utilizing modern technologies to improve the quality and efficiency of healthcare system has increasingly enhanced ( 1 ) . among these types of technologies , picture archiving and communication system ( pacs ) can be mentioned , which has allowed medical images to be transmitted , stored , retrieved , and displayed in different locations of a hospital or health system ( 2 - 5 ) .
it can be stated that with the advancement of digital imaging devices ( such as magnetic resonance imaging ( mri ) , computed tomography ( ct ) scan , and ultrasound ) during the past two decades , the advent of tools and technologies has improved and facilitated their application . since the early 1980s till the present time
, pacs has replaced the traditional imagery paper - based and film - based printing with an accelerated process ( 6 ) . in recent years , setting up pacs in the middle east countries has been significant . among them , countries such as saudi arabia , united arab emirates , and turkey are placed in a higher rank than other countries . it is predicted that the number of hospitals using this technology from 984 in 2010 will reach to 1680 by 2014 ( nearly twice ) .
in addition , the middle east market for pacs and radiology information system ( ris ) till 2014 is estimated to be 140 billion dollars ( 7 , 8) .
pacs has led to abundant well - established benefits such as improving operational efficiency , and productivity of the medical image system , facilitating accessibility of images anytime and anywhere , reducing waiting time for imagery retrieval and turn - around times of clinical reports , and more effective application of radiology equipment ( 9 , 10 ) .
emergency medicine processes highly depend on rapid diagnosis ; thus , using pacs in the emergency department will eventually result in improved efficiency and patient care .
previous studies support and emphasize the benefits of using pacs in the emergency department ( 11 - 13 ) . in spite of the abundant benefits of employing pacs , there are some challenges in implementing and using this technology like necessity to make changes in the work flow , cost , and users resistance to accept the technology
. the present study deals with investigating one of the above - mentioned challenges , i.e. user acceptance of pacs .
denial of a technology is a big barrier that causes the best and most expensive information technologies to fail .
therefore , addressing various aspects of this issue on a technology such as pacs is an essential task ( 9 , 14 - 16 ) .
iran is also among the countries that have widely applied this technology in the health system and consider its development in the future .
few and limited studies have been carried out on the user acceptance of pacs . according to our search ,
only six studies have quantitatively investigated the acceptance issue of pacs of which only one belongs to the middle east region ( 5 , 10 , 17 - 20 ) . in iran ,
significance of this issue , the influence of local features on the technology acceptance , and the critical role of the emergency department in the health system implies the necessity to perform such studies , especially in developing countries ( such as iran ) .
wise use of resources in order to adapt to the growing advances of modern technologies is an important factor in these countries .
all of these hospitals have been using hospital information system ( his)/pacs technology for at least two years .
this study primarily aims to evaluate pacs acceptance level in the emergency department based on technology acceptance model ( tam ) model .
efficiency of this model in assessing it acceptance in the health field has been proved by numerous studies , and it has been previously used in more than 20 scientific studies in various health related its ( 21 ) . this assessment has been performed in three big educational hospitals in tehran in order to assess the user acceptance of pacs in the emergency department , compare its acceptance in three different hospitals , and investigate the effect of socio - demographic factors on the user acceptance .
in this study , a variant of tam model has been used in order to measure the acceptance level of pacs .
the original tam model , which is rooted in the theory of reasoned action ( tra ) , describes how a technology is accepted and applied by users . in this model developed by davis ,
two parameters of 1-  the degree to which a person believes that using a particular system ( perceived usefulness ( pu )  and the degree to perceived ease of use ( peu ) would enhance his or her job performance and 2-  the degree to which a person believes that using a particular system would be free from effort  have been specified as the primary variables .
peu has a casual effect on pu and each of these variables would influence the component of user s attitude towards use , and eventually , the acceptance issue is defined to be influenced by three factors ( figure 1 ) ( 14 , 22 - 24 ) . in order to describe the acceptance issue more precisely ,
the model was developed in different ways and more variables have been introduced to it . according to the study conducted by lee et al .
