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Patient-Oriented Interactive E-healthTools on U.S. Hospital Web SitesEdgar Huang a & Chiu-Chi Angela Chang ba School of Informatics and Computing, Indiana University,Indianapolis, Indianab Department of Marketing and Hospitality Services Administration,College of Business Administration, Central Michigan University,Mount Pleasant, Michigan

To cite this article: Edgar Huang & Chiu-Chi Angela Chang (2012): Patient-Oriented Interactive E-health Tools on U.S. Hospital Web Sites, Health Marketing Quarterly, 29:4, 329-345

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329

Patient-Oriented Interactive E-health Tools on U.S. Hospital Web Sites

EDGAR HUANG School of Informatics and Computing, Indiana University, Indianapolis, Indiana

CHIU-CHI ANGELA CHANG Department of Marketing and Hospitality Services Administration, College of Business Administration, Central Michigan University,

Mount Pleasant, Michigan

The purpose of this study is to provide evidence for strategic plan-ning regarding e-health development in U.S. hospitals. A content analysis of a representative sample of the U.S. hospital Web sites has revealed how U.S. hospitals have taken advantage of the 21 patient-oriented interactive tools identified in this study. Significant gaps between various types of hospitals have also been found. It is con-cluded that although the majority of the U.S. hospitals have adopted traditional functional tools, they need to make significant inroad in implementing the core e-business tools to serve their patients/users, making their Web sites more efficient marketing tools.

KEYWORDS health care new media, e-health, hospital Web sites, interactivity

INTRODUCTION

The buzzword “e-health” has been in existence for approximately a decade (Harrison & Lee, 2006). One of the authoritative definition is offered by the World Health Organization in 2003:

E-health is a new term used to describe the combined use of electronic communication and information technology in the health sector OR is

The authors would like to thank Brittany Harman for her help with sampling for this study and Aye-Nu Elizabeth Duerksen for proofreading this manuscript.

Address correspondence to Edgar Huang, School of Informatics and Computing, Indiana University, 535 West Michigan Street, Suite IT 471, Indianapolis, IN 46202. E-mail: ehuang@iupui.edu

Health Marketing Quarterly, 29:329–345, 2012Copyright © Taylor & Francis Group, LLCISSN: 0735-9683 print/1545-0864 onlineDOI: 10.1080/07359683.2012.732871

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the use, in the health sector, of digital data—transmitted, stored and retrieved electronically—for clinical, educational and administrative pur-poses, both at the local site and at a distance.

E-health has been primarily executed on the Internet (Eysenbach & Diepgen, 2001; Ball & Lillis, 2001).

Reflected in interactive consumer marketing, e-business, organizational management, and clinical customer service, the benefits of implementing e-health include cost saving, error reduction, transparency improvement, operational efficiency, and patient-friendliness (Baker 2009; Mukherjee & McGinnis 2007). E-health benefits have been evangelized and meticulously delineated by many authors (Fried, Weinreich, Cavalier, & Lester, 2000; Flower, 2004; Bates, Romina, Ahmed, & Hopson, 2006; Harrison & Lee, 2006; Sharma, Xu, Wickramasinghe, & Ahmed, 2006; Anderson, 2007; Mukherjee & McGinnis, 2007). Some early e-health adopters, such as Kaiser Permanente, New York Presbyterian Hospital, Detroit Medical Center, Blanchard Valley Health System, and Hurley Medical Center, have reported highly positive outcomes of such implementation (Taylor, Gombeski, & Dillon, 2005; Keene, 2007; Catallo, 2008). For instance, 53% of visitors who were not previous patients of a hospital were converted by the hospital Web sites to be its new customers (Taylor et  al., 2005, p. 35). Anderson (2007) projected that American hospitals that have converted their systems to completely elec-tronic have the potential to gain $371 billion in net cumulative savings over the next 15 years.

