EVALUATION OF GREEK PUBLIC HOSPITAL WEBSITES

Fotini Patsioura, Spyros Kitsiou and Angelos Markos

Department of Applied Informatics, University of Macedonia, 156 Egnatia Str., Thessaloniki, Greece

Keywords: e-Health, e-Government, Evaluation, Criteria, Hospital, Websites.

Abstract: Hospital web sites need to operate as effective web resources of information and interactive communication

mediums to address the multifaceted requirements of their main stakeholders, (i.e. patients, healthy citizens,

healthcare professionals and local communities). In case of public hospitals, web sites should also be

considered as a mean to provide governmental electronic services. The main objective of this study is to

provide an evaluation framework for hospital web sites. The proposed framework focuses on three main

criteria: information, communication and electronic services. A total of 53 Greek hospital web sites within

the Public Sector were evaluated based on a 67-item scale. The main findings of the study were the

following: (a) the majority of the web sites in the analysis failed to support necessary web-based

transactions between the institutions and their stakeholders (b) web sites are lacking important features

regarding provision of information and communication practices. Improvements on interaction and

information quality are necessary in order for the institutions to provide a viable and useful online

environment for patients and citizens.

1 INTRODUCTION

Direct healthcare providers need to deliver

satisfactory services in a specialized field which

involves a great number of stakeholders with

different concerns, needs and requirements. So far,

hospitals’ policies have been focused on providing

health and medical services to the public. Limited

attention has been given on their responsibility to

provide useful, accurate health information of high

quality to their key publics mainly by facilitating

interactive communication with patients, citizens,

physicians and community services.

To date, hospitals are turning increasingly

towards the Internet and develop their own web

presence in order to enhance the provision of

information and also employ interpersonal and

interactive communication practices. Moreover,

public and private health institutions acknowledge

the importance of building relationships with current

or potential patients by providing a friendly and

functional online environment. In this setting, public

hospitals should go one step forward taking into

account their authority in providing and supporting

governmental or public electronic services such as

provision of documentation, facilitation of routine

transactions (e.g. appointment scheduling, billing

procedure handling) and gathering of valuable

feedback in order to evaluate the quality of their

overall services. Internet-based consumer services

provided through hospital web sites are necessary to

improve relationship management, citizens’

convenience and patient care, but also required in

order to enhance the operation of these web sites as

a complete public marketing instrument.

Many evaluation instruments on hospital and

public sector web sites were examined and analysed.

Most of them focus on information content and

communication aspects. Little research has been

conducted regarding their capability to provide

interactive and transactional services. This study

aims at providing an evaluation framework for

hospital web sites that examines their overall

performance as reliable information web resources

and advanced interactive and transactional e-service

mediums. It should be mentioned that the proposed

framework mainly focuses on the capabilities of

hospital web sites to meet the requirements and

needs mainly of their key stakeholders (i.e. patients

and citizens). It is in the authors’ opinion that this

approach should provide better understanding and

analysis of the hospital web sites’ multidimensional

role.

223

Patsioura F., Kitsiou S. and Markos A. (2009).

EVALUATION OF GREEK PUBLIC HOSPITAL WEBSITES.

In Proceedings of the International Conference on e-Business, pages 223-229

DOI: 10.5220/0002194402230229

 SciTePress

2 LITERATURE REVIEW

Mukherjee & McGinnis (2007) discussed how

important is for healthcare providers to utilize the

internet and the new technologies in order to

improve healthcare services, further implement their

facilities, and also support two main activities of

their stakeholders on the Internet, information

searches and communication requests. For hospitals,

web sites are the key platform to accomplish

information provision and communication services

outside their facilities. Research has shown that

people searching for heath care information are

becoming more demanding and sophisticated with

regards to information and web site quality (Bodkin

and Miaoulis, 2007). Although hospitals have paid

attention to this trend, limited action has been

undertaken to take advantage of the Internet

capabilities in order to meet their stakeholders’

requirements and needs and deliver technologically

useful services.

The analysis of current situation by evaluating

private and public hospitals’ web sites is essential in

order to identify the gaps and improve their overall

performance. Most research on this field is focused

on information quality and usability issues. Norum

(2001) evaluated cancer related hospital web sites

based on information provision (general and contact

information) and web sites accessibility aspects

(browser presence and English version web site).