( 25 ) , more than twenty variables including education level , computer application proficiency , socio - demographic variable , system management and support , and user s interaction in different versions of tam have been used .
subsequent to the investigations performed in this regard , including unified theory of acceptance and use of technology ( utaut ) , holden and karsh s study ( 21 ) , and tam2 , the model used in the present study was selected ( figure 2 ) . the difference between this model ( similar to the model in aldosari s study ( 17 ) ) and the tam original model is the introduction of the change variable , and also , eliminating the effect of peu on pu ( differentiated it from utaut model ) and omitting the attitude toward use as a variable ( distinguished it from tam2 model ) .
data of this research were collected from the emergency department of three general educational hospitals .
baqiyatallah hospital includes 56 beds located in the emergency department with nearly 95000 admission ratio per year .
imam hossein hospital consists of 68 emergency beds with about 140000 admission ratio per year .
the first part consists of personal information including age , gender , education , occupation , and rate of using pacs .
the study surveyed all health workers in three emergency departments of three educational hospitals selected in a random process .
linguistic validation of the questionnaire was achieved by translation in persian and back translation in english .
twenty participants filled the questionnaire with the time interval of two weeks and intra - class correlation coefficient ( icc ) was calculated to be 0.9 .
student t - test was conducted comparing means in two groups and analysis of variance ( anova ) was used to compare means in more than two groups .
stepwise multiple regression model was used to predict factors influencing acceptance score as the dependent variable .
all variables correlating with acceptance score in bivariate analysis at significance level of 0.1 were entered in the model .
variables that were significant in the model at the level of 0.05 remained in the model .
student t - test was conducted comparing means in two groups and analysis of variance ( anova ) was used to compare means in more than two groups .
stepwise multiple regression model was used to predict factors influencing acceptance score as the dependent variable .
all variables correlating with acceptance score in bivariate analysis at significance level of 0.1 were entered in the model .
variables that were significant in the model at the level of 0.05 remained in the model .
nurses had the largest participation in the study in all three hospitals ( 57% ) .
female workers were significantly lower in baqiyatallah hospital ( chi square : 12.23 , p value : 0.002 ) .
rate of using pacs was higher in baqiyatallah hospital compared to two other hospitals ( chi square : 12.04 , p value : 0.017 ) .
table 2 summarizes the questions related to 4 factors including pu , peu , change and acceptance .
more than 95% of participants had the experience of working with pacs more than one year .
most of the respondents recognized pacs as a useful and simple tool in their daily practice ( mean ( sd ) of pu : 4.25 ( 5 ) , mean ( sd ) of peu : 4.20 ( 52 ) ) . according to change construct , 81% of participants reported that pacs makes their job much easier . 
making their work happier  had the lowest role between change related questions ( mean ( sd ) : 3.98 ( 0.73 ) ) .
the behavioral was the variable measuring acceptance . according to this variable , mean of behavioral was 4.01 with the standard deviation of 0.35 suggesting a high level of acceptance with pacs system in three hospitals . compared to pu
, peu and change , more items in behavioral construct acquired scores less than 4 ( 6/10 ) .
the question asking about cooperation with pacs personnel had the lowest rating mean ( sd ) : 3.65 ( 8) .
considering three hospitals , men had more acceptance than women , but this difference was not statistically significant ( t : 0.28 , p value : 0.80 ) . among the demographic variables investigated here , no statistically significant difference was observed between different subgroups of age and gender for mean score of pu and peu and change .
regarding their educational degree , participants of this study were classified into four groups of people with a bachelor s degree , master s degree , md , phd or specialist .
participants with the specialty degree got a higher acceptance score than the three other groups ( mean ( sd ) : 4.17 ( 0.20 ) ) . running one - way anova and tukey test as post - hoc test
, this difference was statistically significant ( f : 3.33 , p value : 0.02 ) ( table 3 ) . yet
, this difference on pu , peu , and change is not significant . moreover , according to their occupation , participants were divided into four groups of physicians , nurses , residents and other professions .
these four groups were not statistically different in their scores for acceptance , pu , and change .
regarding use of pacs , subjects were classified into three groups including those who always used pacs , those who sometimes used it , and those who rarely used it .
these groups did not show any significant difference in their scores for pu , acceptance , peu and change .