In spite of the benefits and positive outcomes, studies have found bar-riers in implementing e-health among hospitals. Many physicians are accus-tomed to physically writing notes for each patient consultation (Mannan, Murphy, & Jones, 2006). Some physicians perceive electronic medical record as a step against their autonomy (Varshney, 2009). The costs involved in properly implementing a comprehensive e-health system are a major deter-rent for physicians (Hobson, 2011). Hospitals that are experiencing low return on assets and having high levels of debt may have difficulty in further investing in IT (Mukherjee & McGinnis, 2007, p. 361). Stakeholders are trou-bled by the broad, amorphous definitions of e-health, as Ahern, Kreslake, and Phalen (2006) have pointed out. “There was universal frustration with the lack of comparability and standardization within the domain of eHealth. Stakeholders expressed a strong desire for a coordinated, rigorous effort to define and integrate the field” (Ahern et  al., 2006). Consequently, many health care systems are awaiting the development and implementation of e-health (Sharma et al., 2006). Hospitals lag behind other industries in their online presence and treat the Web as no more than “brochure-ware” by offering mostly marketing information from print (Randeree & Rao, 2004; Boehm, Brown, Sage, & Banolomey, 2006; Haugh, 2001). Even the Most Wired hospitals 1 still have a long way to go in e-health implementation

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Patient-Oriented Interactive E-health Tools 331

(Merrill, 2010). Users may pass over most hospital Web sites due to lack of relevant or useful health information and interactive services (Gallant, Irizarry, & Kreps, 2006, p. 6).

As of 2011, no comprehensive data had ever been collected to show to what extent e-health had been implemented in the U.S. health care systems. Because of the diversified understanding of what constitutes as e-health (Ahern et al., 2006), 2 people disagree on what e-health tools should be used on hospital Web sites. 3 Consequently, it is not clear whether, for most U.S. hospitals, e-health still stays on the blueprint stage or is practiced, and if practiced, what has been done. As Keene (2007) pointed out, the continuity of business is vital in any setting and even more so in hospitals where the product is literally life and death, and continuity of business requires thought-ful planning, setup, reaction, and follow-through to ensure everything runs as according to plan. But before a plan is possible, a hospital administrators need to know what e-health literally comprises on the operational level.

While the key stakeholders in the e-health industry include employers, patients, providers, and health plans (Mukherjee & McGinnis, 2007, p. 351), this study focused on examining the hospital-to-patients relationship and patients-to-patients/visitors relationship through hospitals’ interactive mecha-nism via their Web sites for providing information and services. The purpose of this study is to provide empirical evidence for strategic planning regarding e-health development in U.S. hospitals. The study aims to answer one general research question: How have the U.S. hospitals embraced e-health as reflected in the adoption of interactive tools on their Web sites? This general research question broke down into two specific research questions:

RQ1: To what extent have e-health interactive tools been developed on U.S. hospital Web sites for conducting business online?

RQ2: Are there significant gaps (a) between networked and independent hospitals, and (b) between larger and smaller hospitals, in e-health adoption?

LITERATURE REVIEW

In spite of comprehensive discussions of e-health, extensive professional searches with different search strategies across multiple health care data-bases and over the Internet yielded a limited number of empirical studies regarding hospital Web sites. No research that studied interactive tools on such Web sites was found. Therefore, this is a landmark study on how U.S. hospitals have used e-health tools on their Web sites to market themselves and to conduct businesses online.

As Oh, Rizo, Enkin, and Jadad (2005) have noticed, scholars on e-health agree that technology is both a tool to enable a process/function/service and

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the embodiment of e-health itself; e-health technology is dominantly materi-alized on the Internet. Unlike traditional mass media, the Internet gains its unique power from its massive, customized, and almost instant interactivity (Coyle & Thorson, 2001; Song & Zinkhan, 2008). Steuer (1992) defines inter-activity as “the extent to which users can participate in modifying the form and content of a mediated environment in real time” (p. 84). On the techni-cal level, interactivity is made possible largely by different kinds of forms on the front end as a user-interface and often supported by a database on the back end. Since sensitive data transactions are involved, a secure online environment is often needed. Interactivity is a function of three things: (a) the speed with which content can be manipulated: (b) the range of ways in which content can be manipulated: and (c) mapping, or determining or comparing how similar the controls and manipulation in the mediated envi-ronment are to controls and manipulation in a real environment (Steuer, 1992).