Randeree and Rao (2004) provided an evaluation

instrument for American hospital web sites using

eight key criteria factors: access, audience, accuracy,

timeliness, content, authority and privacy to assess

both the presentation and transaction of information,

but also the functionality of the web sites. Results

derived from this study revealed significant gaps in

terms of information accuracy, currency and

customisation. Hospital web sites’ content remains a

major issue, especially when consumers of

healthcare information on the internet remain

sceptical towards the source of information

(Huntington et al, 2004).

Nevertheless, hospital web sites should fulfil

objectives beyond the delivery of accurate and

trustworthy information. Gruca & Wakefield (2004)

emphasize on the importance of communication

processes in facilitating information transactions

between institutions and patients or other

stakeholders. Provision of multiple communication

channels such as electronic mail, online forms, and

discussion forums are necessary to establish direct

personal interaction and satisfy current or potential

patients who expect an easy way to contact their

physicians or other facilities within the hospital.

According to Smith (1997) a friendly interaction

environment for users of hospitals’ web sites should

be considered as an essential online service by the

providers. For hospitals the utilisation of the Internet

is the only money-saving way to “bring patients and

services and clinicians closer together” and most

significantly to build patient relationships in many

ways that have not been possible before (Lewers,

2003). While building relationships is an essential

goal for corporate and commercial web sites

(Keating et al, 2003; Boisvert & Caron, 2006), in

case of hospitals’ web sites it remains an

underestimated element. So far, limited academic

research was conducted to determine the quality of

communication processes delivered to health

consumers on the Internet by hospitals’ web sites.

In terms of web site evaluation, it is apparent that

previous research regarding hospitals’ web sites is

affected by the commercial web sites’ evaluation

research. Criteria like design, accessibility,

readability, interactivity, navigation and content

have been widely used in the past for health related

and hospitals’ web sites (Smith, 1997; Liddell, 2005;

Randeree & Rao, 2004; Llinas et al, 2007). Although

useful, this approach could be inadequate to produce

complete measures as it fails to take under

consideration the electronic services aspect. In the

future, more and more hospitals will invest on

electronic services through their web site to support

functions and activities such as information search,

appointment scheduling, problem solving policies,

billing and payment procedures. For private

hospitals this action is necessary in order to enhance

their consumers’ satisfaction, while for public

hospitals is mandatory as part of their authentication

towards standards approval procedures (Ancarani,

2005). In both cases, electronic services are the next

step to enhance web sites’ performance while

engendering health care consumers’ support.

3 EVALUATION FRAMEWORK

The main objective was to develop a conceptual

framework that can be used in the evaluation of the

overall performance of Hospitals’ web site towards

the multiple objectives of their establishment.

Hospitals websites should ultimately provide

healthcare consumers with the ability to perform the

following main activities: gather accurate and

reliable information for decision-making purposes,

contact and interact either online or directly with the

hospital’s medical and administrative personnel, and

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last but not least, perform a range of online

transactional and interactive activities.

Based on that, the proposed framework identifies

two key categories for hospitals’ web site evaluation

based on healthcare consumers’ needs and

requirements, defined in table 1:

 Information

 Communication and Transaction

Table1: Criteria categories.

Information. According to Jadad et al (2001), in the

new age of e-healthcare, academic, professional and

governmental health organisations need to

communicate health information from institutions to

patients’ home. In case of hospital web sites, the

provision of information has a dual purpose. Firstly,

to enable decision-making toward the selection of

the most appropriate provider and specific medical

services. Secondly, to serve as a reliable source of

either general or specific health information, in order

to improve health and assist consumers in the

management of their own health. Previous research

addressed the issue of citizens’ and consumers’ trust

on healthcare information (Huntington et al, 2004).

Patients should be free of concerns and

insecurities when gathering information about the

hospital or general healthcare information. In health

consumers’ mind, trustworthy healthcare

information comes when visiting a recognised

institution (Lin & Umoh, 2001). A recent study,

conducted by the Health On the Net Foundation

(Health On the Net Foundation, 2004), revealed that

approximately 75% of American and European

patients and healthcare professionals prefer to search

and obtain information from hospital-sponsored

websites.

However, it is equally important and should be in

web site developers’ concern to facilitate the

gathering and selection of accurate and validated

health information by the citizens in terms of

usability issues. Therefore, the proposed framework,

regarding the information content focuses on the

following main criteria groups: (1) hospital generic

information (2) hospital specific information (3)

health information, (3) currency of information, (4)

disclosure of credentials (for the organisation, and

(5) links to external resources.

