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Case Studies of Implementation
of Interactive E-Health Tools on
Hospital Web Sites1
Edgar Huang
Indiana University
Chiu-chi Angela Chang
Simmons College
ABSTRACT
Using content analysis and in-depth interviews, this research has examined three best-prac-
tice hospitals in terms of their approaches to implementing interactive e-health tools on their
Web sites. The study has demonstrated hospital administrations’ visions of and insights into
developing e-health. It concludes that the implementation of interactive e-heath tools can be
area- and hospital-size-indiscriminative; such implementation accomplishes multiple goals,
including service, communication, and education, and serves as an important differentiator
in a competitive industry; by understanding the best practice, decision-making, planning
processes, and outcomes of implementing e-health online, as well as potential obstacles to
such implementation, hospitals can take the lessons learned and design effective interactive
e-health tools on their Web sites.
Keywords: healthcare new media marketing, healthcare IT, e-health, hospital Web sites,
interactive.
INTRODUCTION AND BACKGROUND
Over the past decade or so, thousands of U.S. hospitals shifted some of their business on-
line (Huang, 2009; Huang & Chang, 2012; Shepherd, 2003). This shift is part of the
trend called e-health, which is defined as “the combined use of electronic information and
communication technology in the health sector for clinical, educational, research, and
1. This paper has been accepted for presentation to 2012 Stanford Medicine X Conference in Stanford,
California. Both authors contributed equally to this research.
Case Studies of Implementation of Interactive E-Health Tools on Hospital Web Sites
47
administrative purposes, both at the local site and across wide geographic regions”
(Mukherjee & McGinnis, 2007). Many hospitals have conducted business online via in-
teractive e-health tools, such as finding a physician, paying bills, using an interactive map,
and accessing medical records online. Interactive e-health tool in this study is defined as
an online mechanism that initiates an online transaction between a hospital and a user.
While it is common for hospitals to have their own Web sites and incorporate some
interactive e-health tools, it is not clear what interactive features and functions are con-
sidered to be most helpful from the perspective of the users/patients. In addition, there is
scarce research available regarding how hospitals make decisions about providing interac-
tive e-health tools on their Web sites. Huang and Chang (2012) found that most hospi-
tals were still on the level of implementing traditional functional tools on their Web sites,
such as online search, interactive maps, and finding a doctor (each tool having a national
adoption rate above 55%), whereas online core e-business tools, such as pre-registration
(national adoption rate at 19.4%), making a doctor’s appointment (15.3%), accessing
medical records and lab results (10.1%), and requesting for prescription refills (9.7%),
were hardly available; the only e-business tool that was popularly implemented was pay-
ing bills online (40.2%). In the meantime, there appears to be a gap between what inter-
active e-health tools users/patents desire to see on hospital Web sites and what is really
offered by hospitals. For example, 84% of the users express a strong wish to access to
their medical records online, but only 10% of the U.S. hospitals are currently providing
such a service (Huang, Chang, & Khurana, 2012). In addition, among all the interactive
tools on hospital Web sites, users are least interested (10%) in socializing with hospitals
even though 36% of the U.S. hospitals have actively tried to connect to their users on
social media (Ibid.).
Research in the area of interactive e-health tools on hospital Web sites has been
emerging. The purpose of this study is to investigate three best-practice cases of hospitals
to understand the determinants and outcomes of successful implementation of patient-
oriented interactive e-health tools on their Web sites. Specific research questions include:
1. How have these best-practice hospitals performed e-health on their Web sites?
2. What factors have driven their e-health development?
3. What barriers have they encountered while implementing e-health online?
4. What are the outcomes of and future plans for their e-health implementation?
Answers to these questions will provide insights to many hospitals interested in taking
advantage of interactive e-heath tools on their Web sites to serve their patients. By applying
the findings from this study, hospitals will be able to adopt best-practice ideas, drive their e-
health development efforts, foresee possible barriers and solutions, and evaluate the outcomes
of their e-health implementation. This study will contribute to the literature of e-health by
deepening our understanding of its current practice and providing practical implications.