Interactivity, consisting five dimensions—playfulness, choice, connect-edness, information collection, and reciprocal communication (Ha & James, 1998), has added wings to today’s marketing endeavors. By appropriating jargons from streaming media, Peters (2006) describes interactive marketing as a “pull” method and traditional marketing as a “push” method. Peters wrote, “Using a pull method, the audience is enticed and encouraged to experience and interact with the message. In today’s climate of jaded, sophis-ticated, media-aware audiences it is no longer sufficient to simply push a message” (Peters, 2006, p. 24). He posits that push and pull methods need to work hand in hand in hospitals’ online marketing.

Online services and transaction capabilities enabled by interactivity are desirable components of hospital Web sites (Bishop, Brown, McEnroe, & Banolomey, 2006) because usefulness is the most influential factor in tech-nology adoption (Gefen & Straub, 2000; Gefen, Karahanna, & Straub, 2003; Monsuwé, Dellaert, & Ruyter, 2004). Hospital marketing executives have wanted to build more interactive and personalized content with self-service functionality that includes personalized home pages with patients’ ability to “contact physicians directly to ask questions or get second opinions” and to gain access to medical records and test results (Boehm et al., 2006, p. 7). Interactivity enables more than static presentation of information online and extends the offline services to the Web. As Mukherjee and McGinnis (2007, p. 351) point out, e-health “is also about raising operational efficiency to create patient-friendly services.” Therefore, researchers have called on hospi-tal administrators to tie their IT forces into their online marketing efforts to engage users (Mukherjee & McGinnis, 2007, p. 349; Catallo, 2008, p. 23; Merrill, 2010). John-David Lovelock, a research director and health care ana-lysts for Gardner, says, “If hospitals don’t engage the patient during the decision-making process, they put the patient at risk and their revenue at risk because the patient may go elsewhere” (Catallo, 2008, p. 27).

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Patient-Oriented Interactive E-health Tools 333

Studies over the years have repeatedly and positively correlate interac-tivity to customer satisfaction (Coyle & Thorson, 2001, p. 73; Lin, 2007, p. 373). Singh (2010) argued, “improving the interactivity of the company Web site can help increase conversion rates and improve brand loyalty and rec-ognition.” As users become more Internet-savvy, they expect a mature com-mercial Web site to offer a certain level of interactivity, especially when the Web 2.0 technology has become increasingly popularized (Singh, 2010). Catallo (2008, p. 26) suggested:

Web sites for today’s hospitals should respond to consumer-driven demands for faster and more complete access to interactive information with at least minimal features like consumer-generated comments on service along with interactive media, tours, and demonstrations.

METHODOLOGY

The term interactive tools in this study is defined as any device that is inter-active in nature, such as online form, search function, calculation function, or game, for initiating an interaction process pertaining to a patient/user’s health between a patient/user and a hospital or among patients/users. Simply listing static phone numbers, doctor bios, or patient education materials is not called interactive.

In order to warrant external validity so that the conclusions from this study can portray a precise picture of how the U.S. hospitals were using patient-oriented interactive e-health tools, this study drew a systematic prob-ability sample based on the list of all U.S. hospitals at USNews.com. 4 There were 5,716 U.S. hospitals in the list. One out of every eight hospitals was sampled. Finally, 764 hospitals were included in the sample and studied.

Since this study intended to examine the presence of interactive tools on hospital Web sites, the choice of content analysis became a matter of course. The examination of the literature (Fried et al., 2000; Taylor et al., 2005; Sharma et al., 2006; Catallo, 2008; Song & Zinkhan, 2008; Varshney, 2009) provided the initial list of the interactive tools to measure for this study. The pilot study of 70 randomly chosen hospital Web sites provided more interactive tools that were not mentioned in the literature. In total, 21 of such tools were observed (See the Findings section.).

Based on a coding sheet with all the tools listed, the coding was done from January to February 2011. A pilot study on 70 randomly picked hospital Web sites was conducted to test the coding scheme and for two coders to trade coding ideas to boost intercoder reliability. The intercoder reliability, using Scott’s Pi, reached an average of .93 for all variables.

