Primary care physicians’ continuous usage intention of a B2B telemedicine system: an empirical study based on a hybrid model in China

Gao et al. BMC Health Services Research (2025) 25:1441 https://doi.org/10.1186/s12913-025-13628-2 BMC Health Services Research Open Access RESEARCH Primary care physicians’ continuous usage intention of a B2B telemedicine system: an empirical study based on a hybrid model in China Pan Gao1,2, Dongle Wei1,2, Yu Wang1,2, Wei Lu3, Ruifang Guo4, Yunkai Zhai1,2* and Yan Qiao1,2 Abstract Background Telemedicine has revolutionized healthcare delivery, significantly improving accessibility and efficiency. In China, the predominant mode of telemedicine service delivery is Business-to-Business (B2B). However, the utilization of B2B telemedicine is relatively low. Within the B2B context, primary care physicians (PCPs) are critical users. There is a lack of knowledge regarding PCPs’ continuous intention to use the B2B. To address this gap, the study aims to study and unveil factors affecting PCPs’ continuous usage intention for B2B telemedicine. Method This study proposes an integrated Technology-Individual-Environment theoretical framework to analyze factors and mechanisms influencing PCPs’ continuous usage intention for B2B telemedicine, considering exogenous, technology, and endogenous dimensions. We used Partial Least Squares Structural Equation Modeling (PLS-SEM) and fuzzy-set Qualitative Comparative Analysis (fsQCA) to test the research model. A cross-sectional study was conducted among PCPs with prior B2B telemedicine usage experience across more than 30 primary healthcare institutions in China. Overall, 421 (63.88%) out of 659 questionnaires were valid. Results The PLS-SEM results revealed that within the individual dimension, attitude, perceived behavioral control, and intrinsic motivation positively influence PCPs’ continuous usage intention, while perceived risk had a negative impact. Within the technological dimension, assurance and reliability demonstrated direct positive effects on continuous usage intention, whereas tangibility indirectly influenced intention through attitudinal mediation. Notably, the environmental dimension showed no statistically significant effects on continuous usage intention. Complementing the PLS-SEM findings, fsQCA analysis identified three configurations that lead to high continuous usage intention and three configurations leading to low intention. Based on these results, factors influencing PCPs’ continuous usage intentions are classified into foundation factors, performance factors, and enhancement factors. Conclusion Within B2B telemedicine, this study focuses on the factors and mechanisms influencing PCPs’ continuous usage intention. These findings provide a robust theoretical foundation for policymakers and healthcare *Correspondence: Yunkai Zhai Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Gao et al. BMC Health Services Research (2025) 25:1441 Page 2 of 19 administrators seeking to enhance PCPs’ engagement with B2B telemedicine platforms, ultimately contributing to the advancement of integrated healthcare delivery systems. Keywords B2B telemedicine, Primary care physician, Technology acceptance, Continuous usage intention, PLS-SEM, fsQCA, Configuration analysis Introduction China has been confronted with the persistent problems of low medical quality and efficiency, as well as inadequate and unevenly distributed health professionals [1]. These challenges hinder the implementation and development of the Healthy China strategy. To “build a healthier world for all” and achieve national health coverage by 2030, Chinese leaders have decided to implement telemedicine as one of the solutions to enhance the accessibility and quality of healthcare services [2]. Telemedicine, the integration of information technology and medical skills, is crucial for addressing these challenges by providing remote healthcare services to patients across different regions [3, 4]. In China, the predominant mode of telemedicine service delivery is Business-to-Business (B2B) [5]. In 2024, China’s National Health Commission reports that B2B telemedicine networks now cover all cities and counties, with 70% of township health centers establishing partnerships with higher-level hospitals [6]. Within this model, primary healthcare institutions, including county and district hospitals, community health centers, township health centers, and village clinics, seek remote specialist consultations from higher-tier medical establishments such as provincial-level hospitals through telemedicine platforms [7]. This mechanism facilitates collaborative care between different levels of the healthcare system [8], thereby improving healthcare accessibility, quality, and efficiency while reducing costs [9, 10]. Despite its benefits, adoption rates remain low [11], leading to a significant “best game with no players” phenomenon [12]. According to data from the National Telemedicine Center of China (NTCC), the annual average number of primary healthcare institutions applying telemedicine per hospital was 158.04, 128.33, 97.23, 82.14, 82.74, and 80.35 cases in 2018, 2019, 2020, 2021, 2022, and 2023, respectively. The declining use of B2B telemedicine in primary healthcare institutions suggests potential challenges or barriers hindering its adoption or sustained usage. This issue poses a critical developmental bottleneck for the technology. Moreover, the success of technological implementation depends not only on the adoption stage but also on continuous usage behavior in the post-adoption stage [13]. Primary care physicians (PCPs) represent the cornerstone users within this B2B telemedicine ecosystem. These licensed medical doctors work at primary healthcare institutions, providing medical care, preventive services, and health management within their scope of practice. When encountering complex cases that exceed their clinical capabilities, PCPs serve as the requesting party who utilize telemedicine platforms to obtain spe (...truncated)