Patient Acceptance Analysis on National ID Smart Card in Health Care Organization Using a Thailand Hospital Example

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(1)Taipei Medical University. School of Health Care Administration. Master‘s Thesis. Patient Acceptance Analysis on National ID Smart Card in Health Care Organization Using a Thailand Hospital Example. MALLIKA KEARASARN. ADVISOR: WEN-SHAN JIAN JUNE 2011.

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(5) Acknowledgements Firstly, all thanks and praise be to my mother for everything. Further, this research study cannot be accomplished without kind support guidance and encouragement from many people whom I would like to sincerely thank.. I would like to express my sincere gratitude and great appreciation to Assistant Professor WenShan Jian, my advisor, for his precious guidance, support and valuable suggestion and his patient through the period of the research study. Also, I would like to thank Assistant Professor YuehHsia (Sherry) Chiu, Ph.D. and Professor Yu-Chuan (Jack) Li, M.D., Ph.D. for their valuable contribution in serving as committee members, Professor Hstien-Chia Wen, Professor KuoCherh Huang, Professor Chiung-Hsuan (Meggan) Chiu, Professor Mei-Ling Sheu, Professor YiXin (Elsa) Hsu, Professor Sheu-Wen Zhuang and all professors in school of Health Care Administration for precious suggestion and comments on this research study.. Special thanks are expressed to all professors in school of Health Care Administration and Nongkhai Hospital staffs for their valuable time, kind support and useful information to complete this research study. In addition, my heartiest regards convey to Taiwan International Cooperation Development Fund (ICDF) and Taipei Medical University (TMU) for providing me the scholarship and the great opportunity to pursue master degree in Health Care Administration in TMU.. Moreover, I would like to thank so much to my best friends, especially Phet, Ploy, Jum and Cookie. You are always by my side in any events. Thanks are also extended to my close friends Miss Phanwadee Oraphan, Miss Thidarat Choopolkrang, Miss Jeerapha Kemapornchai, Miss Jongdee Muangthong, Miss Revadee Punlor and Miss Parichat Srifah for their encouragement and support. And, thanks to my TMU friends (Pachuri, Pooky, Sassy, Bird, Ismaila, Awa, Edward, and Q). You make me believe that I can achieve.. Finally, I would like to give the greatest thankfulness to my beloved family for their love, encouragement and understanding in dealing with all the challenges I have faced during my study. To all of them, this research is gratefully dedicated.. i.

(6) Abstract Title of Thesis:. Patient Acceptance Analysis on National ID Smart Card in Health Care Organization Using a Thailand Hospital Example. Author:. Miss Mallika Kearasarn. Thesis advised by:. Assistant Professor Wen-Shan Jian. National ID Smart Card project (e-ID project) is a government policy, under Egovernment project. Thailand has launched e-ID project in 2003. Involving the Health Care Organization, National ID Smart Cards have fully replaced a paper-based health insurance cards in whole country since October 2010. This study uses a quantitative approach to determine an acceptance of patients by using National ID Smart Card. The respondents are the outpatients who live in Nongkhai Province. A total of 250 outpatients were sampled and 176 of them are valid and used. Results of this study revealed that the patient who have not used e-ID Card are intend to use it because they perceived usefulness and ease of use. Moreover, there are significant different between male and female of using it (p<0.001). This study expose to the government for future plan also using a more than decade experience in Taiwan to improve the project. Key words: Patient Acceptance, National ID Smart Card, e- government, Health Care Organization. ii.

(7) Table of Content Page Acknowledgements…………………………………........................................................... I Abstract…………………………………………………………………………...……….. II Contents…………………………………………………………………...…...………….. III Tables…………………………………………………………………………...…………. V Figures…………………………………………………………………………...…………VI. Chapter 1:. Chapter 2:. Introduction 1.1. Background…………………………………………………….…......1. 1.2. Rationale for the Study………………………………………….…....2. 1.3. Taiwan Health Care Scheme………………………………………....5. 1.4. Significance of the Study………………………………………….....6. 1.5. Research Objective……………………………………………..........7. Literature Review 2.1. Definition of Smart Card……………………………………….........8. 2.2. Definition of Patient Acceptance………………………………........10. 2.3. Evolution of Health Card Scheme…………………………………...13. 2.4. Health Financing……………………………………….…………....14. 2.5. Universal Coverage Scheme………………………….…………..…17. 2.6. E-Government………………………………………….…………....17. 2.7. Thai National ID Smart Card…………………………………….….19. 2.8. Lesson from other Countries……………………………...................23. 2.9. Privacy and Security……………………………………………..….25. iii.

(8) Table of Content (Cont’d) Page Chapter 3:. Chapter 4:. Chapter 5:. Methods 3.1. Research Structure.....................…………………………………....27. 3.2. Operational Definition……………………………………….……..28. 3.3. Research Hypotheses.........................................................................31. 3.4. Study Design………………………………………………………..31. 3.5. Study Population & Sampling Technique…………………………..31. 3.6. Data Collection……………………………………………………...33. 3.7. Data Analysis………………………………………………………..33. Results 4.1. Introduction………………………………………………………....35. 4.2. Descriptive Analysis………………………………………………..35. 4.3. Inferential Analysis…………………………………………………37. Discussion 5.1. Discussion………………………………………………………….46. 5.2. Conclusion…………………………………………………………49. 5.3. Recommendations……………………………………………….…51. 5.4. Limitations………………………………………………………....52. References…………………………………………………………………………………53 Appendixes Appendix 1. Millennium Development Goals, target and indicators……………………59. Appendix2. Summary of the 10th National Health Development (2007-2011)…………61. Appendix3. Questionnaire………………………………………………………………63 iv.

(9) List of Tables Table Title. Page. 1-1. Characteristics of Thailand‘s population, 1960-2020………………………… 3. 2-1. Health service utilization pattern for reported I11 persons comparing different survey……………………………………………………………….. 14. 2-2. The key feature of the insurance programs………………………………….... 15. 2-3. The content of Thai National ID Smart Card ………………………….……... 21. 2-4. Total Budget and number of National ID Smart Card Project ….……………. 22. 3-1. Operational Definition of the research………………………………………... 28. 3-2. Validity and Reliability Results………………………………………………. 32. 4-1. General profile of the respondents……………………………………………. 36. 4-2. Average Mean of category variables and Attitude toward using National ID Smart Card……………………………………………………………………. 38. 4-3. Pearson Correlation Analysis on Among six category variables and Attitude toward using National ID Smart Card………………………………………... 4-4. 41. Independent Sample t-test and One-way ANOVA analysis of relationship among Attitude toward using National ID Smart Card and Demographic variables of respondents……………………………………………………... 4-5. 42. Multiple regression analysis of the relationship among attitude toward using and predictor variables……………………………………………….............. v. 43.

(10) List of Figures Figure. Title. Page. 2-1. Feature of Smart Card and Card Reader……………………………………. 8. 2-2. Contact Smart Card…………………………………………………………. 9. 2-3. Contactless Smart Card……………………………………………………... 9. 2-4. Hybrid Smart Card…………………………………………………………. 10. 2-5. Technology Acceptance Model……………………………………………... 12. 2-6. Thai National ID Smart Card……………………………………………….. 20. 3-1. Research Structure………………………………………………………….. 27. 4-1. Distribution of Data Collection……………………………………………... vi. 33.