Independent variables included hospital affiliation (hospital networks vs independent hospitals) and hospital size (represented by number of

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beds). 5 All patient-oriented interactive tools were dependent variables. During the coding, the coders found that some hospitals probably did not have the manpower or expertise in some areas of e-health; therefore, they incorporated or linked to contents or technology from external vendors. Such outsourcing effort was examined as a dependent variable as well. 6 Finally, how hospital Web sites presented these tools was also examined in two additional dependent variables: online service menu and personalized account.

Data collection was conducted online via a shared Google Docs spread-sheet so that collaboration between the two coders could be easily carried out. Both descriptive and inferential statistic procedures were used in data analysis, which was executed in SPSS.

FINDINGS

According to Shepherd (2003), 82% of the U.S. hospitals had their presence felt online by 2002; Shepherd believed that “adoption levels were nearing the end of the late majority stage” when Roger’s diffusion of innovation theory was applied (Shepherd, 2003, p. 21). Huang (2009) found that by the end of 2008, 86% of the U.S. hospitals were online (p. 353). This study found that by February 2011, 93% of the U.S. hospitals had a Web site. The data reported below are based on the 712 hospitals (out of the total of 764 hospitals in the sample) that did have a Web site.

It was found that 59% of U.S. hospital Web sites belonged to a health care network, and the rest were independent hospitals. In terms of hospital size, 54% hospitals had 1 to 100 beds, 26% 101 to 250 beds, and 20% over 250 beds.

In total, 21 interactive tools were identified and examined in this study, and these tools were classified into six categories largely based on their func-tions (see Table 1 for details).

In addition, whether a site had an online service menu or provided a secure Web site for personalized e-business were also examined.

Research Question 1

Tables 1 shows that, among the traditional functional tools, more than half of the hospital Web sites provided online search (66.6%), interactive maps (60.8%), and the tool for finding a physician (56.7%). These popular tools were followed by the “contact us” tool (46.1%) and interactive calendar or event finder (42.8%). However, the virtual tour (9%) feature was barely used by hospital Web sites.

In contrast, the adoption rates of core e-business tools were much lower. In this category, the most widely used tool was paying bills online

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Patient-Oriented Interactive E-health Tools 335

(40.2%). The features of (pre)registration online (19.4%), making a doctor’s appointment (15.3%), accessing health records (10.1%), and refilling pre-scriptions (9.7%) were significantly less adopted.

Among the patient support tools, interactive patient education (47%), including health encyclopedia and interactive tools for risk assessments, cal-culators, quizzes, and symptom checker and care guides, was popular on hospital Web sites. Only 16.2% of the hospital Web sites, however, provided patient caring and support tools such as blog, chat room, submitting and sharing patient stories, or third-party CarePages.

E-card or email for a patient (28.2%) and online nursery (27.7%), in which visitors can view, purchase and/or print photos of a newborn baby, were two most frequently offered visitor-related tools. Much fewer sites

TABLE 1 Interactive Tools on U.S. Hospital Web Sites (by Category and Feature)

Interactive tools Frequency %

Traditional functional tools Online search 474 66.6 Interactive map 433 60.8 Finding a physician 404 56.7 Contact us 328 46.1 Interactive calendar or event finder 305 42.8 Virtual tour 61 8.6Core e-business tools Paying bills online 286 40.2 (Pre)registration online 138 19.4 Making a doctor’s appointment or communicating with a doctor

online109 15.3

Accessing health records, medical records, and lab results 72 10.1 Refilling prescriptions online 69 9.7Patient support tools Interactive patient education or health-risk assessment 335 47.0 Patient caring and support through CarePages, blog, or chat

room115 16.2

Visitor-related tools E-card or e-mail for a patient 201 28.2 Online nursery for viewing/purchasing baby photos 197 27.7 Online flower/gift shop 66 9.3Public relations-related tools Presence on social media, such as Facebook and Twitter 254 35.7 Online caregiver recognition 27 3.9Emerging functional tools ER wait time 40 5.6 Interactive cost estimator 25 3.5 Site or application for mobile devices 14 2.0Online service menua 78 11.0Personalized accounta 76 10.7

Note. Percentage calculations are based on 712 sampled hospitals that had a Web presence. aThese are interface designs that promote some of the interactive tools.

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allowed a visitor to purchase flowers or gifts on a hospital Web site for a patient (9.3%).

