) atthe American College of Physicians (ACP). Aftercreating an online version of the survey usingZoomerang (http://www.zoomerang.com), we sentan email including a link to the survey to all 34 mem-ber practices of CPI. Twenty-four member practicesresponded to our survey for a response rate of 70.6%.Statistical tests conducted on these responses led tofurther refinements in the survey instrument, includ-ing dropping three items with low factor loadings.

Data were collected in waves with assistance fromthree health-related member organizations. In Novem-ber 2006, the ACP sent its monthly electronic newslet-ter including a link to the online version of our surveyto a randomly selected subset of member recipients.Two weeks after the link was sent, ACP membersreceived an electronic reminder. We obtained a totalof 190 responses from this wave of data collection.In January 2007, a link to the same electronic surveywas sent to a randomly selected subset of the mem-bers of the American Medical Informatics Associa-tion (AMIA). We received an additional 25 responsesfrom this second wave. To protect their membership,ACP and AMIA did not disclose the email addresses

or the number of recipients who received our invi-tation; therefore response rate could not be calcu-lated. Finally, in April 2007, ACPnet, a practice-basedresearch network of ACP that volunteers to examinehealthcare processes, allowed us to survey its memberpractices. Seven hundred and thirty ACPnet memberpractices constituting the entire population receivedthe electronic survey and we obtained 58 responsesfor a response rate of roughly 8%. Post data-collectiondiscussions with ACP and AMIA officials confirmedthat response rates for surveys with no financialincentives tend to stay below 10%. Although we areonly able to determine a response rate for one wave ofthe study because of the nature of our data collection,response rate alone is a poor proxy for study qual-ity because it yields scant information about the pres-ence or absence of non-response bias (Rogelberg andStanton 2007). Consequently, we conducted severaltests to assess bias. We conducted an ANOVA test toassess differences in responses from the three differentsources (F4212035 = 10373p > 001) and a two-sample T -test to assess any systematic differences in “early” ver-sus “late” responses (t-value = 00523p > 001). We alsoconducted two-sample T -tests to compare commonlyavailable variables such as the size of 100 randomlychosen U.S. physician practices and those in our sam-ple (t-value = 00683p > 001). Our tests indicated thatthere were no systematic differences, providing evi-dence that non-response bias is not a significant prob-lem with our data (Rogelberg and Stanton 2007).

In summary, through three waves of data collection,we gathered data from 273 respondents. An examina-tion of the data deemed observations from 67 practicesto be unusable because of key missing values, yield-ing a final sample of 206 total usable responses repre-senting unique physician practices. Although we didnot require the respondent to identify him/herself, atthe end of the survey, we offered to send results tothose who provided contact information. From thisinformation combined with the requirement that theyprovide the name of the physician practice and thezip code, we were able to determine that there wereno duplicates. Practices in the Midwest, West, South,and Northeast constitute 17%, 20%, 28%, and 35% ofthe sample, respectively. Respondents at these prac-tices had an average tenure of 11 years. Their jobtitles varied, but the vast majority of them (87%)were Practice/Physician Owner, Physician Partner,and Physician President, suggesting that they serveddual clinical and managerial roles, an ownershiptrend that is becoming more common (Adler et al.2008). Thus, our respondents can be considered well-informed and competent to answer questions at thelevel of the practice. Physician informants are alsoused commonly in studies conducted at the practicelevel in the medical informatics literature (e.g., Simon

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et al. 2007a). The unique characteristics embedded inphysician practices, including highly trained physi-cians with much autonomy and decision-makingpower (Adler et al. 2008), coupled with frequent inter-actions with staff who seek the physician’s guidanceand direction, suggest that the physician is likely toplay an important role in EHRS assimilation, and thisviewpoint predominates the overall attitude at theorganizational level of the physician practice.

Operationalization of ConstructsBecause of the relative recency of electronic healthrecords, limited research on health IT in the IS domain,and limited empirical work in social identity theory,several constructs had to be developed specificallyfor this study. The extensive literature on IT adop-tion and use served as guidance while developing sur-vey items, and we adapted these existing measuresto the context of healthcare and EHRS in particular.Most constructs were measured with multiple indica-tors coded on a seven-point Likert scale (see onlineappendix for items and reliability coefficients).2

The identity enhancement and deterioration con-structs were operationalized based on a comprehen-sive review of medical informatics and IS literature,an appraisal of the popular press, and extensiveobservational data collection through site observa-tions, interviews, and focus groups. Perceived care-provider identity reinforcement (PCIR) is a four-itemscale assessing the viewpoints of doctors about howEHRS influence their role in diagnosing and treat-ing patients. We drew on social network and insti-tutional research to inform our development of theperceived physician community identity reinforce-ment (PPCIR) construct (Teo et al. 2003). In additionwe used the popular press and interviews to identifykey stakeholders that physicians would consider theirin-group. The four items constituting PPCIR reflectour review and discussions.

