The early diagnosis and appropriate stratification of sepsis continues to be one of the most important challenges in modern medicine. Single isolated biomarkers have not been enough to improve diagnostic and prognostic strategies and to progress toward therapeutic goals. The information generated by the human genome project has allowed a more holistic approach to the problem. The integration of genomics, transcriptomics, proteomics and metabolomics in sepsis has allowed us to progress in the knowledge of new pathways which are pathophysiologically involved in this disease. Thus, we have understood the importance of and complex interaction between the inflammatory response and the endothelium. Understanding the role of important parts of the microcirculation, such as the endothelial glycocalyx and its interaction with the inflammatory response, has provided early recognition elements for clinical practice that allow the rational use of traditional medical interventions in sepsis. This comprehensive approach, which differs from the classical mechanistic approach, uses systems biology to increase the diagnostic and prognostic spectrum of endothelial damage biomarkers in sepsis, and to provide information on new pathways involved in the pathophysiology of the disease. This, in turn, provides tools for perfecting traditional medical interventions, using them at the appropriate times according to the disease's pathophysiological context, while at the same time discovering new and improved therapeutic alternatives. We have the challenge of transferring this ideal scenario to our daily clinical practice to improve our patients' care. The purpose of this article is to provide a general description of the importance of systems biology in integrating the complex interaction between the endothelium and the inflammatory response in sepsis. Systems biology allows a holistic integration of the various biological systems in inflammatory and infectious diseases.Endothelial damage in sepsis may be the cause or effect of severe inflammation associated with systemic infection.The omics provide us with very useful diagnostic and prognostic tools to better understand sepsis, and allow the development of therapeutic tools based on a comprehensive understanding of the disease.Sepsis is one of the leading causes of morbidity and mortality. In 2017, it was estimated to have affected 48.9 million people worldwide, accounting for 19.7% of deaths, globally  . At thisSystems biology in sepsis integrates these various genetic expressions with the activation of signaling pathways which release proteins that have very significant biological effects. Biomedical informatics and the various software packages available on the market are essential tools for understanding this interaction . The bioThis approach helps us understand why many studies in animal models do not have the same results as clinical trials . Animal Endothelial activation and damage is one of the essential steps in the cascade of multiorgan involvement in patients with sepsis. Under normal conditions, the ECL has very important functions . It is nIn addition, the ECL controls vascular permeability as it maintains tight junctions (or zonula occludens), represented mainly by proteins such as claudin and occludin. It also has gap or communicating junctions , adherens junctions (mainly cadherins) and syndesmos . These jall or nothing” phenomenon. That is, there is a broad range of presentation which depends on the host's prior conditions, comorbidities and the severity of the noxa, among others  of two or more alleles in a particular chromosome location. The most common type of polymorphism is called single nucleotide polymorphism (SNP), which consists of a substitution, deletion or insertion of a single nucleotide occurring in approximately 1 out of every 1,000 base pairs in human DNA . This SNMore recently, Wong et al. identified 100 genes associated with mortality in septic shock . They wein vivo and in vitro, and has been associated with up to four times greater mortality in studies of patients with septic shock. Early identification of this SNP would allow risk groups to be identified for targeted therapies , the severity of systemic involvement (including the microcirculation and endothelium), and the difficulty in accessing healthcare services are barriers that must be overcome in order to access genomic stratification with therapeutic implications. Likewise, the functional variants of sepsis, modifying phenotypes which alter molecular function, and an exclusive genomics approach could oversimplify and overlook other factors related to the disease which are associated with unsatisfactory outcomes. These include existent comorbidities, germ aggressiveness and resistance, and the limitations to healthcare access mentioned . These factors do not depend on the genetic response and may be associated with mortality and unsatisfactory outcomes.This is the next level of study after genomics . TranscrThis process of gaining access to the gene expression profile is accomplished through three types of techniques, some based on hybridization and others on sequencing: 1) microarrays, (2) RNA-seq, and (3) miRNA  which does not require sequencing information to detect and evaluate transcription, and thus gene activity . The maiFinally, miRNA is a small non-protein coding RNA made up of 20–24 nucleotides which regulates gene expression by inhibiting translation or transcription of the target mRNA . This miThe miRNAs are critically involved in the innate and adaptive immune response in pathological disorders such as arteriosclerosis, diabetes and infections like sepsis , 42. TheChen et al., after transcriptional analysis, evaluated endothelial cell activation and damage in the adrenal microvasculature in sepsis , an impoThis is considered to be the next level in the study of biological systems after genomics and transcriptomics. It is the area of large-scale protein discovery, defined as the one responsible for quantifying and categorizing all the proteins expressed in the cell, tissue or organs . The focAs mentioned previously, Wong et al.  not onlyLikewise, other researchers have measured other inflammatory proteins which are less specific but very useful for orienting toward the severity of involvement and its possible extent . This isThis is the study of the metabolome, a collection of small molecules produced by the cells which are responsible for the organism's metabolic processes. There are specific and nonspecific approaches to studying the metabolome. The specific metabolomic approach is aimed at measuring a specific number of metabolites in a pathway of interest . This alSystemic inflammation has emerged as a key pathophysiological process the induces multiorgan injury and the endothelium is critical in maintaining cellular and inflammatory homeostasis. Wang Yi-Fu et al. found that conditioned meditioned medium of endothelial cells inhibited cyclooxygenase-2 and interleukin-6 expression in macrophages . AnalysiSystems biology provides a comprehensive approach to endothelial damage associated with inflammation in patients with sepsis. Understanding the role of omics as diagnostic tools to better understand the pathophysiology of the disease can help us seek a holistic approach to the bidirectional phenomenon of inflammation and endothelial damage in infection models such as sepsis. Strategies are needed to eliminate barriers and facilitate access to all these systems medicine tools at the patient's bedside, especially in limited resource settings.JF-S, LS, LA, CS, YA, AD, MM, and JC contributed to designing and performing the review. All authors contributed to drafting the manuscript and reviewing the final article. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Academic achievement has been linked to executive functions. However, it is necessary to clarify the different predictive role that executive functions have on general and specific academic achievement and to determine the most predictive executive factor of this academic achievement. The relationship and predictive role between executive functions and their components  with academic achievement are analyzed in this study, both globally and specifically in the areas of Language Arts and Mathematics, in 133 students from 6 to 9 years of age. The relationship obtained in Pearson’s correlation analysis does not differ substantially between overall achievement (r = 0.392) and specific achievement , but task monitoring  and working memory  had a greater relationship with general and specific achievement. Finally, regression analyses based on correlation results indicate that executive functions predict general academic performance (14.7%) and specific performance  for Language Arts and Mathematics, respectively. Furthermore, working memory and task supervision represent 32.5% of general academic performance, 25.5% of performance in Language Arts, and 27.1% of performance in Mathematics. In conclusion, this study yielded exploratory data on the possible executive functions (task supervision and working memory) responsible