Connecting to users via social media Web sites, such as Facebook and Twitter, began to be a new trend for hospitals in 2009. 7 This study found that 35.7% of U.S. hospitals took advantage of this important public-relations tool. Asking patients and visitors to recognize a caregiver, such as a nurse, doctor, or staff member has been a tradition in many hospitals. Now, a few hospitals are trying to move this function to their Web sites (3.9%).

In comparison to most of the above interactive tools, ER wait time (5.6%), interactive cost estimator (3.5%), and providing a mobile site or application for a mobile device (2%) all seem sporadic.

Hospital Web sites presented these interactive tools in diversified man-ners. Most presented such tools without promotion. However, some hospital Web sites were intentionally promoting interactive tools so as to do business online as much as possible. The most sophisticated way was to set up a secure environment to provide personalized access to the hospital Web site so that a user could pay bill, make a doctor’s appointment, (pre)register, refill prescriptions, and/or access their medical records, health records, and lab results. However, only 10.7% of the Web sites had this function. Approximately the same percentage of hospitals (11%) promoted such tools by designing an online interactive tools menu. Usually, a user had to provide personal profile information repeatedly in such an environment since the tools worked independently.

In total, 7% of the 712 hospital Web sites did not have any interactive tools available (see Figure 1); 30.1% of the hospital Web sites had 1 to 3 fea-tures; 29.6% had 4 to 7 features; 22.1% had 8 to 10 features; and 11.4% had more than 10 features. The average number of interactive tools on a hospital Web site was 5.6 (SD = 3.8; mode = 1). Only one Web site carried the maxi-mum number of interactive tools: 18.

In terms of popularity of the interactive tools across the board, online search, interactive map, and finding a physician were clear winners with over 57% of the hospital Web sites offering these tools (see Figure 2). The next four popular tools were interactive patient education, contact us, inter-active calendar/event finder, and paying bills online, with over 40% of the hospital Web sites offering them. In contrast, online caregiver recognition, interactive cost estimator, and mobile site or application were the least popu-lar tools, with less than 4% of the hospital Web sites using them.

When these interactive tools are observed categorically, it is obvious that the traditional functional tools were the most adopted (see Table 2). About 91% of the hospital Web sites provided at least one interactive tool in this category. The adoption rates for all other tools were drastically lower. About half of the hospital Web sites had at least one interactive feature in the categories of core e-business (51%). Nevertheless, this category enjoys such a high percentage of penetration largely because of the presence of the

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Patient-Oriented Interactive E-health Tools 337

FIGURE 2 Interactive tools on U.S. hospital web sites (by popularity).

FIGURE 1 Number of interactive features available on U.S. hospital web sites. Note. Mean number of interactive tools = 5.58, SD = 3.82, min. = 0, max. = 18.

“paying bill online” tool. If this tool is excluded, the adoption rates of the other tools in this category drop to 32.2%. Patient support tools were adopted by 50.7% of the hospital Web sites. About 44% of the hospital Web sites had some kind of visitor-related tools, and 38% of them had public relations-related tools. Finally, the category of emerging functional tools appeared to receive the least attention among hospital Web sites (9.3%).

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338 E. Huang and C.-C. A. Chang

In the past several years, some companies developed dedicated Web sites or syndicated contents for hospitals to link to so that hospitals do not have to repeat similar work. About 34% of the hospital Web sites took advan-tage of such third-party content. These outsourcing efforts were commonly seen in presenting photos of newborn babies in online nursery at our365.com (17%); patient caring and support on carepages.com, where patients, visitors, relatives, and friends can exchange patient information, health care information, greetings, stories and so on (12%); and interactive patient education (10%).