Perceived careprovider identity deterioration(PCID) is a three-item scale that assesses the percep-tion among clinicians that there may be negativeconsequences to their role behaviors associatedwith EHRS assimilation.3 To develop the perceivedphysician community identity deterioration (PPCID)construct, we also drew upon interviews, focusgroups, and popular press reports of physicianattitudes toward EHRS adoption and use. In thiscase, we noted the most common entities to which

2 An electronic companion to this paper is available as part of theonline version at http://dx.doi.org/10.1287/isre.1110.0407.3 Item-level correlations were extremely small for careprovideridentity deterioration indicators. The highest inter-item correlationwas only 0.2. We modeled it both as a reflective and formativeconstruct and our results stayed qualitatively the same.

physicians referred as influential stakeholders thatdo not provide direct care to patients. This resultedin a four-item scale. Finally, the two items used forperceived government influence (PGI), which focuson the impact from governmental entities, werederived from prior theoretical work suggesting thatpowerful external entities impact cognition, incen-tives, perceptions, and actions (Deci et al. 1999, Gagneand Deci 2005).

To control for alternative explanations of assim-ilation, IT infrastructure (ITInfrastructure), staff ITskill (StaffSkill), and patient technology savvy(PatientTechSavvy) were used as control variables andmeasured using three item scales each. Many of theseitems are based on prior work in IT adoption, use,and capabilities (Armstrong and Sambamurthy 1999,Bharadwaj 2000). We also control for several contex-tual and demographic variables that have been foundto be influential in prior adoption and use studiesincluding the size of the practice (Size), cost concerns(CostConcerns); and gender, position, and age of therespondent (Miller et al. 2005). Our controls are simi-lar to those used by Devaraj and Kohli (2003) in theirstudy of the link between IT usage and performancein a healthcare setting (see online appendix).

The dependent variable—EHRS assimilation—isoperationalized using four indicator items. As rec-ommended in IT adoption and use literature (e.g.,Jasperson et al. 2005), rather than employing a binarymeasure of use, we utilize a scale that taps into thenature and extent of EHRS use in various activitiesrelated to patient care. Our qualitative analysis iden-tified EHR assimilation as a four-item factor consist-ing of key functions EHRS provide. These includemanaging the patient’s medical history and clinicalcare record (through electronic notes and documen-tation); the ability to transmit prescriptions directlyto the pharmacy (e-prescribing), thereby avoidingdata recording and communication errors in medica-tion dispensing; electronic linkages to other playersinvolved in patient care such as specialty practices;and electronic receipt of patient data that may begenerated by other entities for medical procedures(e.g., blood tests performed at a laboratory). Theextent of use of these features was assessed usinga seven-point scale anchored by “Not at all” and“Extensively.” Descriptive data and correlations forconstructs are shown in Table 1.

Data Analysis and ResultsData were collected from a single key respondentusing one instrument, therefore, we checked for com-mon method bias. As suggested by Podsakoff andOrgan (1986), we conducted Harman’s one-factor test.Principal components analysis (PCA) resulted in nine

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Tabl

e1

Corr

elat

ion

Mat

rixat

the

Cons

truct

Leve

l

Desc

riptiv

est

atis

tics

No.

cons

truct

Mea

nSt

dDev

12

34

56

78

910

1112

13

1PC

IR50

192

1047

910

000

p-v

al2

PPCI

R40

329

1032

800

102

1000

000

146

3PC

ID30

751

0098

500

185

0017

910

000

0000

800

010

4PP

CID

3097

010

285

0000

200

518

0016

010

000

0097

500

000

0002

25

PGI

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components, accounting for 71.3% of the total vari-ance. The first component accounted for only 17.5%of the variance; hence, there was no general fac-tor accounting for more than 50% of the variation.The generalized tests recommended by Podsakoffet al. (2003) also failed to detect significant com-mon method bias. These results indicate that commonmethod bias is not a significant problem in our study.