(11) CHAPTER ONE INTRODUCTION. 1.1 Background Thailand is located in the center of the Southeast Asia Region, with a land size of 513,115 square kilometers, 76 provinces; 876 Districts; and 7,282 Sub-district (Tambon). It has a total population of around 67.1 million people. It is a Constitutional Monarchy. Thailand shares borders with four neighboring countries, namely Myanmar to the North and West, Laos to the Northeast, Cambodia to the East, and Malaysia to the South. Thailand's abundance of natural resources and advantageous location are the primary reasons for its continuing prosperity. The Thai National Identification (ID) card was implemented following the electronic government (e-government) projects. Many governments under e- government projects are oriented to services by focusing on the implementation as well as the use of widespread digital services through one-stop services of access for citizens (Anthopoulos, Siozons, & Tsoukalas, 2007). In 2003, Dawes, Pardo, & Cresswell study found the dimensions of designing egovernment information access programs. Schedler & Summermatter (2007) also discovered the needs of citizens to create the websites for online government transactions. Consequently, governments have increased infrastructure and services provided to their citizens (Kim, Pan, & Pan, 2007). In 2001, the electronic government (e-government) was launched in Thailand. The, then Thai government created the Information Communication Technology Master Plan to advocate this project. The e-government preliminaries were introduced to develop Thailand to become a country with e- industry, e-commerce, e-education, and then e-society. Then, in 2006, the government has attempted to launch many e-government projects, i.e. Smart Card, e-auction, epassport, and GFMIS (Government Fiscal Management Information Systems). This is a big jump of computerization period in the public sector. These projects were expected to have a great deal of impact to the people and public services since the government had allocated a lot of budget on these projects (Lorsuwannarat, 2006).. 1.

(12) 1.2 Rationales for the study Healthy is very important for people of a nation. A good quality of life is the highest target to developed country. And, the achievement of healthy society is the target of all nations. In Thailand, a solving concept by sustainable is a health reform system which aims to build up Thai health, reduce cost of health which more than 250,000 million baht (around 8,333 million USD) per year, reduce mortality rate of protectable diseases, and makes the people feel comfortable and convenience as the Thai Constitution (2007), section 51 mentioned that the Thai people has an equality right to get a suitable service and have a standard with free of charge (Suchonwanich, 2010). On the other hand, the medical records and healthcare service system are very important to access the goal of this section and the government needs to pay attention as well. Accordingly, Thai population has increased and consequently problems of management also increased. The Thai government tries to find the ways to solve this problem by improving the healthcare system. Therefore, the government had launched project named ―e- ID Smart Card Project‖ to improve a delay and inconvenience problem. However, many things still are questions for instance: Can the ID smart card solve the real problem? Is it secure? Is there the system prompt to implement? Moreover, many people still do not know about this project. And, when they go to the hospital, they still have to use many cards to get the medical services. 1.2.1. Demographic characteristic of Thai population More than 30 years ago, Thailand has registered outstanding advanced with declines rates of infant and maternal mortality, leading the country to meet the Millennium Development Goals (MDGs) (Appendix1). The size of Thai population has increased between 1960 and 2000, the infant and maternal mortality rates have declined, but the life expectancy has increased. From 1980 to 2000, life expectancy for males increased from 60 to 66 and 70 to 75 years for females. Also from 1960 to 2009, the infant mortality rate declined from 84.3 per 1,000 live births to 12.5 per 1,000 live births (Table1-1). This was due to a successful immunization program and the provision of maternal and child health services were emerged. The five major causes of death among people of all ages, as of the year 2005, were malignant neoplasm, accident and poisonings, hypertension and cardiovascular disease, disease of the heart, and diseases of the respiratory system, (Angkasuvapala & Siasiriwattana, 2006).. 2.

(13) Table1-1: Characteristics of Thailand‘s population, 1960-2020. Source: Updated Health Policy in Thailand 2009, Bureau of Policy and Strategy, MOPH. (P) = Projection.. 1.2.2. Socioeconomic status of Thai population Basically, Thai economy mostly was agriculture based but over past ten years it has been transformed into a product of the National Economic and Social Development Plans that were started in 1961 to support this modification. In 1960, the proportion of agriculture decreased from 40 percent of gross domestic product (GDP) to 10 percent in 2002, and industry sector increased from 13 percent to 37 percent of GDP. The economic growth has been excessive exceeding thirty years until year 1996 when Thailand faced an urgent economic crisis swiftly (Sakunphanit, 2006). This economic crisis procured a 60 percent detracting of the baht and negative growth effects many years later. To this, Thailand had a structural reform loan of US$17.2 billion from the International Monetary Fund (IMF). In 1997, the Thai economy has generated a negative growth rate of 1.4 percent, and a greater decline to minus 10.5 percent in 1998. Nevertheless, a restart of the Thai economic growth exposed since 1999, with a rise of 4.8, 5.3 and 6.3 in 2000, 2002 and 2004 respectively. In 2006 growth rate is decline a little bit to 5.1 (Sakunphanit, 2006). The objectives of Tenth National Economic and Social Development Plan (2007– 2011), which related to develop health care for Thai citizens as to increase the potential of communities by linking them in networks to serve as the foundation for developing the 3.

(14) economy and quality of life such as to conserve, rehabilitate, and utilize the environment and natural resources in a sustainable fashion to achieve sufficiency and reduce poverty, and to reform the production structure for goods and services for value creation on a foundation of knowledge and innovation (Appendix2). 1.2.3. Development of Information Technology Information technology (IT) is emerging more and more in health care. It is evident that the use of modern information technology offers tremendous opportunities, but there are also hazards associated with information technology in health care: modern information systems are costly, their failures may cause negative effects on patients and staff, and possibly, when insufficiently designed, they may result in spending more time with the computer than with the patient Therefore, a rigorous evaluation of IT in health care is recommended and of great importance for decision makers and users of future information systems (Rigby, 2001.) In the healthcare industry, Houghton (2002) stated that there are some areas where leading-edge ICT developments are employed and developments at the leading-edge will be important. In other areas the health system is some way behind other industries in the adoption and application of information management and information systems. In general, the situation seems to be one of relatively slow progress through the evolving computing paradigms of functional computing, enterprise computing and network computing. Some functions are highly automated, but integrated enterprise computing in hospitals and clinics is still rather rare. The healthcare sector's fragmented constituencies and complex transactions present a major barrier, making the application of Information and Communication Technology (ICT) enabled information management systems extremely difficult. It is too early to right-off the potential impact of ICTs as mere hype, but it is clear that progress is slow and there are many hurdles to overcome. Consequently, at the system level, the impacts of ICTs are likely to be in overall management and cost control, and in influencing decisions at the point of care. In terms of care, the impacts are likely to be in such areas as quality control, patient safety and general improvements in services, outcomes and performance (Houghton, 2002). Since new technology changes our lives relentlessly. Innovations are a pervasive force in an organization and in society. Innovation will not go away - it is not the next big thing – it is away there. Technology induced-changes in the workplace have profound impacts on organizational effectiveness, careers and workplace comfort. Some company leverages technology to sustain success, others do not. Either way, there is no place to hide. That is, there are three primary reasons why attention to the issue of technological change is critical. First, technology-driven change is everywhere and always present. Second, in the world of work, 4.

