THEORETICAL DEVELOPMENT

The e-Health Service in NTUH

National Taiwan University Hospital (NTUH) established a tele-health center in 2009, which emphasized the delivery of personalized healthcare services through ubiquitous devices.

In this so-called NTUH e-Health service, patients use remote controls and touch panels for uploading their daily biometric information into the database (Figure 1). Physicians read this information using their mobile phones and provide real-time medical advice. Subsequently, patients and their physicians engage in an interactive video conference every week in order to discuss the data analysis results and methods for improving the patients’ health.

Figure 1. Devices used in the NTUH e-Health service system

Depending on each patient’s medical situation, which is determined on the basis of their diseases and symptoms, one of the following six services may be chosen for their treatment:

1. Tele-education. This service provides current information and knowledge on healthcare, which facilitates empowerment of individuals. This service emphasizes the preventive approach and motivates individuals to lead a healthy life.

2. Tele-diagnosis. The service provides immediate treatment to patients on the basis of the transmitted tele-monitoring data or teleconsultation.

3. Tele-monitoring. The case managers at call centers proactively contact patients for

monitoring their progress and ensuring that they are following the healthcare plan determined by their respective physician.

4. Tele-consultation. This service provides remote healthcare consultations. Patients receive consultation through videoconferences, which incorporate digitization and transmission of patients’ relevant medical records including text, diagnostic images and medical charts.

5. Tele-therapy. This service provides psychological counseling and rehabilitation treatments through high-quality live videos.

6. Lifetime health. This service provides a continuum of personalized, proactive, and

prospective lifetime health plans for enabling individuals to sustain a sound state of health.

Three main stakeholders involve in this service system. The case managers monitor the health of a patient through ubiquitous devices, the physicians focus on the integrative

management of patient wellness, and patients co-create the value by proactively providing the data into the system. The three stakeholders also form the service triangle in NTUH e-health sector, depicted in Figure 2. Physicians give the objectives and deal with accountability. They are the coaches, responsible of empowering, enabling as well as guiding, supporting, encouraging, and rewarding their case managers. Case managers are frontline staffs, who deliver the service.

They have a large portion of the control of the relationship in the front stage and demonstrate the service value through a one-to-one relationship. Customers customize and integrate the service through their participation. They give direct feedback or lodge a compliant.

In this research, we suggest that a sustainable e-health service needs to satisfy the three stakeholders, and thus it is important to develop a valuation system that incorporates their value perspectives in a concerted manner. The stakeholder theory is the core theme behind this

statement. We will discuss it further in the following section.

Physicians

Figure 2. Stakeholders in the NTUH e-Health service system

Stakeholder Theory

As outlined originally in Freeman (1984), stakeholder theory was concerned with the problem of value creation and trade. Since different stakeholders often have different

expectations of a corporation, how to manage the relationship among stakeholders and create as much value as possible for stakeholders becomes the major problem that corporations need to resolve. To solve the problem, stakeholder theory suggests that it is important to see stakeholder interests as “joint” rather than “opposed (Freeman et al. 2010).” The stakes of each stakeholder group are multifaceted, and inherently connected to each other. Serving all stakeholders without resorting to trade-offs is the best way to produce long term results (George 2003).

Based on the stakeholder mindset, a set of value components that categorizes the needs of patients, case managers, and physicians was proposed to highlight different purposes of e-health service (Table 1).

1. Value to Patients. Many research studies have applied SERVQUAL (Parasuraman et al.

1988), a standard instrument for measuring functional service quality to assess patients’

opinions of healthcare services (Kastania and Zimeras 2009; Lam 1997; Yum and Chun 2008). In this study, we aim to use SERVQUAL to develop a comprehensive scale to evaluate patient value propositions for the e-Health service. Eight value components are considered in this study: tangibles, reliability, responsiveness, assurance, empathy, convenience, control, and choice.

2. Value to Physicians: Past literature has posited that the physicians must fully understand the potential of tele-health services before making the services successful (Ball and Lillis 2001).

In this research, we propose four important benefits that physicians care about: productivity, accessibility, communication, and wellness.

3. Value to Case Managers: Since case managers, are involved in producing, delivering, and marketing the service, the extent of their participation determines the success of the system.

Therefore, besides investigating the value offered by this service proposition to the NTUH, it is also important to evaluate the willingness of the healthcare employees to participate in the delivery of this service. We adopt the theory of human motivation in order to investigate their expectations from this service (Benson and Dundis 2003; Maslow 1943). The five value propositions are: physiological needs, safety needs, social needs, ego needs, and needs for

self-actualization.

Value Propositions

Definitions

Patient Value Propositions (Harrison et al. 2006; Kastania and Zimeras 2009; Yun and Chun 2008):

Tangibles The physical facilities, equipment, and personnel are visually appealing.

Reliability The information and knowledge provided by the service is dependable (available whenever required) and accurate

Responsiveness The service is prompt (i.e., it provides timely information and knowledge).

Assurance The service inspires trust and confidence in patients for managing and paying attention to their own health.

Empathy The service provides considerate and personal attention to patients.

Convenience The service fulfills patients’ demands for convenience (e.g., lesser delays and convenient scheduling for treatment as well as reduced paperwork).