Communication and Transaction. A virtual

environment is effective in terms of communication

when online consumers’ or citizens feel the

familiarity and personal attention of face-to-face

communication. Especially, for hospitals’ web sites

communication between current or future patients

and physicians will strengthen the hospital’s

relationship marketing policy. The Internet

facilitates interactive transactions and interpersonal

communication with the use of a variety of

technologies and practices. The provision of

multiple communication channels is a means for

accomplishing direct personal interaction with

limited effort and time. When evaluating a hospital’s

web site, it is vital to examine its capabilities to

respond to consumers’ inquiries and allow their

direct contact with the hospital’s medical,

managerial or administrative services. The proposed

framework investigates the provision of adequate

contact and communication information and the

site’s capability to facilitate direct, interactive and

personal communication.

Regarding the aspect of transactions, in

commercial web sites online transactions services

are provided to support online customers throughout

their overall shopping experience (Zeithaml et al,

2002). In the public sector, online transaction

services encompass supportive activities, including

provision of information and documentation,

complaints management, and sometimes more

specific transactions such as supplies handling,

contracting and billing (Ancarani, 2005). With

regards to hospitals, Gruca and Wakefield (2002),

along with others (Llinas et al., 2008; Gallant et al.,

2007; Zingmond et al., 2001) describe online

transactions as the capabilities of hospital websites

to facilitate interactive communication between the

institutions and their stakeholders (e.g. via online

forms, online forums, support groups, chat boards,

etc.) or more sophisticated such as online

appointment scheduling, online reporting of clinical

test results, online payments and management

requests. Hospitals should go one step forward

taking advantage of the unique characteristics of the

Internet and the information and communication

technologies in general with the aim to deliver

services electronically to hospitals’ main

stakeholders. Facilitation of information search and

selection, web site personalization, the delivery of

Criterion

Category

Definition

Information

Web site’s capability to provide

adequate information about the hospital

and general health

Communication

and Transaction

Web site’s capability to facilitate direct

communication among the hospital and

health consumers and enable interactive

transactions to enhance consumer

services

EVALUATION OF GREEK PUBLIC HOSPITAL WEBSITES

225

documents electronically, fully online transactions

such as billing procedures and payment processes

are some of the facilitating and supportive services

that should be the evolution of a transactional and

interactive online hospital website environment.

Therefore, the proposed framework, regarding

the aspects of communication and transactions

focuses on the following main criteria groups: (1)

contact and communication content, (2) interaction

and transaction mechanisms, (3) user support and

ease of use.

Based on the above discussion, Figure 1

illustrates the proposed evaluation framework. Each

of the two aforementioned criteria categories that

comprise the proposed evaluation framework are

further analysed in 9 criteria groups. These 9 groups

encompass a range of web site features to support

the evaluation of hospital websites.

Figure 1: Evaluation Framework.

4 METHODS

Between June and July of 2008, a thorough

evaluation study to assess the information and

transactional features of Greek Hospital Web Sites

was carried out.

For the identification of public hospital websites,

we used the online national directory of the

Greek Health Ministry. When no hospital website

was identified, a telephone call was made to the

hospital to confirm that there was no website.

Based on the 9 criteria groups of the evaluation

framework, an instrument comprising of 67 explicit

evaluation criteria were developed and utilized for

the assessment of the websites. The websites were

evaluated based on the presence (1) or absence (2) of

each criterion. This approach was chosen by the

authors to minimize subjectivity by the evaluators

during the assessment process. The two authors of

this paper (F.P. and S.K.) carefully examined the

websites using a standard browser (Internet

Explorer, Microsoft) and completed the evaluation

instrument during their in-depth visit in order to

provide reliable results.

For the final database and the recording of the

results the authors used Microsoft Excel 2003 and

the SPSS version 15 for statistical analysis.

Next, to assess the reliability of the instrument,

coefficients of internal consistency were used.

Precisely, internal consistency was tested by

calculating Cronbach’s alpha for the dichotomous

items of the information and the interaction-

transactional criteria groups. Table 2 presents the

reliability results, which generally establish the

correctness of the proposed measurement structure.

The Cronbach’s alpha values for the two criteria

groups that were used in the study are very

satisfactory and generally establish the correctness

of the instrument structure and thus the structure of

the proposed evaluation framework.

Table 2: Reliability Results (Cronbach’s alpha).