(15) competitors use technology as part of major success strategies. Third, value-capture from new technology is challenging and never guaranteed (Ettlie, 2006). The electronic health record, or EHR, is a means of storing important patient information and electronic medical records for later analysis and retrieval. EHR, technology represents a vast improvement over paper-based systems, and is changing the way healthcare is administered in medical practices. Accessing patient information and medical histories from a handheld device or desktop computer gives physicians, clinicians, and office personnel instant access to the information they need without searching through paper files. EHRs help to streamline clinical workflow, leading to improved patient care, reduced practice operating costs, and increased billing opportunities. The study of Thai National ID Smart Card is different from others because it provides a unique perspective into the deployment of smart card. Being totally different from the optional usage of smart cards in developed countries; the usage of smart cards in Thailand, currently, is a "mandatory" for all Thai citizens. This situation provides important policy implications for the government and relevant stakeholders, the Thai citizens themselves.. 1.3 Taiwan Health Card Scheme (HCS) More than ten years experiences in Taiwan, which launched a nationwide Health Smart Card project in 2002 to help reduce fraud, facilitate electronic claims and improve health care quality. Hsu, et al. (2010) mentioned that there are two versions of the card; one for citizens, one for professionals and they are used mainly to track access to care of the insured. But they are also used to store such data as prescriptions, medical procedures, vaccinations and allergies, and are a flag for organ donation willingness. They also found the health care providers can use the card as a powerful tool to retain continuity of care. It is almost like a personal and portable electronic health record summary. In 2006, Hsu said that the system of Taipei Municipal Wanfang Hospital (which is managed by Taipei Medical University) is able to detect drug–drug interactions for prescriptions from different hospitals by checking the electronic prescription records on the patient‘s National Health Insurance (NHI) integrated circuit (IC) card. These cards have been in use since July 2003 and have fully replaced paper cards since January 2004. Hospitals must be able to use and support the IC cards to provide medical services for insured patients. Four types of information are stored on the NHI IC card: personal information, NHI-related information, medical service information (e.g., drug allergies, long-term care prescriptions, ambulatory care prescriptions, and certain medical treatments) and public health information (including personal immunization 5.

(16) records and willingness to donate organs). The electronic prescription records on the NHI IC card are a valuable way to detect drug–drug interactions between prescriptions from different hospitals. Whilst, Liu, et al. (2006), founded that very few hospitals complained about the interruptions caused by nontechnical problems; instead, the major problems that caused the interruptions of medical services were the impairment of NHI-IC cards and online authentication testing. Therefore, they recommendations for those who are planning to implement similar projects as: (1) provide public-awareness programs or campaigns across the country for elucidating the health smart card policy and educating how people can use and store the cards, (2) improve the quality of the NHI-IC cards, (3) conduct comprehensive tests in software and hardware components associated with NHI-IC card systems before operating the system, and (4) perform further investigations in authentication approaches and develop tools that can quickly identify where and what the problems are. Although there was not enough direct incentive for hospitals to adopt NHI-IC cards into their medical services, the cards are simple and convenient for the public to access medical services. It is expected that the project will gradually move to the phase 2 and phase 3. Hence, more and more patient health information can be stored in the cards as well as in the TBNHIs database. The healthcare providers can take the advantages of the availability of such data to provide better quality of care, while the TBNHI can keep track of the use of medical resources precisely to prevent the potential medical frauds timely. These also can implement or adapt to improve e-ID Smart Card project effectively in Thailand.. 1.4 Significance of the Study There are some people, especially the rural area, who have not known that they can use just National ID Smart Card to get the medical services and also have not got enough information about what this card is?, how does it works? And how useful it is? In a paper-based system, the work flow process takes a long time for patients. Privacy and Security still are the issues that most patients are worried and there is no law to protect patients from the misuse of personal data by government officials. Therefore, it hopes that study can come up with recommendation that can be based to enact a law to protect user of National ID Smart Card. Moreover, after the government implemented this project, there was someone still using another health card with ID card to get the medical services.. 6.

(17) 1.5 Research Objectives This research study focuses on the study of National ID Smart Card on Patient Acceptance regarding health care organization in Thailand to investigate an acceptance to use National ID Smart Card through an evaluation behavior, attitude, concerning and opinion of the patient. The specific objectives of the study are as follows: . To find factors effect on e-ID usage.. . To determine perceived usefulness (PU) and perceived ease of use (PEOU) regarding using e-ID.. . To investigate perceived barriers of taking action (PBTA) factors affect to use e-ID.. . To explore internal and external cues affects to use e-ID.. . To discover the differences of each categories of e-ID usage.. 7.

(18) CHAPTER TWO LITERATURE REVIEW. 2.1 Definition of Smart Card Smart Card is a simple plastic card, just at the size of a credit card, with a microprocessor and memory embedded inside is a smart card. Beside its tiny little structure it has many uses and wide variety of applications ranging from phone cards to digital identification of the individuals (Tolga, 2001). In terms of National ID Smart Card, it is a portable document, typically a plasticized card with digitally-embedded information that someone is required or encouraged to carry as a means of confirming their identity. (Anneshwa, 2007). Figure 2-1: Feature of Smart Card & Card Reader. 2.1.1 There are three types of Smart Card 1. Contact Smart Card is the card which is easiest to use. There is 8 pins on a contact area of approximately 1 square centimeter (0.16 sq in), comprising several gold-plated contact pads. These pads provide electrical connectivity when inserted into a card reader.. 8.

(19) Figure 2-2: Contact Smart Card. 2. Contactless Smart Card A second card type is the contactless smart card, in which the card communicates with and is powered by the reader through RF induction technology (at data rates of 106– 848 Kbit/s). These cards require only proximity to an antenna to communicate. They are often used for quick or hands-free transactions such as paying for public transportation without removing the card from a wallet.. Figure 2-3: Contactless Smart Card. 3. Hybrid Smart Card or Combination Smart Card Dual-interface cards implement contactless and contact interfaces on a single card with some shared storage and processing. An example is Porto's multi-application transport card, called Andante, that uses a chip with both contact and contactless interfaces.. 9.

