Prioritizing the factors affecting adoption of e-commerce using multi-criteria decision making techniques in Tehran hospitals in 2021

ABSTRACT

Background:

The global use of the Internet has led to the growth of e-commerce in industries. Similarly, in health care, e-commerce is essential to meeting the high expectations of patients and providing high-quality and affordable health care services in clinics, hospitals, and other health centers.

Purpose:

This study aimed to prioritize the factors influencing the adoption of e-commerce in hospitals of Tehran (Iran( in 2021 using multi-criteria decision-making techniques.

Method:

The independent variables included organizational, contextual, environmental, and technological factors, while the dependent variable was e-commerce acceptance. To answer the research question, the data were collected via documentary research method (secondary data) and survey (primary data). The instrument used for the survey was a pairwise comparison questionnaire that was completed by 186 experts selected via random sampling method, based on Morgan’s table, and with respect to inclusion and exclusion criteria. Using these instruments, the factors affecting the adoption of e-commerce were assessed using multi-criteria decision-making techniques and the AHP method.

Results:

The results of the prioritization of factors affecting the adoption of e-commerce in Tehran hospitals, from the experts’ point of view, showed that the technological criterion (weight: 0.31918) is the most important factor, followed by organizational (weight: 0.30291), contextual (weight: 0.20346), and environmental (weight: 0.17445) factors. The consistency coefficient of the model was 0.021142.

Conclusion:

The findings indicate that it is possible for doctors, nurses, patients, and medical centers to exploit the benefits of e-commerce in primary care, environmental, financial, organizational, human-related, and technological factors in healthcare.

Introduction

E-commerce is a domain of the digital economy that includes all financial and commercial transactions in the context of computer networks and related business processes. Initially, e-commerce relied on non-Internet communication and was carried out using independent information exchange standards and protocols. The development of the Internet has significantly reduced the cost of using e-commerce due to the low cost of information exchange. E-commerce companies can fulfill the role traditionally played by intermediary suppliers. E-commerce has also made it possible to collect information on sales and customers to lay the ground for a complete analysis of business and marketing research. Therefore, business processes that are carried out electronically will decrease costs.[1]

Still, the global use of the Internet has led to the growth of e-commerce in all industries. Similarly, in health care, e-commerce is essential to meeting the high expectations of patients and providing high-quality, cost-effective health care services in clinics, hospitals, and other health centers.[2]

Electronic health (digital health) is an activity using electronic information resources in the health care sector to ensure quick access to medical professionals and patients on the e-commerce platform. The digital health market diagram displayed in Figure 1 shows the extent of the development of information technology in health and healthcare. According to Figure 1, the amount of investment in the first half of 2021 was $14.7 billion in 372 transactions, with an average volume of $139.6 million per transaction. which has had a remarkable growth compared to 2020 ($14.6 billion in 460 transactions, with an average volume of $131.7 million). This has directed more attention to the field of e-commerce in health care in developed and developing countries.[3]

Figure 1.

Digital health market in 2011-2021[3]

According to the compound annual growth rate of international reports presented in Figure 2, the digital health market is expected to reach $379 billion by 2024.[3]

Figure 2.

Digital health market up to 2024[3]

According to Chen et al.[4] (2019), the quality of hospitals and health care products can be improved by optimizing medical costs. Similarly, by launching new businesses and commercializing them, e-commerce leads to the emergence of the market in various distribution channels as a source of economic growth and sustainability.[5] However, the emergence of e-commerce in the healthcare industry has forced IT personnel to move beyond infrastructure design and maintenance and consider multiple customer-facing aspects such as consumer data privacy and security. E-commerce has widespread use in healthcare. The advancement of technology aids caregivers in treating and saving patients.[6]

Figure 3 illustrates the amount of electronic business financial exchange in health care in North American countries from 2012 to 2021 and the forecast for 2022. This diagram indicates the increase in receiving services and conducting electronic transactions in health care in North American countries. According to Figure 3, the amount of financial transactions in 2021 has reached above $100 billion per annum, which demonstrates the position of e-commerce in healthcare in North American countries.