The reliability of constructs, as measured by com-posite reliability, varied from 0.72 to 0.92, suggest-ing adequate reliability. PCA showed that all itemsloaded highly on their expected construct but noton other constructs, establishing unidimensionality(see Table 2). We assessed convergent validity byreviewing indicator loadings. The loadings varied

Table 2 Principal Component Analysis to Establish Unidimensionality and Validity

1 2 3 4 5 6 7 8 9

1 ITInfrastructureinfra2 00838 00118 00263 −00033 00109 00075 00117 −00234 00013infra1 00806 00249 00171 00057 00053 00048 00149 −00232 −00061infra3 00727 00336 00204 −00003 00023 −00037 −00026 −00018 00073infra4 00701 00325 00193 00057 00023 00043 −00072 00082 00107

2 StaffSkillstf_skl4 00142 00892 00055 00165 00291 00013 00124 −00023 00033stf_skl5 00259 00742 00050 00158 00217 −00052 −00235 00274 −00044stf_skl1 00446 00666 00082 00145 00171 00066 −00122 00173 −00007

3 EHRS assimilationUSE_ERX 00135 00023 00887 00008 00057 00013 −00037 −00014 −00048USE_NOTE 00238 00121 00857 00081 00025 −00024 −00085 −00126 00032USE_COMM 00159 00096 00908 00093 00044 00058 00000 00005 00040USE_LAB 00207 00125 00820 00097 −00067 00086 −00031 −00102 00085

4 PCIRenh_cir1 00078 00108 00094 00804 00024 00138 00080 −00043 00159enh_cir2 00082 00075 00076 00827 −00015 00055 00115 −00159 00099enh_cir3 00052 −00057 00009 00737 00051 00149 00016 −00088 00123enh_cir4 00140 00101 00134 00831 00021 00029 −00058 00136 00027

5 PatientTechSavvypt_tech1 00143 00123 −00023 −00011 00915 −00036 00031 −00013 00070pt_tech2 00155 00150 −00015 −00003 00943 −00032 00066 −00021 00040pt_tech3 00249 00275 00099 00113 00873 00026 00042 −00014 −00024

6 PPCIRenh_comp 00093 00073 00073 00067 00084 00659 00404 00022 00210enh_hosp 00007 00055 −00002 00070 00039 00754 00233 00240 00243enh_docs 00113 00113 00119 00106 −00035 00709 00073 −00020 −00233enh_admt −00074 −00096 −00006 00044 −00105 00744 −00011 00256 00000

7 PPCIDinf_jcah 00017 −00022 −00173 00083 00013 00335 00443 00259 −00011inf_vend −00051 −00121 −00109 00042 00052 00089 00766 00025 −00135inf_drug 00053 00042 00020 −00007 00077 00202 00733 00138 00078inf_insu −00001 00057 −00038 00113 −00020 00113 00607 00555 00173

8 PGIinf_govt 00070 00127 −00196 −00039 −00007 00210 00308 00766 −00043enh_fed −00128 −00128 −00053 −00152 −00043 00229 00052 00733 −00057

9 PCIDthr_cid2 −00003 −00222 00087 00114 00111 00051 00246 −00209 00432thr_cid3 00071 00043 00050 00135 00042 00042 −00047 00019 00854thr_cid1 −00023 −00145 00044 −00663 −00064 00127 00034 −00033 00290

Notes. PCIR: Perceived careprovider identity reinforcement; PPCIR: Perceived physician community identity reinforcement; PCID: Perceived careprovider iden-tity deterioration; PPCID: Perceived physician community identity deterioration; PGI: Perceived government influence.

from 0.29 to 0.94 and were significant (p < 00001),establishing convergent validity of the scale (Gerbingand Anderson 1988). We assessed discriminant valid-ity by performing the confidence interval test. For eachpair of constructs, a confidence interval was calculatedusing the estimated correlation plus or minus twicethe standard error. None of the intervals included 1.0(see Table 3), supporting discriminant validity for allthe constructs (Gerbing and Anderson 1988).

