Digital health literacy as a driver of continued electronic health record use: insights from necessity and sufficiency analyses

Continued use of Electronic Health Records (EHRs) remains a significant challenge despite widespread digitalization. Existing models often overlook key psychological and informational factors essential for continued engagement. This study extends the Unified Theory of Acceptance and Use of Technology (UTAUT) by incorporating digital health literacy, trust, and privacy concerns to better explain continued EHR use. A cross-sectional survey across 21 Turkish cities yielded 480 valid responses from users of the national EHR system (E-nabız). Data were analyzed using Partial Least Squares Structural Equation Modeling (PLS-SEM) to identify usage intention predictors, and Necessary Condition Analysis (NCA) to determine must-have factors for continued use. UTAUT constructs were confirmed as relevant predictors of continued EHR use. Effort expectancy, facilitating conditions, and trust emerged as necessary conditions. Trust also reduced the impact of privacy concerns, which had only a weak negative effect. Social influence affected intentions but was not a necessary condition. Digital health literacy significantly predicted performance expectancy, effort expectancy, and facilitating conditions and proves critical to ongoing EHR usage. Educational interventions aimed at enhancing digital health literacy can significantly increase EHR continued use through multiple pathways.