Criteria Categories Cronbach alpha

Information criteria groups (6)

0.804 (41) **

Interaction and Transaction

criteria groups (3) *

0.701 (26) **

*Number of criteria groups

** Number of items/criteria

5 RESULTS

Out of the 131 public hospitals that operate in the

context of the Greek public healthcare system, a

total of 57 hospital web sites (43,5%) were

identified. Of the 57 public hospitals, 39 were

general hospitals (68,4%), 6 (10,5%) were operating

both as primary care health centres and general

hospitals, 5 were teaching hospitals (8,8%), and 7

(12,3%) were specialty hospitals. Regarding their

size in terms of clinical beds, 10 hospitals (17,5%)

were small in size (25-100 beds), 13 (22,8%) were

small to medium size hospitals ranging from 101-

250 beds, 29 (50,9%) hospitals were medium to

large (251-750 beds), and 5 hospitals were large

(8,8%) having more than 750 clinical beds.

Information. On the first criteria group of the

information category, which evaluated the presence

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or absence of “general hospital information”, the

vast majority of the websites consistently reported

information about the history (93%), the location

(77%), and the size (65%) of the organization in

terms of number of beds. Also, 65% of the websites

provided information about the structure of the

organization by illustrating their organizational

chart. Many hospitals take advantage of the web to

apprise visitors with current news and

announcements (65%) about the institution. On the

other hand, it was found that most hospital websites

fail to guide visitors on how to get to the hospital by

making available information on transportation

means (28%) and lodging or travelling, including

maps and directions (35%). For large hospitals in

large cities that often have many locations,

numerous buildings and, perhaps multiple entrances

for the same buildings this was considered to be an

important limitation.

Regarding the second group, which encompasses

criteria on specific hospital information that play an

important role in the decision making process of

health consumers towards the selection of the most

appropriate provider, it was found that specific

information regarding the range and type of clinical

and administrative departments and services were

present at the majority of the web sites, 92% and

74% of the times respectively. However, basic

information regarding the clinical personnel of the

hospital (e.g. physicians and nurses) such as

directory lists with names and specialties were

present less than half of the times. Moreover,

important information about physicians’ background

and experience was significantly limited (2%).

Information about hospitalization guidelines such as

admission procedures (37%), necessary documents

(40%) and information about insurance coverage or

plans (28%) were also found at low frequencies.

These results are considered to be very

disappointing. According to Clines and Haynes

(2001), information about core competencies of

physicians, hospital specialties, insurance coverage,

and general hospitalization guidelines can influence

consumers, in terms of decision making and

selection of the most appropriate healthcare provider

based on their situation. Also, a recent study

undertaken by Gallant et al (2007) found that access

to physicians’ information, reputation, and

background experience can encourage the creation

of trust, which is considered to be a vital aspect of a

hospital’s relationship with its public (Hesse et al.,

2005). Therefore, the aforementioned results

demonstrate that Greek hospital websites fail to

create basic elements of trust with their current and

potential customers.

Health information access is also considered to

be an important service that hospital web sites can

provide to their uses. Unfortunately, the vast

majority of the Greek hospital websites that were

surveyed did not provide any kind of either general

or specific health information. Only 28% had a

devoted section for consumer health information

regarding specific diseases, research studies or

consumer-oriented educational material.

Concerning currency of information, less than a

third (29%) of the websites in the sample provide

dates of last page updates and only 16% of them

provide dates of page creation. This is an important

drawback taking into account that visitors need to be

certain at all times about the currency of specific

information such as visiting hours, hospitalization

costs, health information and duty hours of hospitals.

As regards to disclosure of credentials,

unfortunately only 5% of the evaluated websites

include information on credentials or certifications

of services about the institution (e.g. markers of

excellence, awards, quality credentials, ISO, EFQM,

etc.) Such low levels demonstrate that the majority

of Greek healthcare organisations do not fully

comprehend the vital significance of credibility

appraisal toward the development of consumers’

trust. Moreover, it is also a negative observation that

only 35% of the websites provide information about

the participation of the institution in scientific

studies and its research contribution which could

enhance the institution’s image on the community.

Links to other health care websites or general

health information sites were provided only by less

than half of the surveyed hospitals (37%), while the

frequency of links to other healthcare organizations

was also low (32%). However, having external links

to health and medical information is considered to

be an important feature that hospital websites should

have, in order to strengthen their usefulness.