(20) Figure 2-4: Hybrid Smart Card. 2.1.2 Smart Card Reader Dhir (2004) defined like an essential part of smart card system. The card readers can exchange or transfer information. There are several types of card readers each specific to a particular application. One type connects to PC to purchase via the internet (e-commerce) or to load money onto smart card through on-line banking. Another type is a handheld wireless terminal used by taxi drivers and in restaurants.. 2.2 Definition of Patient Acceptance The alternative to avoidance is acceptance. Etymologically, acceptance comes from Latin root ―accipere‖ meaning to receive or take what is offered. Psychologically, it connotes an active taking in of an event or situation. Psychological acceptance at its lowest level is implicit in any psychotherapy, because, at the minimum, the client and therapist must ―take in‖ the fact that there is even a problem to be worked on at a higher level, acceptance involves an abandonment of dysfunctional change agendas and an active process of feeling feelings as feelings, thinking thoughts as thoughts, remembering memories as memories, and so on (Steven C, et al., 1999). Acceptance applies to different areas in different ways—it is not always the appropriate action. ―Taking what is offer‖ (acceptance) is always the best course in the area of personal history, because history is never changeable. Private experiences are a more complex case. Both acceptance and first-order change may be relevant. Most of people are those for whom deliberate change has already shown itself to be problematic, but at more moderate levels the regulation of private experiences may be somewhat successful. At the other extreme, ―taking what is offered‖ is rarely the best course in the area of overt behavior, because overt behavior is changeable and there is no reason to accept that which is negative and changeable. The ultimate test between two is workability (Hayes, S.C., et al, 1999). 10.

(21) Technology Acceptance Model (TAM) Generally, acceptance is defined as an antagonism to the term refusal and means the positive decision to use an innovation Simon (2001). Even though there are many theoretical frameworks for researches about IT acceptance, for instance: Theory of reasoned action (TRA) and Theory of planned behavior (TPB) by Ajzen in 1985 and 1991, Motivational Model (MM) by Vallerand in 1997, Combined TAM and TPB (C-TAM-TPB) by Taylor and Todd in 1995 and Innovation Diffusion Theory (IDT) by Moore and Benbasat in 1991 etc, still, among them, TAM is believed to be ―most robust, parsimonious and influential in explaining IT adoption behavior‖ (Yu, Liu, & Tao, 2003). According to Gentry & Calantone (2002), TAM is recommended not only because this model is applicable in general situation, but also because it can be applied to all attitudes in different contexts. Based on the Theory of Reasoned Action; TRA, Davis (1986) developed the Technology Acceptance Model which deals more specifically with the prediction of the acceptability of an information system. The purpose of this model is to predict the acceptability of a tool and to identify the modifications which must be brought to the system in order to make it acceptable to users. This model suggests that the acceptability of an information system is determined by two main factors: perceived usefulness and perceived ease of use. Moreover, Karahanna, Stuab & Chervany (1999), also Venkatesh & Davis, (2000) said that the purpose of TAM is to explain and predict Information Technology (IT) acceptance and to facilitate design changes before users have experience on a particular system. It formed the foundation of many researches in the early days that used to predict users adoption of IT in the organizational workplace. For example, TAM was used to explaining usage of e-mail system, word processing and graphics software, and it later extent usage to cover system applications like Window-based working environment. In the theory of reasoned Action (TRA), the Technology Acceptance Model postulates that the use of an information system is determined by the behavioral intention, but on the other hand, that the behavioral intention is determined by the person‘s attitude towards the use of the system and also by his perception of its utility. According to Davis (1986), the attitude of an individual is not the only factor that determines his use of a system, but is also based on the impact which it may have on his performance. Therefore, even if an employee does not welcome an information system, the probability that he will use it is high if he perceives that the system will improve his performance at work. Besides, the Technology Acceptance Model hypothesizes a direct link between perceived usefulness and perceived ease of use. With two systems offering. 11.

(22) the same features, a user will find more useful the one that he finds easier to use (Dillon & Morris, 1996).. Figure 2- 5: Technology Acceptance Model from Davis, Bagozzi et Warshaw (1989). According to Davis (1986) perceived ease of use also influences in a significant way the attitude of an individual through two main mechanisms: self-efficacy and instrumentality. Selfefficacy is a concept developed by Bandura (1982) which explains that the more a system is easy to use, the greater should be the user‘s sense of efficacy. Moreover, a tool that is easy to use will make the user feel that he has a control over what he is doing (Lepper, 1985). Efficacy is one of the main factors underlying intrinsic motivation (Bandura, 1982) and it is what illustrates here the direct link between perceived ease of use and attitude. Perceived ease of use can also contribute in an instrumental way in improving a person‘s performance. Due to the fact that the user will have to deploy less effort with a tool that is easy to use, he will be able to spare efforts to accomplish other tasks (Davis, 1986). It is however interesting to note that the research presented by Davis (1989) to validate his model, demonstrates that the link between the intention to use an information system and perceived usefulness is stronger than perceived ease of use. According to this model, they therefore expect that the factor which influences the most a user is the perceived usefulness of a tool. Furthermore, application of the distinction comes from one of the most research models of the relationship between cognitive-attitudinal factors and health behavior change, the health believe model (HBM). The HBM is a health behavior change and psychological model developed by Irwin M. Rosenstock in 1966 for studying and promoting the uptake of health services. Another meaning is generally used in any studies on health behaviors, especially in explaining or predicting health-related behaviors (Sun, Guo, Wang, & Sun, 2006; Lajunen & Rasanen, 2004). The model was furthered by Becker and colleagues in the 1970s and 1980s. 12.

(23) Subsequent amendments to the model were made as late as 1988, to accommodate evolving evidence generated within the health community about the role that knowledge and perceptions play in personal responsibility. Originally, the model was designed to predict behavioral response to the treatment received by acutely or chronically ill patients, but in more recent years the model has been used to predict more general health behaviors (Ogden J, 2007). The purpose of this model that three constellations of factors or determinants are associated with the likelihood of change at the individual level: socio-environmental and demographic factors, the individual‘s perception of the potential value of treatment (Strecher & Rosenstock, 1997).. 2.3. Evolution of Health Card Scheme in Thailand The health insurance card scheme was introduced as the Health Card Project (HCP) in 1983. This program was based on the risk sharing of health expenditures with no cost sharing in a voluntary health insurance prepayment scheme. Frequent adjustments in both the strategies and objectives of the program have included voluntary risk sharing with cost recovery in addition to service provision. The HCP needs a large enough number of enrollees to ensure a sufficient pool of risks. However, in 2001, the government of Thailand has committed to rapidly extending health care coverage to all Thai citizens. All uninsured Thai citizens will have access to required health services for a flat fee of 30 Baht ($0.67), regardless of the type of disease treated in line with the small co-payment charged for treatment. People joining the scheme receive a gold card which allows them to access services in their health district, and, if necessary, be referred for specialist treatment elsewhere. Even though the HCP was suppressed and replaced by this program in October 2001 (Supakankunti, 2001). The HCP can be assessed as relatively progressive, serving rural areas, poor and near poor groups. An employment, education, and the presence of illness are significant factors influencing card purchase. Problems of program performance include issues of program and financial management: marketing, quality control and cost recovery; ineffective referral systems, and lack of limits on episodes and ceilings for expenses (Supakankunti, 2000). There was an increasing expectation and use of public outlets staffed by physicians and a decreasing trend in using self-prescribed drugs and traditional medicines, or attendance of the healers (Table2-1). This reflects the aim of the Fifth National Health Development Plan (1982-86) to achieve one hundred percent district coverage in the country and the three-year compulsory service program at MOPH district hospitals imposed on all medical graduates in 1972. The consequence was an increase in the number of hospitals and doctors at the district levels, which undoubtedly 13.