ResultsWe employed ordinary least squares (OLS) regres-sion using PASW Statistics version 18 (formerly SPSS)to test our hypotheses. We estimated the researchmodel using moderated regression analysis (Cohen

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Table 3 Confidence Interval Tests to Establish Discriminant Validity

PPCIR PCID PPCID PGI StaffSkill ITInfrastructure PatientTechSavvy

PCIR 0.102 (0.078) 0.185 (0.103) 0.002 (0.081) −00190 (0.064) 0.222 (0.082) 0.261 (0.073) 0.067 (0.074)6−000541002587 6−000211003917 6−001601001647 6−003181−000627 6000581003867 6001151004077 6−000811002157

PPCIR 0.179 (0.093) 0.518 (0.062) 0.448 (0.052) 0.001 (0.075) 0.070 (0.068) 0.000 (0.065)6−000071003657 6003941006427 6003441005527 6−001491001517 6−000661002067 6−001301001307

PCID 0.160 (0.053) 0.010 (0.043) −00005 (0.056) 0.098 (0.050) 0.099 (0.043)6000541002667 6−000761000967 6−001171001077 6−000021001987 6000011001977

PPCID 0.500 (0.049) −00058 (0.073) -0.019 (0.066) 0.094 (0.063)6004021005987 6−002041000887 6−001511001137 6−000321002207

PGI −00054 (0.091) −00125 (0.081) −00002 (0.079)6−002361001287 6−002871000377 6−001601001567

StaffSkill 0.607 (0.050) 0.349 (0.058)6005071007077 6002331004657

ITInfrastructure 0.283 (0.066)6001511004157

Notes. Correlation coefficient (standard error); [95% confidence interval]; PCIR: Perceived careprovider identity reinforcement; PPCIR: Perceived physiciancommunity identity reinforcement; PCID: Perceived careprovider identity deterioration; PPCID: Perceived physician community identity deterioration; PGI:Perceived government influence.

and Cohen 1983). We estimated the model initiallyusing only the control variables and subsequentlyadded the main effects and interaction effects tothe base model. The full model estimated can beexpressed as:

Assimilationi

= �0 +�1 ∗Positioni +�2 ∗Genderi +�3 ∗Agei+�4 ∗Sizei+�5 ∗StaffSkilli+�6 ∗ITInfrastructurei+�7 ∗PatientTechSavvyi +�8 ∗CostConcernsi

+�9 ∗PCIRi +�10 ∗PCIDi +�11 ∗PPCIRi

+�12 ∗PPCIDi +�13 ∗PGIi +�14 ∗ 4PCIRi ∗PGIi5

+�15 ∗ 4PCIDi ∗PGIi5+ �i

where �0 is the constant term; �1 through �15are the coefficients associated with study constructsand control variables; Positioni, Genderi, and Ageireflect respondent details; StaffSkilli, ITInfrastructurei,and CostConcernsi represent practice details; Patient-TechSavvyi accounts for the technological savvynessof patients; PCIRi = perceived careprovider identityreinforcement for the ith practice; PCIDi = perceivedcareprovider identity deterioration for the ith practice;PPCIRi = perceived physician community identityreinforcement for the ith practice; PPCIDi = perceivedphysician community identity deterioration for the ithpractice; PGIi = perceived government influence forthe ith practice; and �i is the error term.

A series of tests were performed to confirm thesuitability of the OLS approach to analyze the data.Outlier analysis conducted using DFBETAS valuesindicated that there were no influential outliers fromamong the 206 usable responses. Next, the distribu-tional assumptions of the error terms were verified.

Visual inspection of the normal probability plot sug-gested that the error terms can be assumed to be froma normal population. The Shapiro-Wilk test (Shapiroand Wilk 1965) also suggested that at the 5% sig-nificance level, the assumption of normality of errorterms was not violated. The correlations between con-structs and values for variance inflation factors (VIF)indicate that multicollinearity is not a problem (high-est VIF = 106). The Breusch-Pagan test was performedto test for heteroscedasticity, and it was not detectedat � = 0005. These steps suggest that the OLS regres-sion approach is appropriate for our data.

The regression results are reported in Table 4.Model 1 includes only control variables. The resultsindicate that two control variables—ITInfrastructureand costConcerns—are significantly related to EHRSassimilation, and the overall model is insignificant.Model 2 includes the main effects, in addition to con-trol variables. The overall model is significant, andfour out of the five main effects coefficients are sig-nificant, as is the change in R2 compared to the basemodel (F change = 2026; p < 0005). Model 3 includesthe moderating effects, in addition to the main effectsand control variables. The change in R2 between themain effects model and the moderated effects modelis significant (F change = 3004; p < 0005), with boththe interaction effects having significant coefficients.Model 3 accounts for 22.9% of the variance in EHRSassimilation and the variance explained increases sig-nificantly from Models 1 to 2 and 2 to 3.