Figure 3.

Financial transactions of e-commerce in healthcare in North American countries (2012-2022)

The UK e-commerce market is worth $93.89 billion per annum. In this market, 12.1% of purchases are made via tablets, 16.5% via smartphones, and 71.4% via desktop computers. Moreover, 33% of online sales are made after 6 p.m. E-commerce accounts for 30% of the UK economy. The share of e-commerce in the UK GDP is 6.1.[1] Similarly, Malaysia’s healthcare industry is a significant contributor to the country’s economy in the context of e-commerce. The healthcare industry of Malaysia contributes 10% to its GDP. Reports from the Malaysian Investment Development Authority (MIDA) show that Malaysia has become a health tourism destination.[2]

What is noteworthy is that today, e-commerce is not limited to buying and selling on the Internet; rather, it includes the transfer and transportation of products, services, or information through Internet networks.[7] E-commerce is not only responsible for altering supply chain management, but also enables a better flow of information in various forms, including electronic data exchange, direct communication with suppliers, the Internet, etc., In this way, organizations such as medical centers can benefit from advantages such as increased speed of data transfer, reduced errors, promoted accuracy of received and sent data, decreased warehouse inventory, planning supplies and inventory control, decreased product delivery time, etc., thereby improving their competitive status.[8]

Although e-commerce confers numerous advantages for manufacturers, providers of products, services, and patients in hospitals, technologies also suffer from limitations that pose a barrier to e-commerce. These factors include different standards of technology, the consumer (user) culture and behavior, feasibility (in e-commerce problems related to the feasibility of the promised actions may not be overcome, e.g. it may take a long time to deliver the product or service to the consumer), low download speed, small screen and memory, and limited processing power of smart systems, the difficulty of working with mobile devices, high costs, tiresome tracking, typing difficulty, unreliable services, low data transfer speed in network platforms, and security. Therefore, the most important obstacle of using e-commerce is providing appropriate technological infrastructure.

Electronic health has been implemented to some extent in Iran, like other countries; however, there are many obstacles such as the lack of standard programs due to multiple data formats, the cost of electronic health systems (hardware, software, and maintenance), training, legal problems related to the refusal of electronic documents by judicial courts, technical problems (e.g. network and server problems), educational problems caused by the changes in the work shifts of health care providers, resistance to change by health care providers including hospital managers, medical staff, family physicians, general primary care providers, etc.

Success on a large scale requires the examination of numerous and extensive parameters; depending on the type of business and the needs of medical centers, managers can address multiple priorities and perform the necessary examinations to improve the hospitals and health centers scientifically and practically. In trade and business, speed and accuracy are among the facilities offered by information and communication technology to this industry. But is this enough for the generalization and acceptance of this phenomenon in business? All this said, does moving from traditional to new business always lead to profit, reduces administrative processes, facilitates service, facilitates communication between patients and family physicians and ensures success for hospitals and primary care providers, or are there certain criteria to determine healthcare centers’ strategy for success? Thus, the challenge is, “What should healthcare centers’ managers keep in mind before making a decision to achieve good outcomes in e-commerce? Can the priorities to achieve these outcomes be predicted and defined?”

The process of evaluating and choosing appropriate solutions, methods, and options in treatment projects is complex due to the involvement of different decision-making groups, mutual relationships between health, technology, and the surrounding environment. As such, it needs an examination of different and, at times, conflicting opinions of experts, taking into account multiple and complex quantitative and qualitative factors, and investigating the mutual relationships between them. The main problem addressed in this research is, “What factors cause the adoption of e-commerce in hospitals and healthcare centers?” “What key factors in satisfying customers or service recipients are emphasized by hospitals and healthcare providers?”