(24) began to meet the previously unmet demand for health services in rural areas, and led to a significant three-fold increase in the use of public hospitals in 1985 compared with in 1979 (Tangcharoensathien, 1995).. Table 2-1: Health Service Utilization Pattern for Reported Ill Persons Comparing Different Surveys Choice of Outlet. 1970. 1979. 1985. No treatment. 2.7. 4.2. -. Traditional Medicine/ Healers. 7.7. 6.3. 2.4. Self-prescribed drugs. 51.4. 42.3. 28.6. Public health centers. 4.4. 16.8. 14.7. Public hospitals. 11.1. 10.0. 32.5. Private clinics/ hospitals. 22.7. 20.4. 21.8. Source: Tangcharoensathien (1995) originally from Health Planning Division, MOPH. 1970, 1979; Institute for population and Social Research, Mahidol University, 1988.. 2.4. Health Financing Donaldson, D., et al, 1999 demonstrated that there are 5 major forms of comprehensive health insurance in Thailand. There are other limited insurance programs for work (WCS) or vehicle-related (TAPS) accidents. The five schemes are Civil Servants‘ Medical Benefits Scheme (CSMBS), Social Security Scheme (SSS), Voluntary Health Card Scheme (VCS), Lowincome Card Scheme (LICS), and Private Indemnity Insurance. Approximately 76 percent of the population is covered one of these health insurance programs. The remaining 24 percent must either pay out-of-pocket fee-for-service, or receive free/subsidized services from public health facilities. As can also be seen from the table 2-2, there is a number of provider payment mechanisms. These mechanisms lead to observing higher utilization rates under fee-for-service (provider-induced demand), and lower rates of service under capitation. Each of the major public health insurance programs will be reviewed in further detail below. 1. The Civil Servants’ Medical Benefit Scheme (CSMBS) This scheme covers all government employees and pensioners, and their dependents. The scheme is tax financed and managed by the Ministry of Finance (MOF) – which acts more like a ―rubber stamp‖ than a manager of a health benefits program. There is no program to screen claims for fraud, and no beneficiary database. In real terms expenditures increased by about 14 14.

(25) percent per annum up through 1997. As a consequence of the economic crisis the MOF adopted some demand-side cost control measures such as copayments and elimination of the option to be reimbursed for care from private providers.. Table 2-2: The key features of the insurance programs Name. Cover-. Pop Covered. Age. Source of. Provider Payment. Funds. Mechanism. (‗000,000). CSMBS. 6.6. Civil. Utilization OP. IP. Visits/. Admin/. Capita. 100. General Tax. Fee- for- Service. 5.5. 13.6. Employees in. 1.5%. Capitation. 1.4. 2.6. firms < 10. Employees/. persons. Employer/. Servants & Dependents SSS. 4.8. Government VHCS. 6.0. Near Poor. MOPH Fund. Capitation. 1.7. 5.8. LICS. 27.0. Indigent. MOPH Fund. Global Budget. 0.7. 3.0. Private. 1.2. Premium. Fee- for- service. 2.0. 5-6. Source: The ministry of Public Health (1998). Evidence from analysis of data collected in the Khon Kaen province suggests that these measures resulted in a 13 to 15 percent reduction in expenditure. Specifically cost savings were achieved by the use of essential drugs (there was a copayment requirement for non-essential drugs), reduction in the length of stay (LOS), reduction in use of the private wards, and reduced use of the private sector. Since income from CSMBS patients has been a source of funds with which to cross-subsidize care for the poor, it will be necessary to assess whether the access of the poor to care has also been restricted. 2. The Social Security Scheme (SSS) and the Workman’s Compensation Scheme (WCS) Both schemes are managed by the Ministry of Labor and Social Welfare (MOLSW). While the two schemes cover nearly the same population, i.e. employees in firms of 10 or more workers, they collect premiums and pay providers in different ways. Specifically, the SSS collects 1.5 percent of an employee‘s wages from the employee, the employer, and an equal contribution from the MOLSW, and pays providers on a capitation basis. The WCS collects from 15.

(26) 0.2 to 2.0 percent of total wages depending upon the firm‘s workplace safety record. It is believed that the WCS contribution rate is too low to affect workplace safety standards.. 3. The Voluntary Health Card Scheme (VHCS) Started in the mid-1980s as community revolving funds under the Primary Health Care initiative, and has over time evolved into a voluntary health insurance program aimed at the near poor. The premium collected is currently from three sources: households, the MOPH, and totals 1,500 baht per card.. 4. The Low-income Card Scheme (LICS) This scheme started in 1975 with the objective of reducing inequity by providing free medical care services to the poor. In 1994, five other types of individuals were added to those eligible to receive the low-income card. These groups are: the elderly, children under 12 years of age, veterans, religious and community leaders, and the handicapped. The scheme has been criticized for not correctly targeting the low-income population, and for having expanded to populations which may have other forms of health insurance, or which did not need financial assistance. LICS cardholders are to seek care first at health centers, and if needed be referred to higher level facilities. They often bypass district facilities for provincial hospitals. As a consequence of the widespread distribution of the cards the program is severely underfunded with an allocation of only 250 baht per capita. Over time the allocation formulas to determine the level of funding to any specific province/region have changed, and this has resulted in less or greater equity of distribution on a per capita basis between the poor regions (like the Northeast) and more wealthy areas (like the Central region). The current allocation formula based on the population adjusted by standardized mortality ratios, the outpatient and inpatient output of the hospital, the presence of a regional hospital, and the average income of the population in the province.. 5. Private Indemnity Insurance The Thai private insurance companies can be classified into 2 types, life insurance and catastrophic insurance companies, both of which provide health insurance as supplemental to either life or catastrophic insurance policy. In 1997, 12 life insurance companies attached health insurance to life insurance policy as supplemental while 6 catastrophic insurance companies did so. The number of the privately health insured was around 5.89 million (9.73% of the total population) most of which were the better-off. The actual compensation rate of those life 16.

(27) insurance companies was estimated between 80-90% while the catastrophic companies gave lower at 69.3%. The Department of Insurance determined standard premium rates for collective health insurance. Individual premium rates were set similar among the companies, simply said that the market was a contributing factor. Problematic factors to private health insurance business were from three main players, the insured, care providers, and insurance companies. Even there was a decreasing growth trend to the Thai private health insurance; niche market could be found if the companies would develop the insurance policy more appropriate to the current socio-economic circumstance.. 2.5 Universal Coverage Scheme (UCS) Since 2001, The Voluntary Health Card Scheme (VHCS) and The Low-income Card Scheme (LICS) were integrated to Universal Coverage Scheme (UCS). The bulk of finance comes from public revenues, with funding allocated to Contracting Units for Primary Care annually on a population basis. According to the WHO, 65% of Thailand's health care expenditure in 2004 came from the government, while 35% was from private sources (World Health Organization, 2008). Although the reforms have received a good deal of criticism, they have proved popular with poorer Thais, especially in rural areas, and survived the change of government after the 2006 military coup. And from 2010 onward, abolished the 30 baht co-payment and made the UC scheme free (Hughes & Leethongdee, 2007).. 2.6 e-Governments World Bank, n.d. defines e-government as ―the use by government agencies of information technologies (such as Wide Area Networks, the Internet, and mobile computing) that have the ability to transform relations with citizens, businesses, and other arms of government. These technologies can serve a variety of different ends: better delivery of government services to citizens, improved interactions with business and industry, citizen empowerment through access to information, or more efficient government management. Schumacher, 1973 suggests that poor countries need to help themselves by developing appropriate technology which recognizes the economic boundaries and limitations of poverty. However, the ability to evaluate and search for a technology, which fits with a required task and its context, requires both information and relevant judgment criteria. These are often lacking in developing countries (Dahlman, 1989; Stover, 1984). One acceptable criterion is that the 17.