for good general academic achievements and specific academic achievements in Mathematics and Language Arts. The educational community has shown special interest in the study of academic achievement over time. In this field, academic achievement is defined as the product of the learning process resulting from the different variables or factors that influence that process ,2. As acThe executive functions are understood as a multifactorial structure that intervenes in different important neurocognitive processes and controls thoughts and behaviors to achieve an objective ,7,8. TheExecutive functions have a significant impact on academic results from preschool to university, with the executive level recorded at a specific age being related to results obtained at later ages and replacing the importance of one executive factor with another ,16,17. ABoth flexibility and emotional control comprise the index of emotional regulation . FlexibiThe cognitive regulation index is composed of initiative, working memory, planning, task supervision, and the organization of materials . InitiatWorking memory represents the capacity to store, retain, and retrieve previous information and can be defined as a multifactorial memory system involved in the coordination and regulation of executive control and selective attention functions ,47. VariBaggetta and Alexander  identifiTask supervision and self-monitoring have traditionally been considered using a single scale when studying executive functions  and are The organization of materials allows one to maintain both the area and the materials needed for study in an orderly and organized way. Difficulties in this component often relate to inefficiencies in both private and scholastic life. Learning to organize simple aspects helps improve the achievement of more complex tasks.Numerous studies have addressed the relationship between executive functions and academic achievement ,49,56. SPrevious research has indicated that executive functions are related to scholastic achievement starting from the age of 3 years  and thatTherefore, there is scientific agreement that executive functions and their related skills  are essential to academic achievement . HoweverThe aim of this study was to analyze the relationship between executive functions and academic achievement in children aged 6 to 9, given the importance of executive functions in studies of the last decade as a predictor of academic success ,62. FurtThe sample under study comprised 133 elementary students between the ages of 6 and 9, whose distribution by academic year was as follows: 35.3% in the first year of Elementary Education, 31.6% in the second year of Elementary Education, and 33.1% in the third year of Elementary Education. All of the students attended a subsidized center in the city of Zaragoza (Spain). The socio-economic level of the families was medium-high, with average household salaries of between EUR 36,000 and 42,000 per year as reported by parents. The latest report of the Spanish National Institute of Statistics (2016) put the average income of Spanish households at EUR 26,092 per year. For the distribution of the sample according to sex, 47.4% were girls and 52.6% were boys. The average age was 7.54 years, and the standard deviation was 0.95. The values for academic achievement  were obtained from the average grades of all the subjects taken in an academic year. These values ranged from 5 to 9.4 . Finally, it should be noted that the sampling method was incidental with a convenience sample. The sampling strictly followed the ethics protocol of Committee on Research Ethics in the Autonomous Community of Aragon CEICA . The collaboration of the schools and families was requested in the first instance through a letter of collaboration. Subsequently, the informed consent of the parents was collected alongside consent from the minors. In both documents, the experiment was detailed along with the contact information of the reference researcher.Overall academic achievement was evaluated on the basis of the average grades  obtained by the students in various subjects  during the 2018–2019 academic year. The Behavior Rating Inventory of Executive Function, Second Edition (BRIEF 2), in its Spanish adaptation by Maldonado et al., was used to measure executive functions . Raw scoFirst, the research design was developed and approved by the school where the study was conducted. Subsequently, with the acceptance of the collaboration of the educational center, the research proposal was presented to the Research Ethics Committee of the Autonomous Community of Aragon: CEICA, obtaining a favorable resolution . This committee is in charge of evaluating research projects involving people or personal data from BLINDED University. Afterwards, the information regarding the project was sent to the families along with the informed consent for them to authorize the participation of their children. The confidentiality and anonymity of the data were guaranteed through the development of a coding protocol. The center’s orientation team participated in the development of the tests and provided the tutors for each course involved . The questionnaires, in the family mode, were completed by the parents or legal guardians of the students in their natural contexts. The correction and scoring of the test were performed via computerized procedures (TEAcorrige).A descriptive statistical analysis was conducted on the demographic variables of the sample. Subsequently, Pearson’s correlations were developed to observe the possible relationships between executive functions and their factors  and academic achievement, both overall and specific (Language Arts and Mathematics). Finally, different regression models were applied to examine the predictive power of the executive functions and different scales or factors in different relationships with general and specific academic achievement. It should be noted that in the models tested, the dependent variable was general academic achievement, with specific achievement in Language Arts and specific achievement in Mathematics. The analyses were carried out using the statistical software IBM SPSS Statistics 25.0 .p = 0.629 and p = 0.498, respectively). The same occurred when performing a correlation analysis between sex and age and each of the executive factors, obtaining significance values greater than 0.05 . However, to confirm these data, we proceeded to comparative ANOVA analyses, finding no significance between general executive functions and specific factors in relation to sex and age (p > 0.05), and thus these variables were discarded from the analyses. As shown in p < 0.01), specifically for executive initiative factors , working memory , planning , task supervision , and organization of materials . However, when the general executive functions were analyzed with respect to specific achievements such as those in Language Arts and Mathematics, identical significant relationships were found for both disciplines .First, descriptive statistics were obtained, and correlation analyses were carried out between general academic achievement (GAA); average grade in Mathematics, Language Arts, Social Sciences, Natural Sciences, Artistic Expression, and English; academic achievement in Language Arts (AAL); average grade in Language Arts; academic achievement in Mathematics (AAM); and average grade in Mathematics, along with the scores on general executive function (EF) and each of the factors that compose EF. Neither sex nor age yielded significant results in the correlational analyses with respect to general executive functions (p < 0.01) and planning . In addition, following on from non-significant differences, task supervision was more relevant for general academic achievement  than working memory , but working memory was more relevant for specific achievements, such as those in Mathematics  and Language Arts  than task supervision. However, task supervision offered better results for Language Arts  than for Mathematics .Therefore, the scales that visualize significant relationships for all types of academic achievements studied belong to the index of cognitive regulation according to the model of executive functions linked to the measurement questionnaire. We also observed that the executive functions and their components presented a slightly higher correlation with overall academic achievement than with specific achievements. However, although marginal, the correlation values were slightly higher for academic achievements in Mathematics than for general achievements in both initiative , 12.3% (AAL), and 12.2% (AAM) of the variance in student achievement . TherefoSubsequently, broken down into factors, the predictive power of executive functions on general academic achievement and on specific achievements in Language Arts and Mathematics was analyzed. As shown in It should be noted that the executive functions as a whole offered less predictive value for academic achievement than the model that only included monitoring of the task and working memory. Therefore, these factors and scales of