In H1, we posited that government influence woulddiminish the positive relationship between perceivedcareprovider identity reinforcement and EHRS assim-ilation. As shown in Table 4, Model 3, the coefficientfor the first interaction term is negative and sig-nificant (�14 = −00147, p < 0005); therefore, H1 is

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Table 4 Regression Results: EHRS Assimiliation is Dependent Variable

Model 1 Model 2 Model 3

Unstd coefficient −00029 −00029 −00031Constant [Standard error] 6000667 6000657 6000667Job title of respondent Position −00062 −00039 00013

6000687 6000687 6000667Gender of respondent Gender 00021 00017 00024

6000697 6000697 6000677Age of respondent Age −00048 −00028 −00016

6000677 6000667 6000697Number of physicians in practice Size 00043 00058 00068

6000687 6000687 6000527Staff IT skill StaffSkill 00019 00022 00021

6000887 6000887 6000887IT infrastructure ITInfrastructure 00326∗∗∗ 00283∗∗∗ 00221∗∗∗

6000847 6000847 6000697Patient tech-savvy PatientTechSavvy −00040 −00045 −00047

6000727 6000717 6000707Cost Concerns CostConcerns −00255∗∗∗ −00224∗∗∗ −00220∗∗∗

6000707 6000717 6000727Perceived careprovider identity PCIR 00136∗∗ 00208∗∗∗

reinforcement 6000747 6000787Perceived careprovider identity PCID −00002 00022

deterioration 6000687 6000697Perceived physician community PPCIR 00185∗∗ 00182∗∗

identity reinforcement 6000807 6000827Perceived physician community PPCID −00120∗ −00140∗

identity deterioration 6000707 6000837Perceived government influence PGI −00161∗∗ −00164∗∗

6000807 6000817PCIR × PGI PCIR ∗ PGI −00147∗∗

6000747PCID × PGI PCID ∗ PGI 00081∗

6000497Adj-R2 00119 00180∗∗ 00229∗∗

�= 0005 Fcalc = 2084 Fcalc = 6001F 4

191 = 2026 F 2189 = 3004

∗p < 0010, ∗∗p < 0005, ∗∗∗p < 0001.

supported. In H2 we hypothesized that governmentinfluence would intensify the negative relationshipbetween perceived careprovider identity deteriorationand EHRS assimilation, and as shown, the coeffi-cient is positive and significant (�15 = 00081, p < 0010),which does not support H2. In H3 and H4 we arguedthat perceived physician community identity rein-forcement and perceived physician community iden-tity deterioration would, respectively, be positivelyand negatively related to EHRS assimilation. Boththese relationships are supported (�11 = 00182, p <0005; �12 = −0014, p < 0010).

To obtain a more fine-grained understanding of thenature of moderation, we inspected the interactionsbetween the two careprovider identity constructs andgovernment influence visually (see Figure 2). Twolevels of moderator and main effects constructs werecreated by calculating the mean level of the vari-

ables and adding one standard deviation to the mean(high) and subtracting one standard deviation fromthe mean (low).

The graph displaying the moderating impact ofgovernment influence on the relationship betweenPCIR and EHRS assimilation (Panel A, Figure 2)shows that for every level of reinforcement, assimi-lation is higher when government influence is low.Furthermore, when perceived reinforcement is low,assimilation is low for both high and low levels ofgovernment influence; however, when perceived rein-forcement is high, EHRS assimilation increases onlymarginally for high government influence, whereas itincreases strikingly for low government influence.

The graph displaying the moderating impact ofgovernment influence on the relationship betweenPCID and EHRS assimilation (Panel B, Figure 2) indi-cates that at low levels of government influence,

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Figure 2 Graphical Representation of Interaction Results

–0.4

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Low gov’t influenceHigh gov’t influence

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the relationship between identity deterioration andassimilation is negative, whereas at high levels of gov-ernment influence, the relationship is positive. Whendeterioration is perceived to be low and governmentinfluence is high, physician practices use EHRS spar-ingly. However, at each level of perceived deteriora-tion, EHRS assimilation is higher when governmentalinfluence is low. We discuss our results next.