According to the review of similar articles in other countries, the subject of this research is different from foreign samples in terms of technique and method. Also, about e-commerce adoption in various industries, including agriculture, commerce, service, education, etc., many types of research have been conducted in Iran, but there are no researches related to this topic in medical centers and hospitals, which shows the novelty of it.

Methodology

This was applied research given that it sought to prioritize the effective factors of e-commerce acceptance in hospitals using a multi-criteria decision-making technique, and its results can be used by the target society. In this research, descriptive statistics were used to express what exists in society and help the transparency of the research. In addition, the AHP technique was adopted to analyze the collected data. The required data were collected using a questionnaire, and based on this, this study was a survey. The theoretical foundations of the research were compiled by visiting libraries and written and unwritten documents, and in this sense, this study was documentary research. In the analytical model of the current research, the factors affecting the adoption of e-commerce (organizational, contextual, environmental, and technological factors) were the independent variables, and the adoption of e-commerce in hospitals was considered the dependent variable. The approval from the ethics committee is obtained and the institutional ethics committee clearance code for this study in IRAN is IR.IAU.TMU.REC.1400.279 date of approval: December, 2021.

Figure 4 depicts the research process to identify the factors affecting the acceptance of e-commerce and their ranking using multi-criteria decision-making techniques.

Figure 4.

The procedure of the study

The statistical population comprised all experts working in management, procurement, and informatics/IT units in Tehran hospitals. There are 118 hospitals in Tehran, and of each three experts are selected in the aforementioned units. Thus, the number of experts working in hospitals in Tehran was 354. The sample size based on Morgan’s table was at least 186 people selected via random sampling based on the inclusion and exclusion criteria.

Inclusion criteria

Work experience of more than five years.

Willingness to participate in the study.

Exclusion criteria

Returning incomplete questionnaires.

Withdrawal from the study for any reason at any time.

Based on secondary research, we first collected the research literature from credible Persian and non-Persian articles and books; then, by examining the available documents of similar organizations and reputable websites, we checked the information related to the research background. Subsequently, using field research, we distributed a questionnaire among experts and collected the desired information about the factors affecting the acceptance of e-commerce. A pairwise scale was developed and administered to collect the data required for the research.

The analytical hierarchy process (AHP) is one of the most well-known techniques for multi-objective decision-making. Decision-making includes priorities or degrees of importance, and AHP is a methodology for this purpose. Therefore, to analyze the data collected from the questionnaire, AHP and SuperDecisions were employed.

Results

After reviewing the studies, the most relevant ones were mentioned as the theoretical foundations [Table 1]. For the descriptive analysis of the research data, the frequency distribution of sex, age, and level of education of the sample was examined. Based on the results, 58.5% of the participants were men and 41.5% were women. Moreover, 1.1% were below the age of 20, 10.6% 20–30, 58% were 30–40, 25% were 40–50, and 5.3% were above 50 years old. In terms of the level of education, 5.9% had a high school diploma or lower, 6.9% had an associate degree, 45.2% a bachelor’s degree, 42% a master’s degree or higher. As for work experience, 12.2% had 5 years or less, 10.1% had 5 to 10 years, 35.1% 10 to 15 years, 25.5% 15 to 20 years, and 17% more than 20 years.

Table 1.