executive functions remain the most important, regardless of the type of competence, for academic achievements at 6 to 9 years of age.The purpose of this study was to analyze the relationship and predictive role between executive functions and their components  and academic performance, both globally and specifically in the areas of Language Arts and Mathematics, in 133 students aged 6 to 9 years. Thus, the main findings are that cognitive executive factors are more relevant than behavioral and emotional factors for the prediction of academic achievement . Secondly, within the scales of the cognitive regulation index, the best predictors of overall performance, as well as those specific to Language and Mathematics, were task monitoring and working memory. Thirdly, executive functions, in their general or specific measures, are more influential on general academic achievement than on specific ones. This difference, however, is of a marginal nature, and a future study should be conducted to expand on this issue . TherefoExecutive functions have become an important basis for studying children’s behavior and learning, having shown strong validity in predicting academic achievement . PreviouHowever, it should be noted that both planning and initiative have a greater influence on specific subjects such as Mathematics because of their instrumental power. However, although task supervision is related to general academic achievement more strongly than the other factors indicated above, working memory occupies first place for academic achievements in Language Arts and Mathematics. Studies carried out in the United Kingdom indicate that students between the ages of 7 and 14 who score low in working memory tend to perform below the average expected for their age. Therefore, this executive factor stands out for its importance in academic achievement during these years ,57. SimiThe scales that comprise the index of behavioral regulation (inhibition and self-monitoring) and emotional regulation  have not been found to be relevant in explaining academic achievement in students aged 6–9. Some authors have already noted that inhibition  is a good predictor of academic achievement up to age 7  and thatThe highest predictive weight in this work for an age range of 6–9 years was found for the scales and factors included in the cognitive index of Gioia et al. . Only woWhile the relationship between executive function and academic achievement is identical in the specific domains of Language Arts and Mathematics, the same is not true when this relationship is studied in terms of different factors. Although the behavior is the same, the other components of the behavioral and emotional indexes (there is no significance) relate slightly better to the area of Mathematics, with the exception of task supervision. However, working memory and homework supervision also explain the higher percentage of academic results in Mathematics than in Language Arts. Unlike the present study, some authors consider visuospatial memory and working memory to be good predictors of the mathematical ability of students between 6 and 12 years old, and inhibition, flexibility, and planning to be good predictors of academic achievement in general ,37. NeveIn general terms, the purpose of this paper was partially fulfilled by confirming the relationship between general executive functions and academic performance. However, the study did not find that each of the executive factors is important for the age range studied, 6–9 years. Previous studies have shown that inhibition develops up to the age of 7  and thatIt should be noted that the current research has certain limitations that further work should address. The main limitation is that the small size of the sample does not allow generalization of the data, although these data provide an approximation to this topic, as it is in line with previous studies that have already noted the importance of the different factors of executive functions according to the developmental stage of the student.However, the measurement instrument BRIEF-2 (used in this research) falls within the scales of evaluation for the behavior of executive functions and represents the frequency of achievement of an objective in everyday environments . In addiInitially, we tried to verify the relationship between executive functions and their factor structures with general and specific academic achievements as a result of the learning process at a specific age. However, it would be advisable to carry out a longitudinal study throughout the years of Primary Education (6–12 years), which would provide information on the role that each of the factors plays in academic results according to age. It should also be considered that executive functions explain only 35% of academic achievement. Thus, it would be interesting to investigate other variables that can help to predict the remaining percentage of variance. This would better complete our work by providing a meta-analysis on this subject to gather information and developing intervention proposals that can improve the teaching–learning process in Primary Education and the subsequent academic results.Finally, it should be noted that the present study raises possible theoretical modifications such as the clarification of the existing controversy regarding the executive functions’ inclination to predict general rather than specific performance. However, as observed in this study, when analyzing executive functions as a multifactorial element, some factors present their potential with respect to specific performance. For example, in particular, working memory. This suggests the need for a broader, longitudinal study that, in addition to determining this fact, would allow the generalization of the results and their verification at higher ages. On the other hand, there are practical implications, such as the need to evaluate these executive factors at an early age in order to implement specific work plans that allow for the integral development of the student at a cognitive, behavioral, and emotional level.Firstly, it can be concluded that cognitive executive factors are more relevant than behavioral and emotional ones for the prediction of academic achievement . The low importance of the behavioral and emotional regulation index scales in relation to the academic results of students from 6 to 9 years old is possibly due to the fact that the behavioral components (inhibition and self-monitoring) and the emotional components  have an impact at earlier ages or during pre-adolescence ,49. All Secondly, within the scales of the cognitive regulation index, the best predictors of general achievement, as well as the specific ones in Language Arts and Mathematics, were task supervision and working memory versus initiative, planning, and the organization of materials. This emphasizes that these factors, unlike others, are involved in updating and transforming data to plan and guide behaviors in processes such as language comprehension and mathematical reasoning , as wellThirdly, executive functions, in their general or specific measures, have a greater influence on general rather than specific academic achievements. This difference, however, is of a marginal nature, and a future study should be undertaken to expand on this issue .Finally, the implications of these results in an educational context relate, above all, to the evaluation of the level of executive functions at an early age as a basic cognitive factor for proper personal growth. We should also consider the importance of some of the factors of academic achievement with specific learning related to linguistic competence and logical–mathematical thinking. Early detection of atypical development of executive functions can lead to the establishment of specific work plans aimed at improving development and preventing future educational problems.In short, the present study highlights the relevance of executive functions to scholastic achievement. The importance of the scales of the cognitive regulation index compared to the behavioral and emotional indexes was thus verified. In addition, cognitive regulation scales emerged as better predictors of achievement, task supervision, and working memory. Therefore, a high level in these skills relates to a higher level of school success.However, a number of limitations should also be addressed by, e.g., using a larger sample size and a more sophisticated mediation test. Finally, as a prospective study, it is recommended that these issues should be studied in depth by means of a longitudinal investigation with a large sample.