(28) technology should fit their development objectives. Another criterion is that the benefits of technology should be distributed widely within the social system (Rogers, 1995; Stover, 1984). Otherwise, the diffusion of new technology will widen the socioeconomic gap between the high and the low status members of a system, since the high status members will have a higher potential to be the first adopters (Rogers, 1995). In Thailand, the initial stage of computerization in the Thai public sector started in 1963 when two mainframe computer systems were first installed at the National Statistics Office for processing census data and at the Faculty of Commerce and Accounting in Chulalongkorn University for educational programs (Lorchirachoonkul,et al., 1987). Soon after, computerization in the Thai public sector was established and quickly expanded. At that period, Thai government approved a Master Plan on Information and Communication Technology (2002-2006) in order to increase efficiency of the administration and service delivery of the public sector within 2003. In 1992, the Thai government set up the National Information Technology Committee (NITC) to be the central IT agency. The National Electronics and Computer Technology Center (NECTEC) serves as NITC‘s secretariat. NITC developed policies and plans on IT (IT 20002010 Policy) and got approval from the cabinet in 1996. This National IT Policy covers creating digital opportunity, ensuring proper modernization, forging the knowledge-based society, constructing infrastructure for government and infrastructure for the national economy (Krootkaew, 2002). In 2001, Thailand had pushed government agencies to implement e-government. Information Communication Technology Master Plan (2002-2006) was formulated to support egovernment. A number of e-government initiatives were launched during this period in order to develop Thailand to become a country with e- industry, e-commerce, e-education, and then esociety. Many e-government projects were expected to have a great deal of impact to the public services and Thai people since the government had allocated a lot of budget on these projects. Therefore, a study of e-government projects in Thailand would help to review the appropriateness of its policy direction, whether it is consistent with the country‘s development since there is a limited number of studies on this issue in the country (Lorsuwannarat, 2006). Though there are many e-Government projects implemented in Thailand, many problems lie ahead, especially the readiness of the country seems to be the common problem of every project. People still have low computer and English literacy. There is only one main law supporting e-government: Electronic Transaction Act, B.E. 2001. The other laws on privacy, electronic payment business services, computer crime and so on, are still many years away. One. 18.

(29) of the most important issues is that there is very limited use of evaluation for project improvement (Lorsuwannarat, 2006).. Technical approach as the only approach used in implementing e-Government would ignore the reality of Thai society, i.e., infrastructure, personnel understanding and capacity, training, and regulations. This has led to ineffective implementation of the e-government projects studied. E-Auction has the limitations of lacking top-management support, and inflexibility of the regulations. Smartcard does not have readiness in terms of privacy laws, safety, databases of related agencies, and crime protection. Internet Tambol has no evaluation, infrastructure, and has low computer utilization rate. GFMIS has problems of coordination among central agencies, lack of participation, the readiness of the personnel, equipment, training, and evaluation, problems of process, and difficulty in checking errors of the systems (Lorsuwannarat, 2006).. 2.7 Thai National ID Smart Card The smart card represents the best available solution for three reasons. Firstly, the smart card is easy to carry in a user‘s pocket, and it could be used by most terminals Furthermore, open smart cards, such as Java Cards, can host more than one application, avoiding their cumbersome proliferation in wallets. Marvie, et al, 2000 found that the smart card could contain the description of the home delivering food service application, an electronic purse, and some bank access to allow the payment of the service. Secondly, the smart card protects the information stored implicitly. Finally, it is very simple to use: Accessing the service is simply performed through plugging the smart card in an available terminal and typing a PIN. In Thailand, ―National ID Smart Card Project‖ is a government policy under eGovernment project. In July 2003, the Thai cabinet approved National ID Smart Card Project to replace the existing national identification card. Smart Card is a multi-application smart identification card that simply put microchips into identification cards to store data of the owner. This smart card links individual databases to other databases. The objective of this project was to enable every Thai citizen to use all government services by utilizing one card only, which would provide a more convenient and faster service. It would have also greatly reduced the use of paper, document files and copies. At card issuance, the Ministry of Interior became responsible for initial data, which included birth date, ID number and registration of name/surname. All data were included in the e- ID Smart Card. Other public agencies had the right to record and amend the data directory and fields for which they were responsible, based on the data standard of the card-reading machine, security system, and communication method of the card and reading machine. The planning and 19.

(30) implementation of the system was based on convenience, safety, durability, cost-effectiveness, high quality and uniformed standard across the same database. The parliamentary cabinet also expected to promote and locally produce as much of the necessary hardware and software as possible, with Thailand becoming a base for card and software production, (The National Electronics and Computer Technology Center, 2003.) Thailand implemented pilot projects of smart card by issuing 7,769 cards for politicians, heads of government agency district, people in three southern provinces. The government aims to issue 64 million cards from 2004-2006 with a budget of 7,910 million baht. In health care sector, the Ministry of Public Health abolished the ―Gold Card‖ and also announced to use just National ID Smart Card to get the medical services instead of it since 2010 onward.. Figure 2-6: Thai National ID Smart Card. Gunawong & Gao (2010) said that analysis of the project is limited to the period of 20022006, because after the military coup in Thailand, the political situation fluctuated enormously. There have been five Prime Ministers between 2006 and 2010. Even so, the e- ID Smart Card project was re-launched after its cessation in 2006, but it still faced the same problems. In 2010, it has seemingly been halted again, due to suspected lack of transparency in the auction process. And when describing the idea of an actor-network theory in the e- ID Smart Card project, it could be said that there were some flaws in each moment that caused the project to fail. This section reveals what went wrong in each step and gives possible suggestions or alternative choices for e-government initiatives. Operation Component 1. Cards: The first model of Thai National Identity Card is a paper card, developed to plastic card, magnetic card and Smart Card, at present.. 20.