Edgar Huang and Chiu-chi Angela Chang
48 e-Service Journal Volume 9 Issue 2
As a matter of fact, the U.S. healthcare industry has been (in)famous for lagging
behind other industries in adopting new information technology (Gallant, Irizarry, &
Kreps, 2006). Gartner Inc., a New York-based research and consulting firm, found in a
study that less than 1% of hospitals were aggressive about finding and implementing new
technologies, and the vast majority of hospitals (84%) were risk-averse and would use
only the technologies that have been on the market and that have a solid, proven track
record (Gillespie, 2001). It is likely that pioneers, that 1% among the hospitals, have led
the progress of information technology and e-health implementation for the entire
healthcare industry (Ibid.). It is, therefore, instructive to conduct case studies of best-
practice hospitals to demonstrate the industry’s best practice and shed light on their plan-
ning and decision-making processes and consequences of implementing e-health online.
In their study investigating hospital adoption of information technology, Burke et
al. (2002) found that the average hospitals had adopted 57% of the total available IT ap-
plications (from a minimum of 8% to a maximum of 90%). Huang and Chang (2012)
found that individual hospitals in the United States adopted, on average, 5–6 of the 21
identified interactive e-health tools on their Web sites. Therefore, there remains room for
further adoption of interactive tools that are helpful to hospital Web site users.
The benefits of implementing e-health can be illustrated by the adoption of an elec-
tronic medical records (EMR) system. Every hospital has hundreds of forms to process on a
routine basis. One of the main efforts of e-health in recent years has been to turn all major
paper forms into EMR (Mukherjee & McGinnis, 2007). From the healthcare administra-
tion’s perspective, EMR can enable physicians to improve their quality of patient care, re-
duce the number of medical errors, and eventually save healthcare cost (Ibid.). For instance,
Sentara Healthcare, a Norfolk, Va.-based, six-hospital delivery system, processes 1.3 million
administrative forms in its hospitals per year. Fifteen different paper forms are used for dif-
ferent transactions, such as a change of address or purchasing requests. By automating the
processing of those forms, Sentara Healthcare can potentially reduce costs by $3.4 million
per year, said Bert Reese, vice president and CIO of the healthcare system (Gillespie, 2001).
For Reese, the foundation of all Web portal strategies should be to either increase revenue or
decrease costs. If portals don’t do either, then they’re just vanity pages, he affirms (Ibid.).
From the users’ perspective, EMR can bring great convenience and empowerment.
For instance, filling out an online pre-registration form or checking out ER Wait Times
online can greatly reduce the time a patient has to spend in a hospital/clinic before treat-
ment. A patient can access his or her medical records and lab results online 24/7 without
having to nag a doctor or nurse to mail them, make a doctor’s appointment easily online
without being constantly routed by a robot phone system, or request for prescription re-
fills with just a few mouse clicks (Mukherjee & McGinnis, 2007; Varshney, 2009).
Unfortunately, many hospitals have not taken advantage of these useful interactive
tools that can facilitate their business online and achieve diverse goals, including saving
Case Studies of Implementation of Interactive E-Health Tools on Hospital Web Sites
49
costs, reducing errors, improving transparency, increasing operational efficiency and pa-
tient-friendliness, and effectively marketing a hospital. In this article, the case studies of
three best-practice hospitals, each of which has been aggressively implementing e-health
on their Web sites, can help other hospitals better understand the what, how, and why of
using interactive e-health tools.
METHODOLOGY
Case studies have been widely used as a research approach in government, military, infor-
mation technology, law, businesses, education, and so on. Through comparisons of some
chosen cases, themes can surface. Using more than one research method, a case study
involves a holistic and in-depth investigation (Feagin, Orum, & Sjoberg, 1991). Com-
mon methods in a case study are in-depth interviews, surveys, focus groups, and content
analysis. The triangulation of findings from different methods provides a systematic way
to find out “What’s going on here” in each case’s real-world context and to ensure con-
struct validity (Wimmer & Dominick, 2005, p. 129; Yin, 1994). This study has adopted
both content analysis and in-depth interviews as research methods.
A case study often contains one or a few cases. Using “small sample” to discount a
case study misses the point (Tellis, 1997). Although case studies generally do not require
a random sample, uncovering best-practice hospitals, which can serve as models for oth-
ers, demands a thorough investigation of the hospitals in the nation. Therefore, starting
with a representative sample of 765 hospitals—roughly 12% of the hospitals in the na-
tion, the authors of this study examined the presence of 21 interactive e-health tools on
their Web sites and came up with a short list of 25 hospitals of different sizes (number of
beds) and locations (urban verses rural) that had the most of these tools.2 Contact of
these 25 hospitals for voluntary participation yielded the following three participating
hospitals based on their representativeness in size, geographic location, and autonomy in
Web marketing development:
• Eastern Idaho Regional Medical Center (http://www.eirmc.com), affiliated
with Hospital Corporation of America (HCA, Inc.),
• Sycamore Shoals Hospital (http://www.msha.com), affiliated with Mountain
States Health Alliance, and
• Sharp Grossmont Hospital (http://www.sharp.com/grossmont/about-us.cfm),
affiliated with Sharp Healthcare.