This study reconsiders behavioral and functional data from studies investigating the anatomical imitation (AI) and the related mental rotation (MR) competence, carried out by our group in healthy subjects, with intact interhemispheric connections, and in split-brain patients, completely or partially lacking callosal connections. The results strongly point to the conclusion that AI and MR competence requires interhemispheric communication, mainly occurring through the corpus callosum, which is the largest white matter structure in the human brain. The results are discussed in light of previous studies and of future implications. This study described imitative behavior and its relationships with mental rotation (MR). Imitative behavior is a form of interaction emerging in the first month of life, allowing babies to do what they see adults doing. Imitation is to copy spontaneously or on education what another individual acts, or to reproduce the behavior of another individual serving as a model . Since tIn the past, several aspects of imitation have been addressed [see literature in It is known that in particular situations, the imitative competence is impaired, as in children with autism spectrum disorders ; in thesMany clinical and experimental studies showed that in psychiatric and neurological disorders in which the imitative competence and MR are reduced, morphological structural alterations of the corpus callosum (CC) are also evident, in shape and/or size and/or myelination . It coulThis study describes our recent researches focused on the anatomical perspective-taking in imitating intransitive meaningful gestures, on the MR ability, and on their relationships with the CC. Since AI is basic for learning, for social behavior, and for rehabilitative therapies, the knowledge of the neural circuits underpinning AI and MR and of the timing of CC development and maturation could have important influences on the children and adolescent educational and social integration programs and on physical therapy programs.The imitation is a behavior reproducing observed actions; it allows individuals to establish the first form of relationship between infants and parental figures, and it is basic for learning. In everyday life, the actions to be imitated are generally presented with the imitator facing the model, i.e., in third-person perspective.When invited to imitate gestures of someone facing them, individuals can choose either an anatomical mode, activating exactly the same effectors as the model (therefore the same nervous mechanisms), or a specular (mirror) mode, activating the effectors sharing an external spatial reference with those activated by the model .Previous investigations on imitative competence showed that (1) young children were likely to use a mirror mode imitation strategy, but with increasing age, the anatomical perspective prevailed ; (2) perTherefore, it was hypothesized that the natural tendency of humans is to mirror movements, and anatomical performances would replace the mirror in the presence of certain stimulus information . When thThe choice to mirror acts executed by others could be likely related to cortical patterns of activity, consistent with the existence of the mirror neuron system (MNS), and reflecting a close connection between the mirror strategy and the specific neuron system that matches observed and executed actions.Investigations of cortical activation during anatomically and not anatomically matching gestures have highlighted different functional MRI patterns of frontoparietal activation for mirror and AI , generatRecent behavioral studies from our group tested the hypothesis of the mirror mode of imitation as the primary one. For this purpose, adult healthy participants  and epilThe investigation was focused on the perspective assumed by the subjects in imitating gestures, to evaluate whether the participants’ choice preferred a mirror-mode or an anatomical perspective-taking.same. The same with respect to what/whom? Encoding the concepts of same requires the analysis of spatial coordinates; someone could choose a purely spatial matching between the stimulus and the response (like to be in front of a mirror) or could change its mental body image (through an abstract operation as the MR) so as to align one’s body parts with the other’s body parts.To perform the driven imitation task, the subject has to primarily conceptualize the term same limb. This lays for split-brain patients to differently encode for the same concept, or not to be able to translate the same concept into a motor schema based on anatomical criteria.In the above-mentioned studies, participants’ responses produced enlightening results: both groups used the mirror perspective when free to imitate, but only the control group (with intact CC) used the anatomical perspective when asked to use the Later, the cortical activation pattern evoked in the two previous conditions, i.e., mirror and AI of intransitive gestures, was investigated with functional MRI (fMRI). To reduce artifacts, distortions, and signal loss, some adaptation was made to the experimental protocol: in the free imitation task, participants had to simply watch the videos, by assuming that simple gesture observation does activate the cortical pattern for mirror imitation; in the driven imitation session, they had to image to imitate gestures using the same limb as the model.This study was aimed to identify the following in healthy control subjects:1.The cortical areas activated during the observation of intransitive meaningful gestures performed by a model, presented in video clips in 3rd person perspective (condition likely simulating the mirror mode imitation).2.The cortical areas activated by imaging to imitate intransitive meaningful gestures performed by a 3rd person model, using the same limb of the model .The results showed that, in control subjects, the simple gestures’ observation activated the cortical regions belonging to the MNS : left meA similar activation pattern was observed in patients in the first task: the activation of the MNS cortical circuitry evoked by sole observation was, however, less consistent than in control subjects . A diffeIn fact, our results indicate that the imitation according to an anatomical criterion seems to require the cooperation of cortical areas in both hemispheres: the MFG, IPL, and IFG in the left, the TPJ in the right, and the PO in both hemispheres see also .Therefore, the behavioral and functional results described above have given the input to design further research concerning the mechanism of MR, its involvement in the perspective assumption in imitation behavior, and the role of the CC in this mental operation.Mental rotation is an abstract operation whereby a person imagines rotating an object or a body part to place it in a different position. MR was first studied in behavioral experiments, showing that the time to make a judgment about a rotated object increases in a near-linear fashion with the amount of rotation required to align the object with a comparison one or with a previously learned template . This efPrevious studies, trying to allocate this abstract function in the brain, suggested that objects’ MR belongs to the right hemisphere and body images’ MR to the left, although with less evidence ; howeverMental rotation is strictly concerned with AI, as suggested in previous behavioral studies. It was therefore hypothesized that the different AI performances of the split-brain patients with respect to controls could possibly be due to an impaired capacity for MR, in which the CC might have a role. Assuming the existence of a causal link between callosal fiber functionality and the AI performance, the MR ability was investigated in the same group of subjects previously tested, i.e., patients with partial or total resections of the CC, and healthy adults with intact CC.To test the hypothesis of a central role of the interhemispheric connections in MR, two separate experimental sessions were set: a verbal task, in which participants answered by voice whether the hand holding the cup in the displayed picture was the left or right, and a motor task, where participants responded by lifting their own left or right hand. In this task, it was possible to evaluate the MR ability through a hand-laterality judgment.The results demonstrated that control subjects performed MR almost perfectly, in verbal and in motor sessions, both with the model in first and in third-person perspective. Callosotomized patients showed some impairment, mainly in the verbal session and when the model was in 3rd person. The results indicated the central role of interhemispheric connections in MR, and therefore, because of the need for the cooperation of both hemispheres to be performed, strongly suggest considering the MR as an asymmetric function .The behavioral data just described all agree in the observation that, concerning egocentric transformation, back orientation (first-person presentation) produces better performances than front orientation (third-person presentation). The difference increases in childhood and senior age, both periods of life in which alterations of the cerebral white matter are observed.Subsequent research was designed with the aim to identify, by fMRI, the cortical areas activated during an MR task with human body pictures. Attention was also paid to relate the extent of callosal resection with MR ability. A block-designed protocol derived from that previously used in the behavioral study  was admiThe results from imitation studies provide further support to the