abbreviations : pacs , picture archiving and communication system ; sd , standard deviation . at - test for comparison of variables between two groups ,
stepwise multiple regression model was used to predict the significant variables influencing acceptance as the dependent variable . in our model , all three variables of pu , peu and change had a significant effect in prediction of acceptance .
the most influencing factor was change with the beta of 0.21 ( p value < 0.001 ) .
the second factor was pu with beta of 0.18 ( p value < 0.001 ) and the third factor was peu with beta of 0.17 ( p value < 0.001 ) .
studies that have investigated the acceptance of pacs system are small in number . among the middle east countries , only one study has been carried out investigating the acceptance level of pacs in the radiology department of a hospital in saudi arabia ( 17 ) . pare and trudel investigated the challenges of pacs actualization in hospitals . in their study , they pointed to the significance of human factors among other factors ( 6 ) .
have examined the acceptance of pacs quantitatively in the radiology department of a hospital in belgium . in their study , user acceptance of pacs was examined before and after its initiation in the hospital ( quantitative investigation ) ( 18 ) . in a study carried out by pynoo et al .
( 20 ) , two factors influencing physicians acceptance of pacs and the possibility of changing these factors by enhancing their experience in pacs utilization were considered .
finally , a research performed by white et al . focused on the challenges of emergency department in employing digital radiology instead of the traditional paper and film - based system for printing images . among the findings of this research ,
the model used in the present study to evaluate pacs acceptance is in accordance with the model applied in the existing studies .
use of tam model is one of the routine methods in assessing the acceptance of information technologies . in holden s review , this method is generally capable to evaluate 30 to 40 percent of the changes and factors affecting the acceptance level ( 21 ) . in the current study ,
all three factors of pu , peu , and change have significant effect on the acceptance .
the factor that had the highest impact was change , which includes factors affecting practice situation .
the tam model was also used in the mentioned study , and it was concluded that all three factors of pu , peu , and change influenced the acceptance , and the model obtained in that study also predicted 41 percent of acceptance change , which corresponds to the value gained in the present research . in a study conducted by aldosari ( 17 ) , pu had the highest effect on predicting the acceptance changes and in the present study , change had the greatest coefficient . to account for this difference
, it could be mentioned that the present research was performed in the emergency departments of those referral and busy hospitals of tehran . in these emergency departments , the change that has been made by pacs system in the performance of physicians and nurses due to patients crowd is mostly regarding the participants perception about the system itself . on the other hand
, it is expected that according to the existing infrastructures in the developing countries , pacs performance may have more dysfunctions compared to other countries where the studies have been carried out ; hence , pu and peu factors may differ . according to the study performed in imam khomeini hospital of urmia on pacs problems in iran ,
4.38 percent of the administrative practitioners of the hospital and 6.21 percent of the staff were not aware of pacs benefits ( 26 ) .
since the questionnaire was distributed among all subjects , this can be considered as one of the reasons for low effect of pu on pacs . in a study performed by bayat et al . in iran , technical infrastructures
have been introduced as the greatest barrier in utilizing health technologies in iran ( 27 )
. a closer look at the pu factors , makes it evident that facilitating the work and making it efficient as well as enhancing the quality of patient care and control over the system require a system with appropriate infrastructure than change factors .
hence , this factor differs with the study carried out by aldosari ( 17 ) . on the other hand , the study performed by aldosari ( 17 )
was performed in the radiology department . in the emergency department , due to the higher significance of diagnosis speed and efficiency of the health technology
, it is expected that a change made by technology has more effect on the acceptance level . in the study carried out by duyck et al .
( 19 ) , another model has been used to investigate the acceptance , but in that model , pu and peu have been among the factors affecting the acceptance .
the applied model has also predicted 33 percent of acceptance , which is approximately in accordance with the current model ( 19 ) . among the other results of this study
are the effects of age , gender , occupation , and educational degree on the four factors of acceptance , pu , peu , and change . in this study , different age and gender groups did not have a significant effect on the investigated factors .
studies conducted by duyck et al . ( 18 ) and aldosari ( 17 ) also confirm this finding . in a review by ward et al
( 28 ) , gender and age did not have a significant effect on the participants attitude towards health - related it . in a study carried out by duyck et al .