DiscussionThis study was motivated by the observation thatalthough EHRS offer considerable promise in alle-viating problems associated with the delivery ofhealthcare, their assimilation has been limited. Lowassimilation among physician practices is particu-larly vexing because EHRS can facilitate access toconsistent data among a wide variety of dispersedstakeholders in the healthcare value chain suchas hospitals, laboratories, pharmacies, and physi-cian practices. Although practitioner-oriented articleshave discussed and speculated about the reasons forlow adoption rates, theoretically grounded academicresearch examining the assimilation of EHRS in physi-cian practices has been sparse. Drawing upon the roleand social identities of physicians, we suggested that

perceived identity reinforcements and deteriorationsare simultaneously consequential in explaining theassimilation of EHRS in physician practices. To ourknowledge, ours is among the first studies in IS touse identity theories to conceptualize notions of iden-tity reinforcement and deterioration and apply themto understand the assimilation of technological inno-vations in the healthcare industry. We thus providea novel lens that extends extant theory developmentin IT adoption and use. The support obtained for theproposed research model underscores the applicabil-ity of the conceptual foundation and suggests that itcan serve as a robust basis for researchers to exam-ine the adoption of technological innovations in otherprofessional organizations.

Tripsas (2009) asserts that identity is the core essenceof entities, directing and constraining actions andreflecting the totality of capabilities, resource bases,procedures, and information filters. Not surprisinglythen, individuals and organizations alike actively tryto manage their identities by claiming, maintaining,revising, or totally altering them. A threat to iden-tity may elicit a visceral reaction. Identity changes andevolutions for physicians are particularly noteworthybecause such changes can have serious consequences,including life and death implications. Identity changescan be triggered by seemingly small technologicalshifts (Tripsas 2009), and thus it is critical to examinethe evolution of roles and identity triggered by trans-formational technological innovations such as EHRSthat have the potential to affirm, as well as to chal-lenge, the core of physician practices.

We posited direct relationships between the twosocial identity constructs—perceived physician com-munity identity reinforcement and perceived physi-cian community identity deterioration—and EHRSassimilation. Both relationships were found to be sig-nificant, supporting our arguments that perceptionsof social identity evolution are associated with subse-quent actions. In the first case, when the action is con-sistent with referent others and enhances physicians’standing within their group, they openly embraceEHRS. In the second case, when out-group others’insistence is perceived as meddlesome, physicianstake action to preserve their identity from threats.

We also proposed two moderated relationships forthe effect of government influence on the relation-ships between (1) perceived careprovider identityreinforcement and EHRS assimilation and (2) per-ceived careprovider identity deterioration and EHRSassimilation. As predicted, the former relationshipis negatively moderated, but contrary to expecta-tions, the latter relationship is positively moderated.That is, government influence negatively impacts thepositive relationship between perceived careprovideridentity reinforcement and EHRS assimilation and

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dampens the negative relationship between perceivedcareprovider identity deterioration and EHRS assimi-lation rather than exacerbating it. The first result sug-gests that when physician practices feel coerced, thispressure dominates their perceptions about reinforce-ments and undermines the direct effect of reinforce-ments. Such dampening effects are particularly strongfor complex tasks such as EHRS assimilation (Gagneand Deci 2005).

To better understand the counterintuitive finding inthe second result, we turn to the interaction graphs(Panel B, Figure 2). The visual inspection of moder-ation suggests an increasing value of EHRS assim-ilation when government influence is high. Ceterisparibus, one would not expect assimilation to increasewhen the perceived threat to careprovider identity isgreater. One explanation for this result is that physi-cians who perceive strong government influence andbelieve EHRS are threatening elect to use them to con-form to mandates and avoid sanctions and reprisals.By contrast, doctors who believe the threat to be smallsimply do not respond to mandates. The modera-tion graphs illustrate the complex nature of interac-tions between governmental influence and physicianrole identity reinforcements and threats in their jointeffects on EHRS assimilation.

Limitations of the ResearchPrior to discussing the implications of this study,we acknowledge its limitations. We used three inde-pendent samples to gather data, and it is possiblethat there was some overlap in the samples. In otherwords, it is possible that a physician practice receivedour survey multiple times; however, we did not seeevidence of this in our data set. The tested rela-tionships are at best correlational; the cross-sectionalnature of data limits our ability to assess causality.Future research can undertake a longitudinal study.Such studies will be particularly useful to investi-gate the evolution of identities among physicians andto assess if such changes have any impact on theirtechnology assimilation. Finally, common-method biasand non-response bias are persistent concerns insurvey-based research. We tested for common-methodbias and found that it was not a significant issue affect-ing our results. As per the suggestions of Podsakoffet al. (2003), we also (1) allowed responses to beanonymous and assured respondents that there wereno right or wrong answers and (2) attempted to havesimpler and more direct questions through iterativepilot testing for ease of understanding. These stepscollectively mitigate the threat of common-methodbias (Podsakoff et al. 2003). However, future researchcan circumvent the issue of common-method biasby employing data collection from multiple sources,including secondary sources. Furthermore, although

our tests demonstrated a lack of substantive non-response bias, future research can take additionalmeasures such as active and passive non-responseanalysis (Rogelberg and Stanton 2007). We note thatwe are able to obtain a robust sample size and sam-pling frames were randomized by ACP and AMIA,thereby increasing the likelihood that our sample isrepresentative of the population.