notion that the AI requires the cooperation of both hemispheres, since different cortical areas were activated in different hemispheres: posterior area 22 and 39 (TPJ) in the right, dorsal premotor area 6 (MGF), areas 39–40 (IPL), and area 44 (IFG) of the left, and the PO of both.Previous functional studies, revised by The cortical areas activated during the AI task communicate with their homologs in the contralateral hemisphere through the CC: area 6 by sending fibers in the central portion , area 44The involvement of the CC has also been suggested in a previous study reporting a gradual shift toward the AI mode in children, as the maturation of the CC progress with age, from 8 to 18 years . In addiThese results from MR investigation are essentially in line with previous numerous studies [refer to data and literature in Since one big difference between control subjects and patients is the total or partial lack of the CC, it can be concluded that both AI and MR require the integrity of the CC and, therefore, the imitative competence is an asymmetrically distributed function. In this study, the findings described confirms that people with partial or total callosal resection display reduced performance in laterality test with stimuli in third person orientation, suggesting an alteration of MR mechanism ; consequFuture studies could collect similar data from healthy children and adolescents of different ages and from young and adult people with defective neural development or neural lesions. Since AI and MR are basic for learning, social behavior, and rehabilitation, the comprehension of the neural circuit underpinning them and the timing of the CC development could be helpful to set efficient programs both for children and adolescents educational and social integration and for physical therapy.The data analyzed in this study is subject to the following restrictions: Privacy. Requests to access these datasets should be directed to MF. Data are available with the permission of Ancona University Hospital Umberto I.The studies involving human participants were reviewed and approved by Comitato Etico Regionale Marche. All subjects involved provided their written informed consent to participate in this study.MF and CP equally contributed to the conception, design of the study and data analysis and interpretation. NF, CP, and GP contributed to data collection. MF prepared the draft article that was critically revised by GP and CP. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The fourth industrial revolution has produced new information technology (IT) that is widely used in the healthcare industry. Although the nature of the institution affects IT adoption, the Technology Acceptance Model (TAM), a dominant theory, has dismissed its role and influence. Our research investigates how institutions influence the adoption of new IT by using the Institution-based Technology Acceptance Model (ITAM). We conducted an empirical test by using survey data collected from 300 employees in the public sector. Structural equation modeling was applied to test the proposed hypotheses. The results showed the total effect of institutions on the intention to use new IT is positive and significant. Second, IT adoption is not only affected by external institutions but also by type of institution; the external institution takes a greater role in inducing perceived usefulness, perceived ease of use, and intention to use than does the internal. Third, perceived ease of use and perceived usefulness play mediating roles between institution and IT adoption. Fourth, an alternative expanded model to which more individual and organizational factors were added confirmed the results of the base model. We concluded that institutions have a strong impact on the level of intention for IT use through perceived ease of use and perceived usefulness. The rapid development of digital technologies has led to many ideas and attempts to change developmental paths in society . These rApplications of the fourth industrial revolution are considered to be revolutionizing structural elements in current society and have garnered attention in many countries . As the Digital innovation is changing the fundamental structure of the public sector. Therefore, innovation strategies that consider the specific contexts and characteristics that exist in the public sector are necessary. Kromidha and Córdoba-Pachón  In order to succeed in the innovation of information and communication technology in the public domain, it is important to overcome the inertia and failure factors that exist inside. Hannan and Freeman  define iTherefore, it is necessary to consider the impact of institutions and the role of governments as key factors to accelerate the usefulness of new technology and regulate basic principles. Governments are positioned to increase data availability and usage and public employees play a critical role for innovation in government ,19,20. CIn the new information age, new theoretical concepts and models related to informatics are required. In the literature regarding new technology adoption, the Technology Acceptance Model (TAM) has been widely used as a theoretical framework for predicting individuals’ acceptance of technology. Since the TAM was introduced by Davis , great tBecause IT has been extensively used in the health field, it is very important to understand the fundamental structure of technology acceptance. Technology acceptance will be critical for providing better healthcare services through online IT, especially during pandemics like COVID-19. Although new technologies help healthcare services through telemedicine and online databases, some barriers to broader adoption of new technology persist. In particular, institutional readiness and the adoption of new technology by employees are necessary. Since healthcare service in nature is a system of combining micro-level individual actors and macro-level intuitional structures, the acceptance of new digital technology for health care service should consider not only humane side factors but also institutional settings which constrain people’s attitude and perception. Digital technologies, the core of new technologies, cannot operate in isolation and require integrated institutional systems. In particular, digital data sources need to be integrated and interoperable into broader institutional settings. On the other hand, the government is one of the main actors in the institutional setting for healthcare services. The use and analysis of this data heavily depends on digital infrastructure and strong support from the public health system by governments. Governments’ responsibility and strategic foresight are especially important in high-risk situations such as a pandemic. In this regard, it is necessary to understand the adoptive mechanism of new technology in the public sector, especially focusing on the impact of institutions. Therefore, our study is expect to contribute to understanding IT services for the healthcare field.The remainder of this study is divided into four sections. First, based on previous research, the authors propose theoretical reviews and hypotheses on technology adoption behaviors of employees and focus on the relationships with institutions and TAM, in particular. The next section discusses the methodology of this study, the sample and data used, and the variables and measurement. Next, the results are presented in the following section to show the relationships among factors affecting technology adoptions. The final section discusses the implications and limitations of the study with a conclusion.The increased and intensive use of IT requires governments to develop IT-based tools to directly deliver public service. The recent technological developments of the fourth industrial revolution emphasize the interconnectivity and reciprocity of the digital revolution and can lead to transformational changes at a societal level .While recent IT developments bring many benefits, it is necessary to recognize the challenges of these new technologies in the public sector. The advantages of implementing new technologies are immeasurable, especially in terms of assisting public organizations in improving their tasks. The new technologies have high usability and flexibility and provide high-performance service delivery at low cost . HoweverWith the unprecedented efforts to utilize digital technologies in the field of government and work processes, the advent of the fourth industrial revolution ushers people into digital transformation in all areas of their personal lives. Due to advanced internet technologies, this movement mainly includes ubiquitous data communication, managerial flexibility, disruptive innovations, and autonomous systems . The curMany other countries also made strategic preparations to support the implementation of a wide range of innovations of the fourth industrial revolution. For example, Canada launched “Digital Canada”, which includes five critical categories in new technology: connection, protection, cybersecurity, economic opportunities, and digital government ,32,33. LAny innovative or transformative movement in large organizations, especially governments, should consider many relevant factors in their implementation. Even though the significant factors of IT implementation in government are diverse and complicated, they could be categorized as technological, structural, and behavioral factors ,39,40.Among the causal factors for successful application, institutions play a significant role when policymakers try to frame and introduce an IT policy ,42,43. TTAM has been continuously studied to estimate users’ acceptance and behaviors; its application has expanded . As a thTAM has been continuously revised and new variables have been added to increase its theoretical explanatory power. Davis ’s originHowever, TAM has several limitations. First, TAM overlooks various preferences because it emphasizes individual utility. According to Chtourou and Souiden , while tSecond, there are objective variables, not just subjective, among the causal factors affecting technology acceptance. On the other hand, TAM disregards these objective variables at the initial stage of development. Since previous research had focused on the variables existing inside the model, it overlooked the external variables. For example, Hu et al.  and DaviThird, TAM neglects the conditions, environment, and context that promote the perceived usefulness and perceived ease of use it IT adoption. Marangunić and Granić  indicateFollowing previous research, this study utilizes the extended TAM to explain the adoptive behavior and influencing factors of the fourth industrial revolution in governments. This study seeks to validate TAM in research on emerging new technology movement by analyzing factors that influence adoptive behavior in the central government of South Korea. Generally seen as a forerunner in the adoption and implementation of IT policies, South Korea is driving IT-based policy initiatives toward the successful transformation of the fourth industrial revolution . TherefoThere have been many debates on the definition and concept of the fourth industrial revolution because of variation in countries’ focus on applications and content ,21. As tTAM and extended ITAM posit complex human behaviors and decision-making processes that are subject to human–computer interaction. Researchers should take into account these intertwining relations in the model. This studies examine not only perceptional factors about institutional ones. A neoinstitutional framework makes links between the individual/behavioral and social/contextual sides of technology acceptance. Neoinstitutional theory applies its theories to explain technology implementation in an institutional environment. It regards informationization as a kind of institutional change and a process of institutionalization ,66. JeppIn an information system (IS) context, institutional approaches focus not only on “how institutions influence the design, use, and consequences of technologies, either within or across organizations” In the TAM model, institutional factors are regarded as external or social process elements. For example, Igbaria et al.  demonstrTAM also focuses on culture, which is a type of institution. The cultural-cognitive approach of neoinstitutional theory emphasizes the role of shared beliefs and ideas in shaping individual and organizational behaviors , p. 52)..52] showHowever, with the wide and different ways of defining culture, it is difficult to examine and measure culture in an observable and constant manner to all individuals with the same cultural backgrounds . TherefoHypothesis 1A.Institution is positively related to the perceived usefulness (PU) and the perceived ease of use (PEOU) of new technology in the fourth industrial revolution.As organizations and their members generally adapt to and operate in institutional arrangements , institutions influence employees’ behavior and define appropriate behavior in these practices ,77. As MHypothesis 1B.External institution is more positively related to the perceived usefulness (PU) and the perceived ease of use (PEOU) of new technology than internal institution.The perceived ease of use is the degree to which the person believes that using the particular system would be free of effort ,54. DaviHypothesis 2.Perceived usefulness (PU) is positively related to the intention to use new technology in the fourth industrial revolution.Davis  suggesteHypothesis 3A.Perceived ease of use (PEOU) is positively related to the intention to use new technology in the fourth industrial revolution.Davis  defined Hypothesis 3B.Perceived ease of use (PEOU) is positively related to perceived usefulness (PU).According to Venkatesh and Bala ’s TAM 3 Hypothesis 4.Perceived ease of use (PEOU) and perceived usefulness (PU) positively mediate the relationship between institution and intention to use new technology in the fourth industrial revolution.The following equations represent the proposed hypotheses. The baseline model posits that the adoption of new technologies is a function of the institutional space that surrounds the organization as well as individual elements.Institution includes laws, regulations, guidelines, strategies, and work proceduresIntention to use is the level of individual’s behavioral intention to adopt new technologiesM plays a mediating role in explaining intention to useBased on these assumptions, the structural model was constructed to test the logic and our hypotheses.The variables in ellipses represent latent constructs that are explained by the reflective indicators depicted with rectangles. In our proposed model, latent variables IU_1 through IU_5 stand for the items in the test for intention to use and e13 through e17 stand for measurement errors (unreliability) in each item. In addition, SEM considers measurement error by modeling it explicitly when estimating latent variables from indicators . These eAt the center of the model lies the assumption that perceived ease of use and perceived usefulness have mediating roles that have an effect on attitudes and behavioral intentions. The model suggests that the indirect pathway, from institution to behavioral intention to use, is determined by a set of personal beliefs that influence usage behavior.As the purpose of our study is to suggest a constructive artifact of digital informatics of human–computer interaction, it is worthwhile evaluating our proposal in terms of information system perspective ,94. InfoNew technology in the fourth industrial revolution is highly based on interactions among individuals, technologies, organizations, and people. Therefore, it is critical to investigate the causal factors to adopt and use IS. In an IS, technology and behavior are not mutually exclusive ,97; reseTAM is widely applied across various fields in IS research. Many researchers have tried to provide an extension of TAM by integrating contextual and external factors. To offer a deeper explanation of technology adoption behavior, both empirical testing of the hypothesized model and investigating new influencing factors are needed. Qualitative research can provide in-depth understanding of IT adoption; however, exploring subjective experiences and subtle aspects of behaviors is a more effective way to learn the underlying reasons and motivations for IT adoption. This study focuses on the growing and recent phenomenon of TAM application in the latest industry techniques. Therefore, a quantitative research approach was chosen for this study. SEM was employed to examine our proposed hypotheses because it is the preferred method of testing a series of complex and multiple relationships constituting a set of an entire theory ,98. In SThe number of samples is a critical issue in SEM. Bentler and Yuan To address the research questions and hypotheses, our study used a dataset from an open archive of the Korea Institute of Public Administration (KIPA). The KIPA is one of the leading public research organizations funded by the central government that mainly focuses on administrative developments and practices affecting public employees. Various surveys on policy and practical issues were exclusively conducted by KIPA to support government policymaking and implementation. Thus, datasets from the surveys are provided by formal request and review for further research . AccordiThe survey into the state of new digital technology in the fourth industrial revolution was designed to identify primary factors that influence the adoption of new technologies in the public sector. The survey was conducted by KIPA through an online web page from 5 to 28 September 2018. Public employees who work in IT services in the central governments of South Korea were the target population of the survey. Random and cluster sampling methods were used for data collection. A total of 333 target respondents were randomly selected from employees of IT service divisions from 18 central government ministries, which are regulated by the Government Organization Act of South Korea. The candidates were contacted by phone prior to the survey to ensure that they agreed to participate