( 18 ) , no significant difference of acceptance scores was observed among different occupations which accords with our results , although in the mentioned study , various medical specialty groups have not been compared with each other . in our study ,
the group with specialty degree had a higher mean acceptance score compared with the other three groups which is also statistically significant .
regarding the reasons for these results , it can be noted that this group has the highest application of pacs and on the other hand , working with the technology is easier for them and they do not just rely on the instructional courses to work with pacs ( 29 ) . comparing the three hospitals with each other , baqiyatallah hospital has a higher mean acceptance than the other two hospitals .
this hospital has more robust infrastructures to set up a pacs system than the other two hospitals .
it is worth mentioning that in our results , the use of pacs was also higher in baqiyatallah hospital .
further studies are required in this area in order to justify this result . among the strengths of this study
, it can be noted that according to our research , this study is the first one that has examined the acceptance in the emergency department .
( 30 ) , when employing a technology , success of that technology can vary from section to section . on one hand , the emergency department is one of the departments that has the highest level of pacs system use in a hospital ( 12 ) and performing this study in the emergency department will largely contribute to the literature on pacs acceptance .
on the other hand , this study has been carried out in the emergency department of three educational hospitals in tehran that are among the most crowded and most referral emergency departments .
although emergency specialists are young people with more acceptance of new technologies , they are the main target of pacs in hospitals .
( 21 ) , a key point in increasing the use of it is to enhance the acceptance , and high acceptance in these emergency departments can be evidence for an overall increase in using pacs in iran .
on the other hand , today , the model used in this study in order to assess the acceptance is the gold standard model ( 21 , 31 , 32 ) . despite being simple
, this model constitutes 10 percent of the literature on the evaluation of acceptance ( 21 ) . according to the limitations of this study
, it can be mentioned that using the resulted model , less than half of the acceptance changes can be predicated . in spite of being in accordance with other studies in this area ,
this means that there are unknown and uninvestigated variables that must be considered in future researches .
another limitation of this study is the low response rate and low participation of residents .
this is a potential source of bias that residents with more positive attitude have more participation in our study . in conclusion , pacs is highly accepted in all three hospitals especially among the specialists .
. our study can be used as an evidence of pacs acceptance in emergency wards .
further studies are needed in order to discover other factors influencing pacs acceptance or to compare the acceptance levels in different wards .
 backgroundpicture archiving and communication system ( pacs ) has allowed the medical images to be transmitted , stored , retrieved , and displayed in different locations of a hospital or health system . 
 using pacs in the emergency department will eventually result in improved efficiency and patient care . in spite of the abundant benefits of employing pacs 
 , there are some challenges in implementing this technology like users resistance to accept the technology , which has a critical role in pacs success.objectivesin this study , we will assess and compare user acceptance of pacs in the emergency departments of three different hospitals and investigate the effect of socio - demographic factors on this acceptance.materials and methodsa variant of technology acceptance model ( tam ) has been used in order to measure the acceptance level of pacs in the emergency department of three educational hospitals in iran . a previously used questionnaire was validated and utilized to collect the study data . 
 a stepwise multiple regression model was used to predict factors influencing acceptance score as the dependent variable.resultsmean age of participants was 32.9 years ( standard deviation [ sd ] = 6.08 ) . 
 participants with the specialty degree got a higher acceptance score than the three other groups ( mean  sd = 4.17  0.20 ) . 
 age , gender , degree of pacs usage and participant s occupation ( profession ) did not influence the acceptance score . in our multiple regression model , 
 all three variables of perceived usefulness ( pu ) , perceived ease of use ( peu ) and the effect of pacs ( change ) had a significant effect in the prediction of acceptance . 
 the most influencing factor was change with the beta of 0.22 ( p value < 0.001).conclusionpacs is highly accepted in all three emergency departments especially among specialists . 
 pu , peu and change are factors influencing pacs acceptance . 
 our study can be used as an evidence of pacs acceptance in emergency wards . 
1. Background
2. Objectives
3. Materials and Methods
3.1. Statistical Analysis
3.2. Ethical Statement
4. Results
5. Discussion