Research Question 2

Shepherd (2003, pp. 22–24) and Huang (2009, p. 357) both found that online marketing was positively correlated with hospital size; large and medium-sized hospitals were more likely to be engaged in online marketing, to purchase external Web content than small hospitals, or to use videos as a marketing tool. This study has corroborated these findings. Table 3 shows a summary of the cross tabulation results to answer research question 2. Hospitals affiliated with a health care network generally were more likely than independent hospitals to have interactive tools on their Web sites (all p < .05), with the exception of the tools of virtual tour, e-card/email a patient, online nursery, and cost estimator. Moreover, there was no difference in these two types of hospitals in the category of visitor-related features (χ2(1) = .05, n.s.), although significant differences were found for the rest of the categories (all p < .01). In addition, networked hospitals had more inter-active tools in total on their Web sites than independent hospitals (Mnetworked = 6.57 vs. MIndependent = 4.19; t (657) = 8.8, p < .001). There was no association between hospital affiliation and the possibility of using third-party contents or technology (χ2(1) = 2.32, p > .1).

In terms of hospital size, overall, larger hospitals were more likely than smaller hospitals to provide interactive tools on their Web sites (all p < .05). This pattern was true across all six categories of interactive tools,

TABLE 2 Interactive Tools on U.S. Hospital Web Sites (by Category)

Interactive tools category Frequency %

Traditional functional tools 645 90.6Core e-business tools 363 51.0Patient support tools 361 50.7Visitor-related tools 310 43.5Public relations-related tools 263 36.9Emerging functional tools 66 9.3

Note. Percentage calculations are based on 712 sampled hospitals that have a Web presence. Numbers in the “Frequency” column indicate the numbers of hospitals that have at least one tool in a given category.

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Patient-Oriented Interactive E-health Tools 339

as well as the functions of online service menu and personalized account. In addition, hospital size was related to the total number of interactive tools available on a hospital Web site (F (2, 709) = 81.1, p < .001). That is,

TABLE 3 Summary of Cross-Tabulation Results

Association between an interactive feature (or category) and an independent variable

Independent variable

Hospital affiliation (network vs. independent)

Hospital size (small vs.

medium vs. large)

Traditional functional features Online search 46.74** 88.20** Interactive map 37.71** 16.16** Finding a physician 38.46** 117.87** Contact us 9.22** 10.46** Interactive calendar or event finder 12.91** 54.95** Virtual tour 2.06 7.24*Core e-business features Paying bills online 32.08** 42.92** (Pre)registration online 21.65** 12.37** Making a doctor’s appointment or

communicating with a doctor online18.15** 27.06**

Accessing health records, medical records, and lab results

18.04** 12.11**

Refilling prescriptions online 18.20** 10.44**Patient support features Interactive patient education or health-risk

assessment38.67** 72.53**

Patient caring and support through CarePages, blog, or chat room

13.31** 16.68**

Visitor-related features E-card or e-mail for a patient 0.05 33.29** Online nursery for viewing/purchasing baby

photos1.18 16.23**

Online flower/gift shop 12.26** 21.18**Public relations-related features Presence on social media, such as Facebook

and Twitter20.11** 67.82**

Online caregiver recognition 8.20** 14.18**Emerging functional features ER wait time 20.11** 20.41** Interactive cost estimator 1.93 6.47* Site or application for mobile devices 4.34* 12.22**Online service menu* 12.16** 21.90**Personalized account* 16.50** 21.93**Traditional functional features category 39.90** 30.77**Core e-business features category 61.19** 67.74**Patient support features category 41.69** 76.29**Visitor-related features category .05 36.30**Public relations-related features category 22.84** 73.74**Emerging functional features category 16.21** 20.73**

Note. The numbers in the table are chi-square values. Small hospital = 1–100 beds; medium hospital = 101–250 beds; large hospital > 250 beds. Best hospital designation was based on health.usnews.com. *p < .05. **p < .01.

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large hospitals (MLarge = 8.1) on average had more interactive tools on their Web sites than did medium-sized hospitals (MMedium = 6.64), which, in turn, had more tools than did small hospitals (MSmall = 4.13) (all the post hoc pair comparisons were statistically significant; all p < .001). Large and medium-sized hospitals also were more likely to use third-party contents on their Web sites than small hospitals (χ2(2) = 18.38, p < .001).