in the survey. A website address was sent to them via e-mail and respondents logged onto the website to conduct the online survey; 300 respondents participated in the survey (90.09% of response rate). The total population size of the survey was 132,422 and our sample size was 300 with 95% confidence internal and 5.6% error. Determining an appropriate sample size for SEM is debatable where there is no prevailing consensus. Many guidelines have been suggested for the optimal sample size, such as the N: q rule  which usN < 200) may be problematic. Given these requirements, even though archival data was used, we concluded that 300 participants was appropriate to test the conceptual model.It depends on not only the complexity of the model but also additional factors . CB-SEM requires a larger sample size than PLS-SEM , and theThe survey sample reflects the proportion of the total number of central government public employees and each proportion by ranking. The questionnaires used in this study were designed by KIPA . The iteInstitution. Institution can be conceived as laws, norms, and systems that confine the way people select, implement, and use IT in public organizations [izations ,113. PubPerceived ease of use related to computer self-efficacy, perception of external control, and computer playfulness ,46 were Perceived ease of use. Perceived ease of use was measured by seven items adapted from previous research by Venkatesh and Bala [and Bala  who suggPerceived usefulness. Perceived usefulness (PU) was measured by five items adapted from the study by Venkatesh and Bala [and Bala . They suand Bala , p. 277)and Bala , p. 195)and Bala , p. 191)Intention to use. Behavioral intention predicts and facilitates actual usage behavior. Respondents were asked questions about their attitude toward the use of new technologies . Intention to use was measured using three items that refer to purpose and motivation to use new technologies and intention to put effort into using new technologies.p-value that assesses whether the estimates are significantly different from some reference value.We use SEM as main analysis method. In terms of the statistical approach, SEM has good advantages for testing a series of complex and simultaneous relationships. SEM is a multivariate technique used to test all coefficients (relationships) in the complete model simultaneously. Simple ordinary least squares (OLS) regression cannot assess the significance of particular relationships between variables when moderating effects are hypothesized. In SEM, path coefficients  are parameters of the structural model and are estimated through a series of algebraic manipulations. The maximum likelihood fit function is used to calculate the path coefficients which are iteratively modified . The patThe purpose of SEM is to specify a model derived from theory and the estimation of the parameters of the model is derived from the conventional approach of SEM. The overall objective of the conventional approach is to connect the theory and specification of the model. Within this approach, exploratory factor analysis and confirmatory factor analysis are performed to test the proposed model. At this stage, the measurement model is estimated and the structural model can be estimated later. The full model can be structured through a continuous model modification and evaluation of goodness-of-fit until the model meets the criterion of adequate fit. This is discussed in more detail in the data and methods chapter. The meaning and interpretation of parameters in the SEM are outlined in SEM consists of two powerful statistical approaches: exploratory factor analysis (EFA) and structural modeling where structural path analysis is applied. EFA is used to identify the number of hypothetical factors or latent variables that can be explained by covariance among a set of observed variables. Therefore, a priori specification of the number of variables is not required in EFA ,115. Ins2 = 2498.853, p < 0.0001). The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.849, rejecting the null hypothesis that there was no difference in variances between the groups [The construct validity of measures was investigated in two steps: EFA and CFA. The characteristics of these two steps are outlined in e groups .We followed the two-step procedure proposed by Anderson and Gerbing , which cContrary to EFA, the exact number of factors should always be defined in CFA before analysis. However, CFA does not necessarily confirm the initial restricted model that fits the data. In this case, the modified hypotheses and specified models should be proposed as alternative models . In thisr) in order to evaluate the association between the variables. As shown in r = 0.276, p < 0.01), perceived usefulness , and perceived ease of use .p < 0.001) and perceived usefulness , in support of Hypothesis 1A. This suggests that institutions can play an important role in the adoption and diffusion of new technology, supporting previous studies that focused on the institutional perspective [R2 = 0.107). In terms of Hypothesis 2, the effect of perceived usefulness on intention to use was positive and significant . The results also showed that perceived ease of use had a strong and positive impact on intention to use , supporting Hypothesis 3A. The results indicate that those who perceive that the fourth industrial revolution technology is useful and simple are more likely to have a higher intention to use it. The path coefficient between perceived ease of use and perceived usefulness was positive and statistically significant , in support of Hypothesis 3B. In terms of perceived usefulness, 37.8% of variance in perceived usefulness was explained by predictor variables (perceived ease of use and institution).The structural model was identified in order to test the hypotheses. Beginning with the hypothesis tests, multiple fit statistics were examined for model fit. As shown in spective ,123. Insp < 0.01) in support of Hypothesis 4. In addition, the total effect of institution on (Institution→ perceived ease of use→ intention to use) and (Institution→ perceived ease of use→ perceived usefulness→ intention to use) was positive and significant   . The resIn order to explore more specific institutional settings and to further establish the measure of institution, we additionally adopted two-factor institutional models. The focus of the alternative models is the dimensions of institutions: whether they are created and enforced by entities inside or outside the organization.By adopting externally legitimized formal frameworks and internal administrative process, organizations may strengthen the engagement of their internal members in change and innovations . It is nAn attempt to compare alternative models lets us not only review the variety of institutional systems but also determine the superiority of the conceptual modes. These two dimensions generated two-factor institutional models illustrated in Internal institutions  are implemented by the top of the bureaucratic hierarchy as a means of agency management. As the interrelations between organization and institution are complicated and diverse, actors in organizations tend to choose institutional suboptimal solutions or arrangements to reduce uncertainty and ambiguity in the implementation process . Therefop < 0.01). Regarding the internal institution model (p < 0.01). The findings may indicate that institutional arrangements made by external entities can be more powerful than managerial actions when adopting new technologies in the public sector, therefore confirming our Hypothesis 1B.Our results showed that the directions of path coefficients adhere to the general TAM hypotheses. In terms of model fit, the external institution model showed adequate fit  and the internal institution model also showed adequate fit . In the external institution model , externaon model , perceivRegarding the characteristics of organizational structure, it should be considered that there are possible differences in institutional influences between organizations with high and low hierarchical levels. Because our study was based on a high hierarchical organization , it is worthwhile to discuss possible differences when we apply our two-factor institutional models to a low hierarchical organization . Regarding organizational members’ tendency to reduce uncertainty in the decision-making process , the memHowever, in terms of an organization’s complexity, centralization, and formalization, it would be considered that the influence of internal institutions would have a strong effect on new technology adoption in low hierarchical organization ,133. BecIn SEM studies, the standard procedures provide a baseline model based on general theory and test a modified model based on possible relationships between other indicators . During In doing so, we tried to give a more comprehensive explanation of complex human behaviors and attitudes that are constrained by various conditions and circumstances. The purpose of examining an additional alternative expanded model becomes clear when considering