Table 1 has presented an overview of these three hospitals.
HCA is one of the biggest healthcare systems in the United States, containing
40,500 beds across 20 states. The Web sites of the hospitals affiliated to HCA, Inc.
2. Two studies based on the sample have been published in other venues.
Edgar Huang and Chiu-chi Angela Chang
50 e-Service Journal Volume 9 Issue 2
featured drastically different looks, each having its unique domain name. In other words,
Eastern Idaho Regional Medical Center (331 beds) and other HCA-affiliated hospitals
enjoyed high autonomy in designing their own Web sites. In contrast, Sycamore Shoals
Hospital (115 beds) is much smaller than Eastern Idaho Regional Medical Center, but its
Web marketing depended entirely on its parent system— Mountain States Health Alli-
ance. The hospital’s Web site was under the domain name of Mountain States Health
Alliance—msha.com—and hardly had its own identity. Similarly, Sharp Grossmont
Hospital, like other Sharp Healthcare-affiliated hospitals, was under the sharp.com do-
main. Therefore, in the next section, the analysis of Eastern Idaho Regional Medical
Center will pertain to the hospital itself while the analyses of the other two hospitals will
pertain to their parent systems because of the latter’s high conformity to the system-wide
online marketing and branding strategy.
Content analysis on the above hospitals’ Web sites was conducted by two coders in
late 2011 to early 2012. The intercoder reliability, using Scott’s Pi, reached an average of
.93 for all variables (see the next section for results).
Each hospital went through two rounds of interviews. The first round was a stan-
dardized interview with nine questions. Based on the interview results and the content
analysis of interactive e-health tools on the hospital’s Web site, each hospital then re-
sponded to customized questions in the second round of interview.
FINDINGS
Basic facts regarding the implementation of interactive e-health tools on each hospital’s
Web site are described below and listed in Table 2 for easy comparison.
Eastern Idaho Regional
Medical Center
Sycamore Shoals
Hospital
Sharp Grossmont
Hospital
Web design
autonomy
Independent Relying on parent
system
Relying on parent
system
Number of beds
in hospital
331 115 536
Parent system Hospital Corporation of
America (HCA)
Mountain States Health
Alliance (MSHA)
Sharp Healthcare
Number of beds
in parent system
40500 15 0 0 1870
Location Idaho Fall, ID Elizabethton, TN San Diego, CA
Web site www.eirmc.com www.msha.com www.sharp.com/
Source : http://health.usnews.com/best-hospitals; http://www.hoovers.com/company/HCA_
Holdings_Inc/rhtyki-1.html
Table 1. Facts regarding the three hospitals studied
Case Studies of Implementation of Interactive E-Health Tools on Hospital Web Sites
51
Interactive tools Eastern Idaho
Regional
Medical
Center
Mountain
States
Health
Alliance
Sharp
Health-
care
Nationally
adopted
Traditional
functional
tools
Online search X X X 66.6%
Interactive map X X 60.8%
Finding a physician X X X 56.7%
Contact us X X X 46.1%
Interactive calendar or event finder X X X 42.8%
Virtual tour X X 8.6%
Core
e-business
tools
Paying bills online X X X 40.2%
(Pre)registration online X X X 19.4 %
Making a doctor’s appointment or
communicating with a doctor online
X15. 3 %
Accessing medical records and lab
results
X10.1%
Refilling prescriptions online X9.7%
Patient
support
tools
Interactive patient education or health
risk assessment
X X X 47. 0 %
Patient caring and support through
CarePages, blog, or chat room
X X X 16.2%
Visitor-
related tools
E-card or email for a patient X X X 28.2%
Online nursery for viewing/
purchasing baby photos
X X X 27.7 %
Online flower/gift shop X X 9.3%
Public
relations
tools
Presence on social media, such as
Facebook, Twitter, and YouTube
X X X 35.7%
Online caregiver recognition X X 3.9%
Emerging
functional
tools
ER wait times X X 5.6%
Interactive cost estimator 3.5%
Site or application for mobile devices X2.0%
Tot al
number of
tools
15 14 18
Interface Online service menu* X X X 11.0%
Secure and personalized account* X10.7%
Note. The list of the 21 interactive e-health tools and the numbers in t he National Adopted column are from
Huang and Chang (2012). Percentage ca lculations are ba sed on 712 sampled hospitals that had a Web presence.