Research Contributions and ImplicationsThis paper makes several useful contributions totheory. We conceptualize two distinct identities ofphysicians drawing upon notions of role identityand social identity, careprovider and physician com-munity. We theorize and empirically demonstratethat expected evolution in these identities caused bya technological innovation affects assimilation of theinnovation. In demonstrating this, we advance theliterature in several ways. First, we inform technol-ogy adoption and use research by applying identitytheories in the novel context of EHRS assimilation.Although the practice of medicine is known to engen-der strong identities, especially in physicians (Realet al. 2009), other professions are likely to exhibitequally powerful identities—for example, investmentbankers, lawyers, and professors. To the extent thatour work informs IT assimilation in the context ofpotent professional identities, it is likely to providenew insights into organizational behavior when inno-vations are introduced. We believe that social iden-tity theories hold significant potential for explainingseveral phenomena of interest to IS and health infor-matics researchers. Second, although the broad anddeep research drawing upon and contributing to iden-tity theories has added significantly to the knowledgebase, a vast majority of it has been theoretical, andlarge-sample empirical research in this domain is verylimited. This large-sample empirical study attemptsto fill an important gap in the literature.

Third, we adapt and use measures for various com-ponents of the theoretical model that are instantiatedto the specific context of the physician practice. Thesemeasures can serve as the basis for related futureresearch. In particular, we conceptualize and opera-tionalize physician identity enhancement and deterio-ration constructs that can be applied to other contextswith relatively minor adaptations.

Several promising opportunities for future workremain. First, drawing upon sociological studiesof the practice of medicine and social psychologyresearch, we explored two significant identities thatdefine physicians. However, as underscored in theliterature, individuals can hold numerous identitiessimultaneously. Additions to the physician identityset can be explored through qualitative field work,especially in light of the impending changes to the

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healthcare system. Second, our focus was on EHRSassimilation by physician practices, but the overarch-ing goal of integration and interoperability in health-care requires other entities to adopt this technologyas well. Theoretical models and empirical studiesthat examine EHRS adoption and use by other stake-holders such as hospitals and insurance companieswould provide a useful complement to this research.The evolution of organizational identity could beexplored for these entities. Furthermore, individual-level studies are important to understand the micro-level dynamics of incorporating EHRS into the workpractices of physicians, nurses, and other key person-nel, and group-level studies are important to under-stand outcomes related to resistance to technologyimplementation (Lapointe and Rivard 2007).

Although the focus of this paper was on explain-ing the assimilation of a technological innovationthrough the lens of identity, the notion of iden-tity and its formation, evolution, and impacts canserve as a powerful theoretical foundation to informa variety of IS phenomena. For example, althoughconcepts of identity have been applied in the con-text of technology-mediated communities to under-stand knowledge contribution and satisfaction (Maand Agarwal 2007), emerging interaction channels inthe form of social media that can allow individualsto “affiliate” with multiple collectives simultaneouslyraise interesting questions. Is there an “optimal”number of collectives beyond which an individualexperiences identity conflict? What are the effectsof simultaneous social identities when the referentgroups from which these identities are constructedare characterized by incongruent norms and values?Can identities evolve over time in response to externalfeedback such as that provided by member recom-mendations and feedback? There are also interestingquestions related to individual personality traits andthe interplay with online identities. For instance, canan offline introvert take on personality characteristicsof an extrovert when participating in an online socialnetwork?

Implications for PracticeOur findings have significant practical implicationsand suggest that care should be taken when imple-menting policy and designing incentives targetedtoward increasing EHR system adoption and usewithin physician practices. There has been a per-ception among physicians that the introduction ofan EHR system will fundamentally alter the waythey practice medicine in their clinic and providecare to patients. Indeed, considerable negative emo-tion is being generated among some physicians aboutthe impending digitization of healthcare. It is impor-tant for IT vendors, policymakers, and professional

organizations such as the ACP, American Medi-cal Association, AMIA, and Health Information andManagement Systems Society to craft messages forphysicians and reiterate that EHRS have the potentialto reinforce their roles as careproviders. Policymak-ers need to carefully manage the negative symbol-ism of EHRS before a vicious cycle, characterizedby resistance and innovation implementation failure,takes hold. Professional networks—physicians prac-tices, hospitals, and other physicians—with whomphysicians associate play a central role in the adop-tion and use of EHRS. Identity-reinforcing messagesfrom these practices, hospitals, and physicians, whohave successfully adopted and implemented an EHRsystem, can wield a particularly powerful influenceon the decision of the practice to assimilate.