(31) A capacity of Thai National ID Smart Card is 32 Kbyte comprise of many kind of data inside as table 2-3. (For Thai people, who do not have National ID Smart Card such as the children and the elderly people; can use residence registration or birth certificate instead.). Table 2-3: The content of Thai National ID Smart Card Data Location. Content. Explicit Data. Card serial number, ID number, Name, Date of birth, Address, Picture, Date of issue and Date of expire, Issuer name.. General Personal Data stored ID number, Thai name, English name, Date of birth, inside the chip. Gender, Nationality, Address, Religion, Father‘s ID, Father‘s name, Father‘s nationality, Mother‘s ID, Mother‘s name, Mother‘s nationality, (Date of name changed-latest, if any), Name/Last name before changed, Petition number, Agency, Issuer code, Issuing date, Date of expire, Picture, Spouse ID number, Spouse‘s name, Date of married, Certificate number of married, Date of divorced, Certificate number of divorced, Place of birth, First address, Date of moving to first house, Date of updated data, and Fingerprint.. Health Data stored inside the Province of registration, Code of Medical unit, chip. for. Security purpose. National Health Main medical unit, Vice medical unit, Office. (NHSO) Date of issuing, Date of expire, Drug allergies, Blood type, Forwarded hospital, Forwarded date, Code of capitation payment, Relocation services (times), Access to emergency room (times), Access to emergency room-under the act No.7 (times), Date of updated data.. Source: The Ministry of Interior, February 10th 2004. 21.

(32) 2. Card Readers: 36,000 Card Readers were provided by the ministry of Information and Communication Technology (ICT) to hospitals and primary care units in whole country. Any service units can use a reader to read data both offline and online services, but for offline services cannot receive an updated data. And also the card can use with a kiosk to read, in this case the health care services have to provide by themselves. 3. Software: This system supported many kind of software as DOS, Microsoft Windows, and UNIX. 4. Networking: National Health Security Office (NHSO) has connected with Office of the Civil Service Commission (OCSC)-every 15 days, Social Security Office (SSO)- every 15 days, Immigration Bureau, Ministry of Interior- everyday, Internet registered online 24 hours and offline registration-every 15 days to update data. 5. Services: Call Center 1330 has provided to help and give information to the people and also a service on website http://www. nhso.go.th. Moreover, the number of National Smart Card and budget for this project totally is 7,910 Millions THB would be describing as table 2-4.. Table 2-4: Total Budget and number of National ID Smart Card Project Subject. Year 2004. Year 2005. Year 2006. 12. 26. 26. 2.1Operating System Chip and Card. 1,440. 3,120. 3,120. 2.2Card Reader with Finger Scanner. 230 3,120. 3,120. 1. Total number of E-ID (Millions Card) 2.Total Budget to produce (Million TBH);. Total. 1,670. Source: Thai Government March 23, 2004 As these, total number, amount and the period of this project but until now it has been halted because of the auction and also conflict between the Ministry of Interior who issue the rule for the National ID Smart Card and the Ministry of Information and Communication Technology (ICT) who has a responsibility to procure the bidder. But, the problem is the Ministry of Interior stated that 9 million cards from latest lot (26 million cards) were not on the specification of the rule. This is quite an enormous problem because of the more than 2.4 million 22.

(33) people still using the temporary card which is a paper card and some of them need to use this card more than three months as well. Finally, the ministry of interior has agreed to change some part of the rule to accept 9 millions and also 17 millions which are still pending. In additional, the problem might come from the server which always breaks as right now only one server can use and the other two are pending to fix. There was not only the problem in health care organization, but also expand to another agencies that should concern in the future projects. Previous study in Thailand; Smartcard does not have readiness in term of privacy laws, safety, databases of related agencies, and crime protection Lorsuwannarat, T. (2006). Pintabutra, et al. (2004) studied the suitability of smart card for Thai society by collecting data through documents and in-depth interviews with politicians, academics, law experts, technology business people, people, media, and executives. It was found that the benefits from this project went to the ones who live in the urban rather than rural areas. The National ID smart card project has high dependence on imported technology, especially microchip. Despite a strong belief of some top-management in related agencies that Thailand would produce microchip in the future, the chance is slim. Besides, people do not have an opportunity to participate in project formulation. In most developing countries, smart card technology was first introduced to patients by the government, as opposed to the introduction by the private sector in developed countries, through the implementation of electronic identification cards (e-ID). This was the situation in Thailand, where the Thai government is currently planning for the deployment of e-ID and the implementation of electronic government regime.. 2.8 Lessons from other Countries Despite their usefulness and extensive applications, smart cards have not gained popularity and acceptance worldwide as their supporters once claimed. In some locations, the trial implementation of smart cards was even deemed failure. One major case of failure in smart card implementation was the smart card trial in New York City, U.S.A., launched by Citibank, Chase, VISA and MasterCard. In an empirical study of this trial‘s failure, Truman, Sandoe, & Rifkin, 2003 found that despite the fact that the technology‘s relative advantages were significantly related to patients‘ and merchants‘ acceptance, patients and merchants were disposed against acceptance of smart card technology. In addition, they found that there was no 23.

(34) evidence of any critical mass effects that can be used as a predictor of either consumers‘ or merchants‘ acceptance. Another case where smart cards have failed was the case of the smart card-based retail point-of-sale system, called "Exact," which was test marketed for a full year in 1997 in the Canadian market. Plouffe, Vandenbosch, & Hulland, 2000 conducted a detailed case study of the trial and found that there is an unavoidable "synergistic" aspect to the diffusion of the smart card technology. Their research clearly indicates that the pure convenience and novelty elements of smart card payment are not enough in and of themselves to ensure the technology's longer-term viability and acceptance. In another study done by Kearns and Loy, 2002, it was found that at the global level, there were still a number of issues that inhibit the widespread use of smart cards, especially in open systems. These issues include the unsettled standards to be used for the Chip Operating System (COS), and the users‘ fears against security breaches and attacks of financial data which overweighed the benefits that facilitate adoptions of smart cards. Other studies stated that obstacles to acceptance of smart cards include; . Present lack of infrastructure to support the smart card, particularly in the United States, necessitating retrofitting of equipment such as vending machines, ATMs, and telephones.. . Lack of standards to ensure interoperability among varying smart card programs.. . Unresolved legal and policy issues, such as those related to privacy and confidentiality or to patient protection laws. In Austria, Arami, et al. (2000) studied regarding the user acceptance of multifunctional. smart cards to assess the pilot and to gain insight into further projects, it is necessary to investigate the students‘ point of view and their acceptance of the smart card. Furthermore it would be interesting to gain knowledge about the integration of further functionalities such as payment services or health insurance data. They also have found a strong positive correlation of items concerning current usage of the student ID card and ease of use. In Malaysia, the framework of a new research framework to study the acceptance of MyKad NIC and DL applications is based on the well-known technology acceptance model (the UTAUT model). Two new variables (perceived credibility and anxiety) were added to the constructs so as to suit to the MyKad applications (Loo, et al, 2009). From the practical perspective, the research discovered that Malaysians do not have high intentions to use MyKad NIC and DL applications. While it has proven the preposition that Malaysians accept MyKad because of its cultural characteristics, their intention of using MyKad as NIC or DL is moderate. The main reasons are their lack of understanding or knowledge of the 24.