the fundamental nature of technology diffusion and adoption in organizations. Technology adoption and diffusion occur as a continuous process based on a series of individual decisions that are mostly calculated by the incremental benefits of using the technology. In addition, technology adoption is usually requested by a top-down management and often seen as an investment decision made by managers . ResearcTherefore, the alternative expanded model posits that contextual factors may have direct and indirect effects on intention to use. In order to give a more comprehensive explanation of complex new technology phenomena, we constructed an alternative expanded model and tested non-mediated models. The proposed baseline model only considered causal path relationships of institutions, perceived ease of use, and perceived usefulness to intention to use of new technology in the fourth industrial revolution. To examine the influence of individual factors, we included intrinsic factors , organizational factors , and task-related factors  ,134. AmoWhen introducing new technologies, the ability for individuals to adapt and modify their patterns is challenged. In this respect, a strong cultural foundation will facilitate the acceptance and success of new technologies ,137. HenNew technology in the fourth industrial revolution might influence the types of job tasks required of individuals, which health professionals during the current pandemic have experienced . Thus, wTherefore, we examined the possible impact of individual features  and organizational conditions . Individual experience was measured by “I have experienced public services provided by new technologies in the fourth industrial revolution ”. Voluntariness was measured by “I think it is important to foster public service innovation using new technologies in the fourth industrial revolution”. Specialty was measured by “I have job specialties so that I can adopt new technologies in the fourth industrial revolution”. Organizational conditions were measured by the following: “My organization is trying to foster a culture of new technology in the fourth industrial revolution utilization”, “My organization provides technical security measures to protect IT-enabled public services”, and “Managers in my organization try to foster IT-enabled public services innovation.”Our approach to the expanded modification model with individual and organizational factors can contribute to the development of information system research. From the perspective of “good design science” , studiesWe tested whether significant improvement in model fit was made when adding new variables . In ordeGenerally, the proposed alternative models were acceptable; however, the model fits were not greatly improved over the baseline model. Thus, we concluded that alternative models may not be preferable to the baseline model. Although alternative models did not appear superior in terms of model fits, it should be noted that more conditional variables were considered and the simultaneous effects were examined.Beyond these model fit results, significant path coefficients were found in most of the expected directions and the results supported the verified causal relationships of the baseline model. As with any previous TAM studies, the effects of both perceived ease of use and perceived usefulness on intention to use were positive and significant in the basic parsimonious model. Furthermore, institutions significantly affect perceived ease of use and perceived usefulness. Institutions have a significant and strong indirect influence on intention to use, which would lead one to expect that institutional factors may have a crucial role in new technology acceptance of public employees in South Korean central government agencies. The test results of the alternative models lend support to the important role of institutions as an external facilitating factor, thus confirming Hypothesis 1. While the direct effects of institutions on perceived usefulness did not show significance in submodel 4, its total influence on intention to use was still reinforced by mediating variables. In terms of the total effects of contextual variables, specialty and security showed a negative and significant effect on intention to use in submodel 2 and 3, respectively. However, direct effects were not significant . In submOur study aimed to analyze the links between the impact of institutions, perceived ease of use, perceived usefulness, and intention to use of new technology adoption in the fourth industrial revolution ,31,144. The contributions of our study to the healthcare field are suggested as follows: First, the usage of digital technology and developments in the healthcare field are expected to increase significantly following COVID-19. Regarding the role of information systems in COVID-19, this study implies that institutional environments should be considered when initiating digital health related policies or projects. After tracking websites’ digital communication strategies in Latin America hospitals during the COVID-19 pandemic, Tejedor et al.  suggesteSecond, our findings suggest that institutions had an indirect impact on the intention to use new technology of the fourth industrial revolution. It is important to consider what factors affect government employees’ intentions to use new technology as they introduce and organize various collective strategies on public issues such as pandemics. The institutions do not ensure that the actual application of emerging technologies can occur without the mediation of presumed ease and usefulness. As a result, when we introduce new technologies, we must understand how people actually perceive the ease of use and usefulness of such technologies. In particular, the COVID-19 pandemic involved huge demands that necessitated the collection and analysis of digital health data using new technology. As a result, the role of government employees is critical. Thus, it is worthwhile to investigate the factors of new technology adoption, especially when it is intended to be used by public employees confronting this unprecedented issue.Third, when considering the design of information systems for healthcare services, it needs to consider whether external and internal institutions had a differential effect on the intention to use new technology . In the In Our study empirically investigated the influence of institutions on new technology adoption of the fourth industrial revolution. The characteristics of these new technological developments are complicated , and it New technological advancements like the fourth industrial revolution should be closely interconnected with institutional arrangements such as strategies that allow a structure to adjust or preserve stabilization after experiencing periods of instability . For insCountries like Singapore and Australia launched a digital app and QR tracing, while data encrypted technology was reserved for government-based utilization ,157. In Given the pandemic’s uncertain nature and the risks it presents, it made sense for government authorities to first centralize decision making, such as school openings, and create or implement strategies for delivering instruction to fulfill regulatory requirements . NeverthAs we have seen in the previous examples of response to the COVID-19 pandemic in various countries, new technology adoption does not always lead to complete adoption and use. One of the main reasons for the failure of U.S. governance was not due to technological difficulty but rather to institutional instability and perceived utility . Thus, aIn this study, we assessed the causal path relationships of new technology adoption in the fourth industrial revolution by an empirical survey of public employees of the central government in South Korea. Since government employees play such a significant role in the decision to construct new technology deployment ,162, theWe identified that institutions influence perceived ease of use and usefulness, which mediate the impact of institutions on intention to use new technology . AccordiIn addition, as the results of our alternative expanded model showed, institutions cannot directly impact intention to use new technology without the mediating effect on perceived ease of use and usefulness if we do not control the causal path relationship . It is iThe findings of this study could be meaningful in many respects. However, they also present certain limitations that will provide a basis for future research. This study performed statistical tests and analyses based on cross-sectional survey data collected at a single point in time. Thus, it is not possible to use a panel analysis methodology that examines the trend of usage over time. In addition, even though we conducted several statistical tests to avoid possible methodological bias in our model, mono source bias or correlated measurement error might not be completely excluded.Because of the contextual features of the South Korean public sector, it is necessary to consider biases from contextual factors like culture in further research . Further