* These are interface designs that promote some of the interactive tools.
Table 2. How the three best-practice hospitals have implemented patient-oriented interactive
tools on their Web sites
Edgar Huang and Chiu-chi Angela Chang
52 e-Service Journal Volume 9 Issue 2
Eastern Idaho Regional Medical Center (EIRMC), as the largest medical facility
in the region, is a modern 331-bed full-service hospital, located in Idaho Falls, Idaho.
EIRMC serves as the region’s healthcare hub, offering specialty services including car-
diovascular surgery, cutting-edge cancer treatment, trauma, neurosurgery, intensive care
for adults and infants, and a helicopter and ground medical rescue service.3 EIRMC had
15 of the 21 identified types of interactive e-health tools. In addition, it had an Online
Tools menu that featured many of these tools. It did have ER Wait Times tool, but it was
informational only and did not allow a user to “Hold My Place in Line.”4
Mountain States Health Alliance (MSHA) is a large regional healthcare system
with 1,500 beds in 13 hospitals operating at approximately $1.0 billion in net revenues.
MSHA provides an integrated, comprehensive continuum of care to people in 29 coun-
ties in Tennessee, Virginia, Kentucky, and North Carolina.5 Four Mountain States
Health Alliance (MSHA) hospitals were recognized by U.S. News and World Report as
the Best Hospitals in 2011.6 In addition to its hospitals, MSHA’s integrated healthcare
delivery system includes 21 primary/preventive care centers and numerous outpatient
care sites. MSHA had 14 out of the 21 e-health online tools. In addition, MSHA had an
Online Tools menu for convenient access to its online services. It did have an online pa-
tient records system, but they were only accessible to physicians.
Sharp Healthcare (Sharp) has approximately 2,600 physicians on medical staffs and
more than 1,000 physicians in affiliated medical groups in 57 medical facilities with a total
of 1,870 beds throughout California, mostly in metropolitan areas. It has $1.2 billion in
assets and $1.7 billion in revenue.7 Sharp has been named one of the nation’s “Most Wired”
healthcare systems by Hospitals & Health Networks magazine for 11 consecutive years.8
The results of the content analysis from this study show that Sharp is a national leader in
implementing interactive e-health tools. Sharp had 18 e-health online tools. In addition, it
had both a dedicated and secure patient portal and an online tools menu. The patient por-
tal, mySharp, allowed a patient to send secure messages to a physician’s office, schedule ap-
pointments, review selected lab results, review patient health profile, request prescription
refills, and pay bills online. A secure and personalized patient portal is a feature that is avail-
able only among less than 11% of the hospitals in the nation (Huang and Chang, 2012).
The interviews with these three healthcare systems yielded many comparable re-
sults. Therefore, instead of reporting the results case by case, as traditional case studies
3. Such public information can be verified at www.eirmc.com.
4. This is a feature that some hospitals have begun to use. See an example at St. Anthony Hospital’s Web
site at https://inquicker.com/facility/st-anthony-hospital?
5. http://www.msha.com/body03.cfm?id=43
6. http://www.msha.com/body03.cfm?id=45&action=detail&ref=1263
7. http://en.wikipedia.org/wiki/Sharp_HealthCare
8. http://en.wikipedia.org/wiki/Sharp_HealthCare
Case Studies of Implementation of Interactive E-Health Tools on Hospital Web Sites
53
usually do, the authors of this study have elected to combine similar results and contrast
the differences among the hospitals as follows.
The meaning and practice of e-health
All three hospitals used electronic tools, including e-mail, Web site, and social media, to
connect themselves with patients/users. These hospitals recognized e-health as a com-
petitive differentiator for swaying consumer preference. Based on the interviewers, the
primary goals for their e-health efforts were as follows:
1. Establishing relationships and communication between the hospital and the pa-
tient (e.g., “… the overall intent is to provide online tools, resources, services, and
interaction that…create relationships with patients, prospective patients, physi-
cians, community.”—MSHA),
2. Educating and empowering the user (e.g., “At Sharp we look at e-health as the
electronic connection between the health system and the patient so the patient is
directly involved in managing his/her own health.” “Since statistics bear out that
most people first hit the Web when seeking medical information, we hope they
reference our several Medical Libraries.”),
3. Delivering and enhancing healthcare procedures (e.g., “On mySharp they can
schedule appointments; review selected lab results; pay bills; send secure messages to
their physician’s office; review their health profile; request prescription refills.”), and
4. Increasing overall satisfaction and market share (e.g., “Our ultimate goals…are to
increase awareness, preference, utilization and market share for EIRMC services
among consumers.”).