(35) benefits (i.e. the performance expectancy) of the applications and the lack of facilitating conditions to use the applications. These inadequacies caused lack of social support and credibility regarding the applications. Moreover, the inadequacies do not help to alleviate the anxieties of using the applications. Another study in Malaysia, Taherdoost, et al. (2009) had found the results suggest that an ease of use, security and level of knowledge have a positive influence on the user acceptance. User support is a major factor in the success of a smart card implementation and has stressed the importance of ensuring proper communication, education and functional support. Smart card implementation must be clear to the users (i.e., card holders), or at least have minimal impact on them. On the other hand, there are some habits which are so difficult to change. It is just a matter of awareness. User‘s awareness about smart card can assist them to understand the technology. Different applications involve different user behavior so users should be awarded about the usage and application of their cards. Being user-friendly or ease of use is the main factor to achieve the user acceptance. In all applications, the training of the user is a key element that needs to be integrated in any kind of smart card deployment. The user needs to understand the function of smart card, ways to protect the card and reasons to protect the card.. 2.9 Privacy and Security Health care organizations worldwide are implementing smart health cards supporting a wide variety of features and applications. Smart health cards can improve the security and privacy of patient information, provide the secure carrier for portable medical records, reduce healthcare fraud, support new processes for portable medical records, provide secure access to emergency medical information, enable compliance with government initiatives and mandates, and provide the platform to implement other applications as needed by the healthcare organization. In Asia, 1998, the Philippines Supreme Court decided that smart card conflicted with people‘s privacy according to the constitution, as did the Hungarian government. In other countries, mandatory versus voluntary is a hotly debated issue. In Japan to have a smart card is voluntary since it is private matter. In Malaysia, many researchers have reported that users‘ concern about security has increased and it has been known as one of the most significant factor for technology acceptance. Vijayasarathy (2004) defined security as ―the degree to which a person feels that security is important to them and believes that using smart card is secure‖. By protecting the integrity, 25.

(36) availability and confidentiality of the content in the system, security controls could help to protect the overall content quality of the system (Whitman & Mattord, 2003). Content quality is a major determinant of overall information system quality (Liaw & Huang, 2003), which has a positive effect on individual‘s perceived ease of use of information systems. In Thailand, the involved agencies were not ready in terms of data linkage, security standards, data standard, personnel development, and public relations. This was not a voluntary project, and people inevitably avoided to have this smart card. Also, there is no privacy law at the moment to protect data abuse or identity theft (Lorsuwannarat, 2006). Smart card technologies have been revolutionizing telecommunications and financial transactions for many years. The major driving factors of the growth of smart card usage are the declining cost of smart cards and the added capability that smart cards provide against fraud and security attacks. To date, many government agencies in Thailand are still arguing about what information and applications should be put on the National ID Smart Cards. The key issue with respect to using smart cards in Thailand is not so much about which information or applications are the "right" ones to be put on the cards, but more on the matters of ownership, management and privacy protection of the patients' information on the cards. This issue should be communicated properly and clearly with all Thai people. After all, it is the patients' benefit protection and the Thai citizen's rights to privacy that the government should put the most important considerations to when planning for and implementing the smart card technologies in their e-ID and eGovernment projects (Donyaprueth , 2004). The empirical studies found this project will be useful for the patients, for instance, they did not spend more time in the waiting line and more convenience regarding remedy right investigation. For the physicians and other health care providers, they also will not spend more time to find the patient‘s health information because everything was completed in the card recorder. In contrast, many problems that make the researcher not agree with this project and may be the patients will be worry about the privacy and security.. 26.

(37) CHAPTER THREE METHODS. 3.1 Research Structure This research study is a quantitative method through conducting Patient Acceptance of Thai people regarding using National ID Smart Card. According to Technology Acceptance Model (TAM) and Health Believe Model (HBM), the research structure underlying this study is shown in Figure 3-1. Introduction Literature Review Define Variables. Design Questionnaire. PEOU PU PBTA ATT. BI. PA. ECUE ICUE DEM Statistic Analysis Conclusion & Recommendations Figure: 3-1 Research Structure Note: perceived ease of use (PEOU), perceived usefulness (PU), perceived barriers of taking action (PBTA), external cues to action (ECUE), internal cues to action (ICUE), demographic Factors (DEM), attitude toward using (ATT), behavioral intention to use (BI), and patient acceptance (PA).. 27.

(38) Regarding technology acceptance model (TAM), there comprise five constructs as perceived ease of use (PEOU), perceived usefulness (PU) attitude toward using (ATT), behavioral intention to use (BI), and actual system use (AU). And because this research study base on an acceptance of use National ID Smart Card in Health Care Organization, therefore the health belief model which compose two aspects of health behavior as perceived disease threat (PDT) and behavior evaluation (perceived barrier of taking action- PBTA) should to include to this research structure. Besides, this research also focuses on outpatients, so there is reasonable to exclude PDT out of the structure. Hence, the PEOU, PU, ATT, BI, PBTA, also Cues to action (CUES) are also included to determine actual system use (AU), Acceptance of using National ID Smart Card. 3.2 Operational Definition Table 3-1 Operational Definition of the research Categories I: Patient Acceptance (PA). Operational Definition It was the seeking and acceptance by patients of health service. The alternative to avoidance is acceptance. Etymologically, acceptance comes from Latin root ―accipere‖ meaning to receive or take what is offered.. II: Perceived Ease of Use (PEOU). Referred to Users like and plans to use the system more frequently as the system becomes an easy one to use. Perceived ease of use is the degree to which a person believes that using a particular system is free of effort (Saade & Bahli, 2005). A broader view of ease of use includes elements such as ease of learning, ease of control, and understandability, also to the extent to which a person believes that using a system would be free of mental effort (Davis, 1989). Previous studies have clarified the effect of perceived ease of use on perceived usefulness (Davis, 1989; Szajna, 1996; Adams, et al., 1992). Also TAM posits that perceived ease of use has a direct positive effect on attitudes towards using smart card systems (Szajna, 1996 ;Gefen & Straub, 1997).. 28.

(39) Categories. III: Perceived Usefulness (PU). Operational Definition. Originally defined as the extent to which a person believes that using a system would enhance his or her job performance and effectiveness (Davis, 1989). And also referred to the degree to which a person believes that using a particular system would enhance his or her job performance (Venkatesh & Davis, 2000). Individuals who believed that using smart card systems could lead to positive outcomes also tended to have a more favorable attitude towards it. In addition, there is an empirical support for the relationship between perceived usefulness and attitude towards use (Agarwal & Prasad, 1999; Moon & Kim, 2001).. V: External Cues to action (ECUE) VI: Internal Cues to action (ICUE) VII: Attitude toward using (ATT). Referred to an external action as triggers that stimulate people to take action (Strecher & Rosenstock, 1997) Defined as an internal action as triggers that stimulate people to take action (Strecher & Rosenstock, 1997) Referred to a hypnotized to be a major determinant of whether or not he or she actually uses it, and also is a function of two beliefs; perceived usefulness and perceived ease of use (David, 1991).. VIII: Behavioral intention to use (BI). It could be the decisions to act or not act are the result of an assessment of the likelihood of specific outcomes associated with the act along with the subjective value assigned to those outcomes. Intention is the amount of effort one is willing to exert to attain a goal (Ajzen, 1991) or simply ―proximal goals‖ (Bandura, 1997).. 29.