Descriptive display and results of reviewed studies

Author	Objective	Method	Identified factors	Results
Kong et al.[9]	Investigating the acceptance of artificial intelligence in e-commerce in the healthcare industry	Questionnaire and the TOE framework	Data transparency, cost pressure, comparative advantage, legal regulations	The influence of the identified factors was confirmed in the TOE framework.
Bedoya Reina et al.[10]	A deconstructive review of the Haven Healthcare Center in the US health care system	An overview of actions taken at the Haven Healthcare Center	Identifying strategies to reduce treatment costs and examine patient satisfaction in the US	Amazon’s expertise and capabilities in e-commerce, such as logistics, big data management, and supply support Haven’s efforts to solve healthcare inefficiencies.
Poritska et al.[11]	A review of e-commerce and e-health strategies and administrative activities in the UK	A review of e-commerce practices in the UK	Identification of e-health sub-specialties such as blockchain, health IT, virtual and augmented reality, sensors, personal genomics, telemedicine, big data, e-health, mobile health, electronic medical records/electronic health records, artificial intelligence, and machine learning	Presenting the amount of UK public and private sector investments in healthcare and mentioning its $93.89-billion e-commerce market. E-commerce accounts for 30% of the UK economy. The share of e-commerce in the UK GDP is 6.1%.
Shahzad et al.[2]	Examining the effect of COVID-19 on the use of e-commerce in the Malaysian healthcare industry	Adopting the TOE framework using a questionnaire	Organization readiness E-commerce knowledge Supply chain integration Technological infrastructure External pressure	Organizational readiness, e-commerce knowledge, and supply chain integration have a significant positive effect. In contrast, information technology infrastructure and external pressure have a negligible effect on the use of e-commerce.
Rajak and Shaw[12]	Evaluation and selection of mobile health applications	AHP and fuzzy TOPSIS techniques	User Satisfaction Performance Being easy to learn and use Information quality	The factors of “user satisfaction,” “performance,” “being easy to learn and use,” and “quality of information” were identified as the most important factors in the evaluation and selection of health mobile apps in order of importance.
Nilashi et al.[13]	Identification of factors affecting the adoption or the existing obstacles to the adoption of hospital information systems in Malaysia	AHP technique	Environmental Human-related Organizational Technological	Technological (weight of 0.467) is identified as the most important factor in the acceptance of hospital information systems. Environmental (weight of 0.277), organizational (weight of 0.160), and human-related factors (weight of 0.095), in that order, were the other important factors in the acceptance of the hospital information systems based on the experts’ opinion.
Lin et al.[14]	Presenting a B2B e-commerce evaluation management model to evaluate organizational factors in hospitals and identify the relationships between the benefits of B2B e-commerce	Mixed methods: qualitative (content analysis) and quantitative (questionnaire)	Information technology maturity Information technology investment evaluation methods Allocation of information technology evaluation resources The process of determining user information needs E-commerce advantages	The maturity of information technology has a significant positive effect on the acceptance of information technology investment evaluation methods, and the process of accurate and complete determination of user information needs has a positive and significant effect on the allocation of information technology evaluation resources. These, in turn, have a significant positive effect on realizing the benefits of B2B e-commerce. Furthermore, the maturity level of information technology has a relative influence on the ability of hospitals to allocate information technology assessment resources.
Lin et al.[15]	The fit between the organizational e-commerce policy (B2B), information technology maturity, and evaluation methods on (B2B) electronic business performance in Australian healthcare organizations	Qualitative content analysis	Organizational e-commerce policy and strategy Organizational information technology maturity Information technology investment evaluation method The method of realizing the benefits of information technology E-commerce advantages E-commerce satisfaction	Positive relationships between organizational B2B e-commerce policy and strategy, maturity of organizational information technology, effective use of IEM and BRM, the level of benefits of B2B e-commerce, and the level of satisfaction with B2B e-commerce
Peikari and Rezazadeh[16]	Determining the relationship between professional errors and UTAUT factors for using the electronic prescription system of the Social Security Organization (Iran) by pharmacists in Isfahan using the UTAUT model	Descriptive-correlational	Expected effort Reducing professional errors Expected performance of pharmacists Facilitative factors Social factors Intention to adopt the technology	Expected effort and reduction of professional errors affected the pharmacists’ expected performance (P<0.001). Expected performance, expected effort, facilitative factors, and social factors have a significant effect on the intention to adopt the technology (P<0.001). Acceptance intention and facilitative factors have a significant effect on system acceptance (P<0.001).
Motallebzadeh et al.[6]	Evaluating the effect of effective factors on the acceptance of electronic health services from the perspective of Social Security Insurance employees	Descriptive-correlational	Systemic factors Perceived usefulness Perceived simplicity Attitude towards application with a behavioral decision for use	Systemic factors with perceived usefulness, systemic factors with perceived simplicity, perceived simplicity with perceived usefulness, perceived usefulness with attitude toward use, perceived simplicity with attitude toward use, perceived usefulness with behavioral decision to use, and attitude toward use with behavioral decision to showed significant relationships.