Decision-making for e-health implementation on hospital Web sites
All three hospitals had taken both top-down and bottom-up decision-making approaches
when implementing e-health tools on their Web sites. In EIRMC’s case, the architecture
and functionality of such tools as “find a physician,” “health library,” “online pre-registra-
tion,” and “online bill pay,” were provided by the corporate. On the other hand, “virtual
tours,” “thank an employee,” “email a patient,” linking to social media, and many other
features were developed by the hospital. At MSHA, while some initiatives had come from
the executive team, their e-health efforts primarily stemmed from various departments,
specifically its Communications and Marketing Department (on the corporate level).
Sharp’s Web strategy team in marketing examined the idea of a patient portal in 2000. It
took eight years of discussions and lobbying before medical group and system leadership
began to make commitments. In 2007, the CIO and the CEO of Sharp Rees-Stealy, one
of the Sharp medical groups, approved the initiative and put the structure in place for
Edgar Huang and Chiu-chi Angela Chang
54 e-Service Journal Volume 9 Issue 2
multi-disciplinary teams to begin designing and implementing the patient portal,
mySharp, based on customer research (What did our patients want?) and feasibility anal-
yses (What could we implement? What data could we access? What workflows could be
moved online?). “We used a Six Sigma Black Belt to facilitate the process and help the
teams prioritize the development,” said John Cihomsky, Vice President of Public Rela-
tions & Communications at Sharp.
Barriers to implementing e-health on hospital Web sites
Resource shortage, lack of medical practice standardization, and insufficient infrastruc-
ture were cited as major problems for all three hospitals when they implemented e-health.
EIRMC was highly self-driven in creating its own Web marketing development strategies;
however, the pace at which EIRMC could implement facility-originated ideas was con-
strained by the fact that scarce resources had to be shared among many HCA hospitals.
MSHA had a two-person communications team responsible for a healthcare system that
consisted of thirteen facilities. At Sharp, the physician practices encountered the challenge
of standardization across organizations, which was required for implementing online
tools. All three hospitals raised the issue of insufficient infrastructure since data or content
sources, as well as backend systems automated with electronic medical or health records,
had to exist in order to make e-health feasible. Limitations and poor integration of the in-
formation system (e.g. policy restrictions that prevented team members from participating
in social media during work hours) (MSHA) and encryption functionality on the main
Web site (EIRMC) were also acknowledged as barriers to interacting with users online.
Outcomes of implementing e-health on hospital Web sites
All three hospitals used some form of analytics to document the outcomes of implement-
ing e-health on their Web sites. EIRMC’s data showed that “find a physician,” “online
bill pay,” “online search,” and “contact us” were among the most-used interactive tools for
patients on its Web site. MSHA indicated (1) that over 1,400 visitors visited its women’s
services page each month (more than half of them looked at photos in the online nurs-
ery), (2) that there were over 900 downloads in the previous month for their smart phone
application, and (3) that other popular features included health risk assessment tool and
ER wait times. As for Sharp, there were nearly 60,000 patients with mySharp accounts at
Sharp Rees-Stealy, one of the affiliated medical groups. The hospital was seeing an aver-
age of 0.9 logins per user per month; the most popular tools were the access to lab results
and secure emailing with physicians via mySharp. The data also showed female mySharp
users were the majority (63%); the 35–49 age group was the largest segment, followed by
the 50–64 and 18–34 segments.
Case Studies of Implementation of Interactive E-Health Tools on Hospital Web Sites
55
Less clear are the business implications of e-health implementation. Cindy Smith-
Putnam, Executive Director of Business Development, Marketing & Community Rela-
tions at EIRMC mentioned: “It is difficult, if not impossible, to isolate the ‘cause’ and
‘effect’ revenue value of e-health strategies from all other growth strategies.” None of the
healthcare systems had hard data to support a business case for e-health implementation.
John Cihomsky at Sharp mentioned anecdotal evidence and survey results to suggest
that patients “have selected Sharp Rees-Stealy or have selected to stay with Sharp Rees-
Stealy because of their experience with mySharp.” He also suggested that savings to the
organization could be measured; that is, online tools that help patients make bill pay-
ments, schedule appointments, access lab results, and communicate with staff ultimately
reduce unnecessary calls to the call center or physicians’ offices.