DISCUSSIONS AND CONCLUSIONS

This study has provided empirical evidence to answer the broad research question: How have the U.S. hospitals embraced e-health as reflected in the adoption of patient-oriented interactive e-health tools on their Web sites? A content analysis of a representative sample of the U.S. hospital Web sites has revealed the current state of implementation of patient-oriented interactive e-health tools, filling a great gap in our knowledge of e-health development in the United States. The findings of this study are most useful for hospitals that are interested in gauging and benchmarking their e-health development effort. Since a hospital Web site is an important contact point between a patient/user and the hospital, hospitals must take advantage of the interac-tive e-health tools to better serve their patients/users and make such tools part of their interactive marketing endeavor.

This study has yielded many substantive findings that have practical implications. First, 21 interactive tools as well as two structured approaches of presenting these interactive tools have been identified. The levels of prev-alence of these interactive tools are documented both on the individual level and on the categorical level. Since there has been no empirical study in this field, these findings and categorization will provide a benchmark for future health care interactive marketing studies. Benchmarking also means “the process of identifying, learning, and adapting outstanding practices and pro-cesses from another organization to help improve performance,” as defined by the American Productivity & Quality Center (APQC). 8 As Roberts (2008, p. 38) argues, benchmarking “is something that all hospitals will need to become more familiar with as the health care industry moves towards trans-parency.” Therefore, the findings from this study will provide evidence for U.S. hospitals when they do their e-health benchmarking.

Second, among the hospitals that had a Web presence, 7% of them did not provide any interactive tools; 84% of such hospitals were small hospitals, and 74% of them independent hospitals. Also, 11.1% of hospital Web sites used only one interactive tool (freq. = 79). Obviously, these hospitals with no to extremely low-rate e-health adoption need IT expertise assistance and probably also a mindset change in their online marketing strategy. To catch up with the pace of the e-health development in this nation, these hospitals can start with implementing most of the traditional interactive tools, which

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require comparatively lower-tech expertise, and adopting third-party con-tents and technology.

Third, the fact that, on average, a typical hospital Web site used 5.6 interactive tools suggests that many hospitals missed most of the useful inter-active tools to conduct business online. In other words, they missed the opportunities to save cost, reduce error, improve transparency, and increase operational efficiency and patient friendliness (Mukherjee & McGinnis, 2007). Hospitals need to be aware of the presence of the available patient-oriented interactive tools identified by this study and should consider implementing at least the 10 interactive e-health tools that have exceeded a conservative 25% adoption rate shown in Figure 2 since these tools have become or are becoming the industry standard. Since the use of portable wireless devices has boomed over the past years, hospitals should consider adopting those emerging tools mentioned in this study, such as ER wait time, interactive cost estimator, and sites or apps for mobile devices, so as to pro-vide convenience to those who use hospital online services on the go.

Fourth, core e-business tools have been sparsely used. Except for the “paying bill online” tool, which reached 40.2% adoption rate, all other tools in this category did not exceed 20%. All hospitals need to make ends meet. It is understandable why many hospitals, no matter how small, had at least a “Pay Bill Online” button. While this online service certainly makes patients’ lives easier when they try to make a payment, it serves the interests of a hospital more than its patients. On the other hand, (pre)registration, making a doctor’s appointment, accessing records and lab results, and refilling pre-scriptions essentially serve patients more than serving a hospital. These core e-business tools are central to any medical-related transaction and constitute the substance of e-health. If implemented, they will enhance both operating efficiency of a hospital and user-friendliness. To make a hospital Web site more relevant to patients/users, in the years to come, hospitals need to implement further and faster core e-business tools on their Web sites to fully enjoy what these crucial interactive e-health tools can offer.

Fifth, considering the fact that 66.6% of the hospitals had no or less than seven interactive tools on their Web sites and that most of these tools were traditional functional tools, it is understandable why most hospitals did not promote such tools. However, being aware of the advantages of using inter-active e-health tools to conduct business online, some hospitals (11%) intentionally built an online service menu to promote some of their more advanced interactive tools. But a better direction is probably for hospitals to learn from those 76 hospitals (10.7%) that used a secure Web environment for a patient/user to access a personalized account so that he or she can pay bill, make a doctor’s appointment, (pre)register, refill prescriptions, and/or access the personal medical record, health record, and lab results—the core e-business tools—in a carefree manner and without repeatedly providing the personal profile information. If a hospital does not have the expertise to

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build such an infrastructure, at least it can take advantage of a third-party technology, such as myChart, which is arguably the most popular tool spe-cifically designed for conducting advanced, multiple e-businesses on a secure and personalized hospital Web site.