Based on experts’ opinions, the degree of importance of each criterion and its related indicators was determined. This factor has been used as a basis for comparing the priorities of the factors influencing the adoption of e-commerce in Tehran hospitals and to determine the weight of the influencing criteria. In other words, the weight and status of each criterion were determined based on the desired criteria, and finally, using the governing relations in the AHP, the contribution of each indicator was determined in the evaluation. After calculating the normalized table, it was observed that there are four main criteria for ranking and examining the degree of importance by experts, in order of weight. The technological ranked first and was the most important (weight: 0.31918), followed by organizational (weight 0.30291), contextual (weight 0.20346), and environmental (weight 0.17445). The model’s consistency coefficient was 0.021142, which is smaller than or equal to 0.1 and indicates the acceptable consistency of the system.

The results of this analysis revealed that the use of different technologies in the healthcare industry has been effective in the quality of healthcare and investment domains. The range of technology goals in the reviewed studies aims for the adoption of e-commerce and information technology in the healthcare industry. Based on the majority of studies, it is possible for doctors, nurses, patients, and medical centers to exploit the benefits of e-commerce in care, environmental, financial, organizational, human-related, and technological factors in healthcare. These results show researchers’ attention to health information technology and the benefits of using e-commerce.

Discussion and Conclusion

In this research, studies on e-commerce and the factors affecting its acceptance in the healthcare industry were examined. Although the number of studies conducted in this field is relatively small, the results of this review revealed that the use of different technologies in the healthcare industry has affected the quality of healthcare and investment domains. The range of technology goals in the reviewed studies aims for the adoption of e-commerce and information technology in the healthcare industry. Based on the majority of studies, it is possible for doctors, family physicians, nurses, patients, and medical centers to exploit the benefits of e-commerce in care, environmental, financial, organizational, human-related, and technological factors in healthcare. These results show researchers’ attention to health information technology and the benefits of using e-commerce.

Poritska et al.[11] have mentioned the benefits of investing in e-commerce and e-health. They have pointed out the importance and success of artificial intelligence and machine learning in health and treatment and presented the increase in the investment of UK public and private sector companies in health and treatment in 2019 and 2020. This indicates the importance and status of health technology and e-commerce in health and treatment in terms of the profitability of companies and improving the quality of services offered by medical centers to their patients.

Compared to e-health, mobile health as a part of e-commerce is more frequently used due to its portability and increased system flexibility. The advantage of the mobile health system includes its use in rural areas where access to conventional medical facilities is difficult. Mobile health can serve as a low-cost alternative for providing health facilities to citizens. Compared to traditional health care providers, mobile health has the potential to reduce the cost of health care services.[17] Mobile health can also provide all health-related information to people, thereby leading to a healthy lifestyle.[18] Mobile health is a useful tool in managing chronic and debilitating diseases. However, with the increasing number of health-related applications, it has become extremely difficult to decide which apps are suitable for users and which ones are not. Since one of the problems of adopting e-commerce in the healthcare sector is the lack of a framework for evaluating mobile health apps, Rajak and Shaw[12] proposed a relatively comprehensive framework for assessing the performance of mobile health apps. This framework has several managerial implications. It can be adopted by developers of mobile health apps to rate the apps. Moreover, the performance of the app can be improved using the result of the framework. By using this framework, doctors can also recommend suitable apps to patients.