Closing the gap: using core e-business tools, including providing a patient
portal
Huang, Chang, & Khurana, (2012) found that hospital Web site users highly desire core
e-business tools, especially access to medical records and lab results; however, hospitals’
e-health implementation on their Web sites has greatly lagged behind the users’ needs.
While EIRMC and MSHA provided only the interactive features of paying bills and
(pre)registration on their Web sites, Sharp had already implemented a secure and person-
alized system, mySharp, in which patients could use all the core business tools listed in
Table 2 and more. John Cihomsky from Sharp emphasized the competitive advantage
gained from implementing core e-business tools. He said, “We felt it was a strategic prior-
ity because our patients were requesting these tools…. If we are to compete in a world
that is increasingly driven by consumerism, we needed to put these tools in place.”
MSHA already had an online patient medical record system, but it was open only to phy-
sicians. MSHA was evaluating the possibility of integrating its information systems so as
to deploy a robust EMR system with patient access sometime within the next two years.
Shane O’Hare, Communications & Marketing Corporate Director at MSHA, said:
Ultimately, the Electronic Medical Record and personal portal will allow us
to give patients access to their information (also in a secure setting), and
combine that information to reduce human error, duplication of diagnostics
and create a valuable history of patient information for solid decision-making
(this initiative is well underway and would address all of the pillars of
excellence).
Cindy Smith-Putnam from EIRMC said,
…all our hospitals will move in the direction of a secure Patient Portal for all
purposes, but many interim steps need to occur first, and it is unlikely the
Edgar Huang and Chiu-chi Angela Chang
56 e-Service Journal Volume 9 Issue 2
Portal concept will be realized in the near future.” “We are not Mayo, and we
were arguably slow to retool our Website to be more than a glorified
brochure.”
Emerging trends: social media, ER wait times, mobile phone applications
All three hospitals had a presence on social media (i.e. YouTube, Twitter, and Facebook).
Sharp’s John Cihomsky commented, “For us, participating in this space is a must-have.
When our customers are on the social media sites talking about us and trying to talk to
us, we have to be there.” MSHA illustrated how a hospital may use these social media
platforms, “YouTube as a resource to our creative team, Twitter to speak to our friends in
the media, and Facebook as a tool to communicate with and engage our community.”
MSHA shared its NurseLink tip of the day on Facebook to ensure a daily presence. In
addition, recognizing social media as an interactive relationship-building tool, EIRMC
had two Facebook pages that specifically connected with two respective groups of poten-
tial patients—women of child-bearing age and people who may be bariatric surgery can-
didates—with success in terms of the total number of Facebook fans and daily gross
impressions of posts. This targeted use of Facebook was considered by EIRMC as a bet-
ter way of connecting with prospective patients.
While Sharp was considering adopting the tool of interactive ER wait times,
EIRMC and MSHA already had an information-only ER wait times feature on their re-
spective Web sites. The latter hospitals’ ER wait times feature was not interactive9 be-
cause the hospitals were not keen on the “hold my place in line” concept. The reasons
given by both hospitals were that this practice would run counter to the concept of emer-
gency care, which should be based on acuity, not arrival time, and that this practice
could create unmet expectations and possible legal complexity.
MSHA was the only hospital among the three that had a mobile phone application,
whereby users could check ER wait times to pick the most appropriate ER, use a symp-
tom navigator, gather information on their physicians, and get driving directions. Sharp
was in the final stages of developing an iPhone application and would also add a mobile
site and/or Android apps in the future.
Plans for future implementation of e-health
Responses to the question concerning future plans of e-health implementation varied
across the three hospitals, depending on their specific situations. EIRMC would focus on
implementing full-blown e-commerce capabilities, which will include pre-registration,
9. Some hospitals in the nation have already adopted an interactive ER Wait Times model on InQuicker.
com.
Case Studies of Implementation of Interactive E-Health Tools on Hospital Web Sites
57
online payment, making appointments online in outpatient services, and making en-
crypted medical records accessible online. While Sharp was adding discharge instruc-
tions for hospital patients and visit summaries for ambulatory patients at the time of
interview, it would, in future years, “provide tools for patients to submit forms, partici-
pate in health management/chronic care management activities, and other tools that
drive health improvement,” said Cihomsky. Shane O’Hare at MSHA touched on two is-
sues: customization and integration. The former had to do with customized communica-
tions with patients, depending on their disease conditions and life stages. MSHA was in
the beginning stage of a CRM (customer relationship management) initiative to ensure
that “patients get the messages that are most pertinent to them, regardless of the medium
used to convey the message.” Regarding integration, MSHA had set a goal to integrate
risk assessment tools, which were functioning as stand-alone products rather than being
integrated into any medical record system. MSHA wished to be proactive in helping ad-
dress the health issues of its population and expected these tools it offered online, includ-
ing health screening assessments, heart coach screenings, symptom checkers, health
articles, to serve as catalysts for engaging patients in addressing their healthcare needs.