Finally, the study has found strong evidence that larger hospitals have implemented more interactive e-health tools than smaller ones; hospital net-works have implemented more interactive e-health tools than independent hospitals. Those large health care systems tend to have more funding and more IT expertise for implementing e-health. It is very likely that, as early adopters of interactive e-health tools, those hospitals will exert big influence on smaller and independent hospitals in the years to come. According to Rogers’ diffusion of innovation theory, the early adopters of an innovation profoundly affect the innovation decisions of late adopters (Mahler & Rogers, 1999). Rogers used the term “critical mass” to refer to the point at which enough members in a community have adopted an innovation so that the innovation’s further rate of adoption becomes self-sustaining. Critical mass is usually reached at a 10% to 25% adoption rate (Mahler & Rogers, 1999). After a critical mass is reached, the diffusion of innovation likely becomes irrevers-ible (Mahler & Rogers, 1999). Therefore, e-health here to stay and will con-tinue to thrive.

This is the first empirical study that has systematically investigated the U.S. hospitals’ efforts in implementing e-health on their Web sites; however, it has its limitations, which point to future research directions. First, since this study intended to examine the presence of interactive tools on hospital Web sites, it did not involve users. Some scholars have argued that the mere presence or absence of certain interactive features on a Web site matters only if these features affect how consumers navigate and use the site (Lee, Lee, Kim, & Stout, 2004; Song & Zinkhan, 2008). “For example, the presence of a chat room may not affect consumers’ perceptions of interactivity unless they actually use the chat room” (Song & Zinkhan, 2008, p. 99). It is not clear whether a higher number of interactive tools lead to higher user satis-faction with a hospital Web site. Nor is it clear which interactive tools users need the most. Therefore, a follow-up user study is necessary. Second, hos-pitals can benefit from a study that analyzes the best practices of using interactive e-health tools. Some hospitals in this sample have aggressively transferred anything that used to transact on paper to their Web site while some other hospitals, even large hospitals and large hospital networks, have basically treated their Web sites as shovel ware—shoveling their content on paper to their Web sites—and failed to take advantage of the core feature of the Web—interactivity. The rationales underlying the hospitals’ decisions as to why or why not using interactive e-health tools also need to be inves-tigated. Finally, longitudinal studies are desirable for tracking and measuring e-health development and identifying the latest trends and features for hospitals’ periodical benchmarking efforts.

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Patient-Oriented Interactive E-health Tools 343

As of early 2011, 87% of all U.S. hospitals used at least one patient-ori-ented interactive e-health tools. Although the majority of the U.S. hospitals have embraced e-health on their Web sites, most of them have stayed on the level of adopting traditional functional tools and other comparatively light-weight, easy-to-implement interactive features. Third-party contents and technology have certainly helped hospitals in going e-health. However, much more effort needs to be made in the years to come for hospitals to implement the core e-business tools, especially those that can greatly benefit patient/users so that hospital Web sites will serve as a efficient marketing tool to truly benefit their patients/users.

NOTES

1. U.S. hospitals are ranked yearly in terms of their IT development. More information and rankings can be found at http://www.hhnmostwired.com/hhnmostwired_app/index.jsp

2. People even disagree on how the term should be spelled: e-health, eHealth, E-health, or e-Health.3. See examples in Catallo (2008, p. 27).4. The list can be found at http://health.usnews.com/best-hospitals by searching every state.5. Small size = 1–100 beds, medium size = 101–250 beds, and large size = more than 250 beds.6. Even though some sites incorporated external interactive health care information, such information

was counted as internal since such information was housed under the specific hospital Web site instead of being shown on an alien site. From a user’s perspective, the user may not know that such information is syndicated by an external vendor.

7. Ed Bennett, director of Web Strategy for University of Maryland Medical Center, meticulously docu-mented the trend of how hospital Web sites subscribed to social media on his popular blog site Found In Cache. His updated list of U.S. hospitals on social media can be found at http://ebennett.org/hsnl/

8. See http://www.apqc.org/benchmarking.

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