Communication & Transaction. As for contact

and communication content, findings reveal that

most of the websites provide adequate

communication information to facilitate direct and

interpersonal contact with the institution’s faculty

but mainly about traditional communication

channels (telephone, fax). Specifically, almost all

websites (93%) provide a general phone number and

63% of them include a fax number. In addition,

telephone numbers of administration employees

(68%) and physicians (65%) are often included.

However, communication via e-email is not

EVALUATION OF GREEK PUBLIC HOSPITAL WEBSITES

227

supported by the majority of the websites. Almost

half of the websites (45%) do not include a central

email address. Additionally, physicians e-mail

addresses are included only on 19% of the websites

and employees’ email addresses are provided by

38%. Finally, it is worth mentioning that regarding

scheduling appointments, 72% of the websites in the

sample include the phone numbers of outpatient

clinics.

Interaction and Transaction mechanisms were

unfortunately scarce or absent in the vast majority of

the hospital websites. Specifically, it was found that

only 37% provided a central online communication

form to address consumers’ inquiries about hospital

services, while near 10% included online forms to

enable interpersonal communication with physicians

(9%) and administration employees (12%).

Moreover, there was almost a complete absence of

personalization features (5%) that could enable the

provision of targeted information, content or

services to the website users. Personalization

features can encourage the commitment of the

audience toward the hospital website and the

organization itself, while also according to Gallant et

al (2007) “providing a personalized website for

indivinduals, upon either logging into or automatic

recognition of user arrival, can increase the

usefulness of a website for its audience”. Only 5%

of the websites incorporate real-time interaction

mechanisms such as discussion forums or chat-

boards to enable direct online communication and

exchange of views between the hospital and the

consumers or even among consumers. Also, none of

the websites in the sample provide any kind of

advanced transaction mechanisms for online

appointment scheduling, settling of financial

accounts (e.g. online service payments), and online

access of medical test results.

Regarding “user support and ease of use”

criteria which examine the presence of basic

functionality and usability features and tools, results

show the lack of significant mechanisms that support

ease of navigation and access. Specifically, only 3%

of the websites include a “help” page, and only 5%

provide information on browser compatibility.

Almost a third of the web sites provide a search

engine to facilitate information gathering and less

than 5% support advance search engine features.

Furthermore, less that half (38%) include a site map

on their webpage. With respect to accessibility, only

32% of the websites support a second language

version (i.e. English). Bearing in mind that Greece is

considered to be a frequent travel destination for

many tourists around the world, this is considered to

be a significant limitation for Greek hospital web

sites.

6 CONCLUSIONS

This research presents a conceptual framework to

evaluate the overall performance of Hospitals

websites focusing on the following aspects,

information services, communication services and

transaction services. The proposed framework was

empirically tested in Greek Public Hospital websites.

Findings revealed that less than half of the Greek

Public Hospitals have invested in establishing a

virtual presence. Moreover, the vast majority of

current hospitals’ web sites are mainly informative

but lacking significant information to enable

decision making by Greek health consumers on

choosing a health provider. With respect to

communication services, it is evident from the

results that direct and interpersonal contact by

traditional media (i.e. telephone, fax) is facilitated,

while interactive and real-time communication with

physicians or administration employees through

internet based technologies is scarcely incorpotered.

Moreover, not one hospital website supports

transactions services to enable online routine and

other activities fullfillement in a web-based virtual

environment. The European Union in the “Green

Paper on Public Sector Information in the

Information Society” has defined e-services concept

for public governmental websites in order to provide

a set of standards and classifications to improve

information, communication and transaction services

by governmental and public websites (European

Commission, 1998). Also, a “Certification

Framework for Public Administration, Sites and

Portals” was developed by the governmental

organisation of “Information Society” on behalf of

Greek Ministry of Interior in order to specify a set of

directions and standards to support effective e-

government portals design and development but

mainly to improve e-governmental services. In

Greece, an “e-Health Consumer Trends survey”

undertaken by the Institute of Computer Science in

2005, found that 54.2% of the Internet users go

online to search for information about Health and

Illnesses (H&I) (Chronaki, et al. 2006, 2007).

Moreover, 59% for H&I make their decision

whether to consult a health professional partly based

on information found on the Internet. Bearing in

mind, that Greek public hospitals remain the main

governmental authority to provide citizens with

health and medical services, it is vital that

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improvements on information quality, interaction

and communication of their websites are necessary

in order to provide a viable and useful online

environment.

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