DISCUSSION AND CONCLUSIONS
This study has examined three best-practice hospitals concerning their approaches to
implementing patient-oriented interactive e-health tools on their Web sites. While prior
research indicates discrepancies between hospitals’ execution of e-health online and
users’ preferences of interactive e-health tools, this study, through content analysis and
in-depth interviews, has demonstrated hospital administrations’ perspectives and pro-
vided insights into developing e-health. There are many implications to hospitals that
aim to be more involved in e-health by offering interactive tools online.
All three hospitals have each applied more than half of the 21 identified interactive
e-health tools on their Web sites and continued to develop e-health based on their own
strategies. They all promote these interactive tools through a service menu on their Web
sites. Both MSHA and EIRMC are taking steps to build a secure and personalized pa-
tient portal, which Sharp has already put in place, to enable more core e-business func-
tions online. Such efforts have made a hospital Web site action-driven rather than merely
information-oriented though the sites do contain a significant amount of static informa-
tion as well. These hospitals are well ahead of the crowd because they provide not only
the traditional, functional tools but also advanced and technologically savvy features,
including emerging interactive tools, such as ER wait times and mobile site or applica-
tion). These best practices have set the three hospitals apart in the industry.
A lesson from this study is that the implementation of interactive e-heath tools can
be area-indiscriminative as well as hospital-size-indiscriminative. Among these three hos-
pitals, both Sycamore Shoals Hospital and Sharp Grossmont Hospital almost totally rely
Edgar Huang and Chiu-chi Angela Chang
58 e-Service Journal Volume 9 Issue 2
on their parent systems—MSHA and Sharp—to present them online so that these indi-
vidual hospitals do not have to worry much about building everything or most things
online from scratch. Though affiliated to HCA, one of the largest healthcare systems in
the United States, EIRMC—a 331-bed hospital—probably has the least resources since
it has to largely rely on itself for online marketing and online business. Neither EIRMC
nor Sycamore Shoals Hospital is located in a large city, such as Chicago or New York.
Nevertheless, both hospitals still have been highly aggressive in conducting hospital busi-
nesses online. Cindy Smith-Putnam from EIRMC said,
Hospitals lacking robust marketing and communications budgets may be
MORE likely, not less likely, to consider technology investments a major pri-
ority. This is because compared to traditional communication channels
(paid advertising, print publications, direct mail, etc.), Web sites and social
media are relatively less expensive ways to interact with prospective consum-
ers, with the added benefit of facilitating more two-way (rather than one-
way) communication.
However, more advanced e-health implementation does require significant investment in
information communication technology. “A sound technical infrastructure is an essential
ingredient to the undertaking of e-health initiatives,” as Wickramasinghe, et al. (2005, p.
326) said.
The ultimate driver of these hospitals’ e-health development is their vision and stra-
tegic planning. Sharp and MSHA indicated that their hospitals’ “pillars of excellence”
(e.g., service excellence, stakeholder safety, clinical excellence, and operational excellence at
MSHA) have driven their comprehensive planning process, including e-health; EIRMC
has offered e-health tools to meet consumer expectations, consumer satisfaction, consumer
preferences, and consumer education needs. Further, the hospitals all share the crucial vi-
sion that e-health is the source of competitive advantage. They have used interactive e-
health tools to engage patients/users, thus empowering patients and enhancing healthcare.
The decision-making process of implementing e-health has involved both top-
down and bottom-up approaches across the three cases. While various departments such
as marketing and communications often initiate useful ideas to benefit patients/users,
management support is extremely important as exemplified in the case of developing
mySharp at Sharp. The key is for management to realize the strategic importance of e-
health and coordinate the resources necessary to make it happen. The most important
function of such management support from the corporate level is to help standardize
policies, protocols and procedures and reduce many structural impediments since e-
health spans many parties and geographical dimensions, as Samiee (1998) pointed out.