Control The service enhances patients’ perception vis-à-vis controlling their own health.

Choice The service provides ample choices and information with respect to healthcare.

Value Propositions of Physicians (Bower et al. 2005; Matusitz and Breen 2007; Reed 2005;

Ruckdaschel et al. 2006):

Productivity The service has the potential to improve the productivity of healthcare delivery by reducing labor intensity, incidence of medical error, cost of treatment, traffic in the waiting room, and visits to the clinic as well as by time and paper savings through automated processes, efficient encounters, and improved clinical decision-making.

Accessibility The service improves the access to patients (i.e., it reduces time and cost for accessing the patients)

Communication The service improves patient-physician communication.

Wellness The service improves the wellness index.

Value Propositions of Case Managers (Gerrity 2005; Rowe et al. 2005):

Physiological needs

Healthcare employees are satisfied in terms of their current salaries, working conditions, as well as concentration and convenience requirements.

Safety needs Their jobs are secure and offer a reasonable degree of responsibility.

Social needs The job provides adequate opportunities for improving relationships with patients and co-workers.

Ego needs The job is acknowledged by patients and society.

Needs for

self-actualization

The job provides adequate learning and development opportunities, has a clear vision, and an enhanced sense of achievement.

Table 1. The List of Value perspectives for the e-Health service system To examine the relationships among different value perspectives, stakeholder theorists suggest that understanding entrepreneurship can provide some answers (Venkataraman 1997). In an entrepreneurial activity, executives play a special role. On the one hand, they have a stake which is linked to the stakes of other stakeholders. On the other hand, executives are expected to

look after the health of the overall enterprise. For example, they need to ensure other employees are healthy and happy and are able to work creatively to reach the corporate goals (Freeman et al.

2010).

In the context of NTUH e-health service, physicians are executives and play dual roles in the e-health activities. On the one hand, they are back-stage healthcare workers, supporting case managers in the front stage. On the other hand, they are responsible of service marketing of e-health in the outpatient clinics. Besides, they need to do internal marketing to ensure that case managers fully understand the value of their roles and are willing to act as required. Thus, we can expect that how physicians perceive the value of e-health will affect how they convey the values to frontline case managers and to patients. We thus hypothesize that,

H1: Physicians’ value components are positively associated with patients’ value components.

H2: Physicians’ value components are positively associated with case managers’ value components.

While stakeholder theory focuses on the interactions between executives and different stakeholders to enhance value creation or resolve potential value conflicts, it does not explain the relationships between stakeholders who are inside the corporations and those who are outside the corporations. However, in the service context, this relationship is the key to the service success.

In the next section, we use service profit chain to fill this theoretical gap.

Service Profit Chain

To explain the relationship between profitability, service value, and service quality, Heskett et al. (1994) developed a theory and business model, known as the service-profit chain.

The links in the chain are as follows: Profit and growth are both affected by customer loyalty, which is largely influenced by customer satisfaction. Customer satisfaction is a direct result of service value, which is created by employees’ productivity and performance. Employee satisfaction is a result from high-quality support services and policies (See Figure 3).

Figure 3. The Links in the Service-Profit Chain (Heskett et al. 1994)

According to Joseph (1996), getting employees to become customer-oriented and to work as part of the firm’s team is the best way to improve internal service quality. The company should make the process of attracting, developing, motivating, and retaining qualified employees a priority; however, understanding the needs of the employee goes beyond simply promoting a good work environment (Benson and Dundis 2003). In the healthcare sector, for example, case managers (i.e. front-stage employees) have to face the challenges, including advances in

technology and changes in the demographics and diversity of the workforce; thus, to achieve the

highest value of customer satisfaction, employers must strive to satisfy their case managers’

needs by enhancing job value (Berry 2004). We can infer from Figure 3 that the internal service quality indirectly impacts the external service value through the service delivery system, and thus the following hypothesis is proposed,

H3: Case managers’ value components are positively associated with patients’ value components.

Figure 3 also indicates that the external service value directly influences customer satisfaction and indirectly changes customer retention. External service value can be defined as customers' assessments of service value which is equal to the perceived service quality relative to the price and customer acquisition costs. Customers who have already experienced the service have some power over the business-customer relationship, because they can decide whether or not to repurchase or advocate the service (Teboul 2006). In fact, when referrals are added to the economics of customer retention and repeat purchases of related products, the lifetime value of a loyal customer may be astronomical (Heskett et al. 1994). According to Reichheld and Sasser’s estimation (Reichheld et al. 1990), a 5% increase in customer loyalty can increase profit from 25% to 85%. Thus, we can hypothesize that,

H4. Patients’ value components are positively associated with service sustainability.

Summary

Taken together, these hypotheses imply a research framework (depicted in Figure 4) in which physicians’ value assessment impacts value assessments of case managers, patients and case managers’ value assessment impact patients’ value assessment, and at last, patients’ value assessment impact the sustainability of e-health (Figure 4). There are thee cross-level analyses involved in this model: (1) between the levels of physicians and case managers, (2) between the levels of physicians and patients, and (3) between the levels of case managers and patients.

Physicians’

Value Components