We also find that physician identity is threatenedby pressures from other organizations such as ven-dors and insurance companies, and threat affectsEHRS assimilation negatively. We conjecture that suchattempts are harmful at best and create downrighthostility at worst. We also find that government influ-ence does not have desirable impact on EHRS assim-ilation. Whereas physicians who perceive EHRS asa threat to their role may use EHRS under govern-ment pressure to avoid sanctions, those physicianswho believe in the technology may rebel against thepressure. Policymakers need to reconsider how muchand what type of external mandates and fiats theywish to impose.

Finally, two control variables, which are not thefocus of our study, also provide useful directions tophysician practices and policymakers. From the per-spective of the physician practice, our findings under-score the importance of the IT infrastructure and theexisting state of digitization within the organization infacilitating the adoption of new technologies. Often,infrastructure investments are challenging to justifybecause they do not appear to contribute directlyto business outcomes. However, in the absence of astrong foundation, the practice may forgo the “optionvalue” of the infrastructure (Fichman et al. 2005) andfind itself unable to exploit critical developments inhealth IT. As the nearly $20 billion allocated towardhealth IT in the American Recovery and ReinvestmentAct is being released, it may be worthwhile to remem-ber that IT infrastructure in physician practices has adirect and significant impact on EHRS adoption, andhence a significant proportion of the allocation shouldbe spent on practices that are lagging in IT infrastruc-ture creation. Additionally, our results show that staffIT skill has an insignificant impact on EHRS adoptionand use. This may be good news for practices wherethe staff is not technology savvy, because the priorexpertise of the staff may not be a significant factorand may not be directly applicable in the new context

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of EHRS. The rationale is that whereas the focus ofmost prior technologies is predominantly internal andthe scope limited to a few activities, EHRS focus oninternal processes as well as integration with exter-nal stakeholders. Consequently, the skills and experi-ence of staff familiar with other technologies may notenable them to be sufficiently agile and responsiveand may not be a differentiator in EHRS assimilation.Thus, while designing training programs, relativelymore content should be EHRS-specific and not gen-eral IT training because the latter may not have a sig-nificant impact.

ConclusionThis paper examined EHRS assimilation amongphysician practices in the United States, a topic that,for the most part, has not been studied using perspec-tives strongly rooted in theory. We utilized a noveltheoretical lens: that of physicians’ identities. As pol-icymakers and stakeholders in the healthcare indus-try endeavor to enhance access to patient informationas one mechanism for reducing medical errors andimproving quality of care, it will become importantfor researchers to study EHRS and a variety of othertechnologies among physician practices. To that end,this study has contributed to theory and practice byapplying the lens of identity theory and social identitytheory to understand EHRS assimilation, a context inwhich it has not been used before. Our research modeland results present a fine-grained perspective of therole of perceived physician identity reinforcement andthreat on EHRS adoption and use and extend theempirical research employing social identity theories.Our results indicate how various identity enhance-ments and threats and governmental influence arelikely to be consequential in assimilation, providinglevers that managers and policymakers can mani-pulate. These results contribute to a nascent but emer-ging stream of literature that investigates variousphenomena associated with healthcare IT adoption,use, and impacts. We hope that this study stimu-lates further research to enrich our understanding ofhealth IT and the institutional contexts within whichit operates.

Electronic CompanionAn electronic companion to this paper is available aspart of the online version at http://dx.doi.org/10.1287/isre.1110.0407.

AcknowledgmentsThe authors thank the American College of Physicians andthe American Medical Informatics Association for allow-ing them to survey their members. Financial support forthis research was provided by Pfizer Healthcare Informat-ics. Comments and suggestions provided by colleagues at

Georgia State University and the University of Marylandsignificantly improved the quality of the paper. The authorsare deeply indebted to the Senior Editor, Anandhi Bharad-waj, the Associate Editor, Radhika Santhanam (whose namewas revealed to them after the paper was accepted), andthree anonymous reviewers for their excellent commentsand suggestions throughout the review process.

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