Indeed, resource issues, along with information system infrastructure, integration,
and standardization, are significant barriers to implementing e-health. These limitations,
Case Studies of Implementation of Interactive E-Health Tools on Hospital Web Sites
59
however, should not hinder the adoption of interactive e-health since the favorable out-
comes, shown in these healthcare systems’ Web analytics or consumer survey results, are
well worth pursuing. While it is not yet easy for hospitals to obtain financial data to dem-
onstrate the benefits of implementing e-health, Web analytics is useful for providing be-
havioral data and holding e-health initiatives accountable. All these hospitals studied
have collected diverse Web analytical data to keep track of the impact of their e-health
implementation.
Planning for e-health implementation is dynamic and evolving, according to the
findings of this study. Each hospital has its agenda for the near future based on its specific
situation. Remarkably, following Sharp’s footsteps, both EIRMC and MSHA are explor-
ing the possibility of providing patients with online access to their medical records—the
most desired interactive e-health tool (Huang, Chang, & Khurana, 2012). Matthew Mc-
Cahill, the e-health marketing chief at the ten-hospital Alegent Health, based in Omaha,
Nebraska, predicted that future Web site developments would probably center on the
patient portal to determine what patients want it to provide (Robeznieks, 2011). In fact,
out of the six categories of interactive e-health tools (Table 2), the core e-business cate-
gory is considered to be the most useful by hospital Web site users (Huang, Chang, &
Khurana, 2012); all three hospitals have been making inroads in this specific area to bet-
ter serve their customers. Furthermore, managing healthcare online through a secure and
personalized account or patient portal appears to be an effective way for hospitals to pro-
vide customized services and execute core e-business functions. The process of laying an
infrastructure for a patient portal, as well as coordinating across departments, is com-
plex; hospital administrations have to weigh the cost involved against the benefits for
both patients/users and operational efficiency to come to a sound decision.
This study has its limitations. Responses from independent hospitals that are not
associated with any parent system may add additional perspectives to the current results.
How hospitals have taken advantage of social media to connect to patients needs further
investigation. Longitudinal studies will be desirable for tracking e-health development,
including its latest trends, obstacles, and outcomes.
For future research this study provides some insights to be tested formally. To
begin with, it will be beneficial to demonstrate, with empirical data, how the extent of e-
health implementation on hospital Web sites is related to hospitals’ performance, as re-
vealed in such outcome measures as return on investment and customer satisfaction.
Clarifying the business implications of e-health implementation will encourage more
hospitals to get involved, making effective use of available interactive e-health tools to
achieve diverse goals. In addition, given the determinants of e-health implementation
identified in this study, including resources, top management support, marketing or cus-
tomer orientation, and company visions, a conceptual model may be proposed and tested
to understand what factors are most relevant in hospitals’ e-health adoption decision, as
Edgar Huang and Chiu-chi Angela Chang
60 e-Service Journal Volume 9 Issue 2
well as the interplay between these factors and different types of hospitals (e.g., net-
worked vs. independent). Finally, it will be useful to examine individual interactive e-
health tools, such as mobile phone application and a patient portal, to gain an in-depth
understanding of how each tool is used and evaluated by users/patients and how these
tools contribute to the overall service quality perceptions and patronage decisions.
In conclusion, offering interactive e-health tools on a hospital’s Web site accom-
plishes multiple goals, including service, communication, and education, and serves as
an important differentiator in a competitive industry. Hospitals of various sizes and in
different geographic areas can all take advantage of what interactive e-health tools have
to offer to gain a competitive advantage. The case studies of best-practice hospitals’ e-
health implementation show that hospitals should design action-driven Web sites by ap-
plying interactive e-health tools to conduct more core business online and presenting
them in a service-menu and on a patient portal, that hospitals should foster strategic vi-
sions for e-health and garner top-management support and necessary resources while
being open to both top-down and bottom-up perspectives, and that hospitals can ana-
lyze the outcomes of e-health development through Web analytics and consumer surveys
and eventually connect e-health implementation to financial or other performance mea-
sures. Ultimately, the quality of health care will be enhanced by engaging patients/users
through interactive tools on hospital Web sites.
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ACKNOWLEDGMENT
The authors of this study would like to express their sincere gratitude to the following
individuals and the healthcare systems they represent:
• Cindy Smith-Putnam, Executive Director of Business Development, Marketing
& Community Relations, Eastern Idaho Regional Medical Center
• Shane O’Hare, Communications & Marketing | Corporate Director, Mountain
States Health Alliance
• John Cihomsky, Vice President of Public Relations & Communications, Sharp
Healthcare