The ability of hospitals to allocate resources required to evaluate information technology have mediating effects on the relationships between other organizational drivers such as methods of evaluating information technology investments, the process of determining user information needs, the maturity of information technology, and the realization of B2B e-commerce.[14] The four main factors of human, technology, organization, and environment influence the decision-making to adopt technology and e-commerce. One should also emphasize the factor of external pressures as a vital concept that affects the adoption of technology and e-commerce in the hospital setting. These external pressures can come from competitors and the government as a threatening factor, affecting the adoption of technology and e-commerce by hospitals. In addition to the mentioned problem, another important challenge facing the adoption of e-commerce in hospitals and medical centers is the problems related to choosing a suitable framework for implementing e-commerce in hospitals. Kong et al.[9] and Shahzad et al.[2] developed an optimal framework and method to solve this problem.

Research also shows that investing in B2B e-commerce does not always lead to benefits. Due to the complementary nature of organizational drivers and factors, it is critical to managing them together and not separately. Focusing on one driver of strategic alignment and neglecting other drivers and factors does not lead to favorable performance effects. To solve these problems, researchers suggested that it is essential for decision-making and policy-making managers, especially senior IT managers of hospitals, to precisely assess all the influencing factors on B2B e-commerce investments and ensure the accurate assessment of the maturity level of information technology, the adoption of appropriate methods for the evaluation of an investment in information technology, the processes for determining user information needs, and the level of information technology evaluation resources.[14,15]

A policy seriously pursued by the Iranian Ministry of Health and Medical Education and the Social Security Organization is the elimination of drug prescriptions in traditional insurance books via online registration of medical orders by doctors. Peikari and Rezazadeh[16] examined the relationship between professional errors and the factors of the integrated model of acceptance and use of theoretical technology. They concluded that the use of the electronic prescription system has played a positive role in reducing the professional and operational errors of users, improving the financial and non-financial performance of the pharmacy, promoting the ease of use of this system, facilitative factors, and external and social factors.

Electronic services provide users with easy access to organizational facilities and performance of activities, thereby leading to client trust, which is the biggest asset of organizations. Nevertheless, very few studies have reported the great popularity of electronic services among users of healthcare organizations, and a small percentage of the goals of electronic services have been realized in organizations.[6] By examining Iranian organizations that attempt to provide electronic services at the national level, it is observed that the acceptance of electronic services by employees faces obstacles, and these services have not found their way to these organizations and have failed to fulfill their key role. Regarding the obstacles to the acceptance of electronic services, Motallebzadeh et al.[6] have mentioned that access to technological facilities such as information security, web skills, etc., is among the important indicators of systemic factors that can enable reliable information exchange, facilitate the performance of organizational tasks, etc., in using the technology acceptance model on the perceived usefulness in the acceptance of electronic services. These items make electronic service systems useful for users; as such, systemic factors can influence users’ perception of the usefulness of electronic services. Tavili and Ramezani Qomi[19] also stated that senior managers of organizations should demonstrate their support for the establishment of e-commerce systems by providing suitable and necessary facilities for the implementation of electronic business systems, e.g. providing the necessary hardware and software and following up on their quick installation and implementation.

One of the limitations of this research was the limited studies on e-commerce acceptance in medical centers and hospitals. Since, today, technology and health information systems are intertwined and rapidly expanding, it was expected that e-health and e-commerce technologies should play a more prominent role in Iran’s healthcare sector. Evidence shows that Iranian researchers have entered the field of e-commerce in the healthcare sector later than foreign researchers. One of the reasons for this delay could be the lack of familiarity of health managers and policy-makers with the importance of e-commerce and the state-run nature of most Iranian medical centers. Healthcare system managers must be aware of the measures taken using technology and its positive results in all aspects, e.g. improving the quality of care services, improving the financial performance of medical centers, facilitating the provision of services, facilitating the communication between patients, primary medical care, etc., It is thus suggested that relevant institutions should develop the necessary guidelines to facilitate research on this topic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.