Understanding Dynamic Collaboration in ...

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Understanding Dynamic Collaboration in Teleconsultation a

Ziyu Yan , Xitong Guo

bc

d

& Douglas R. Vogel

a

Department of Information Systems, School of Business, City University of Hong Kong, 83 Tat Chee Avenue, Kowloon, Hong Kong b

School of Management, Harbin Institute of Technology, 13 Fayuan Street, Harbin, People's Republic of China c

Department of Logistics and Maritime Studies, Hong Kong Polytechnic University, Kowloon, Hong Kong

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d

Department of Information Systems, City University of Hong Kong, P7720, 83 Tat Chee Avenue, Kowloon, Hong Kong Published online: 15 Nov 2013.

To cite this article: Ziyu Yan, Xitong Guo & Douglas R. Vogel (2013): Understanding Dynamic Collaboration in Teleconsultation, Information Technology for Development, DOI: 10.1080/02681102.2013.854730 To link to this article: http://dx.doi.org/10.1080/02681102.2013.854730

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Information Technology for Development, 2013 http://dx.doi.org/10.1080/02681102.2013.854730

Understanding Dynamic Collaboration in Teleconsultation ∗

Ziyu Yana, Xitong Guob,c and Douglas R. Vogeld


a Department of Information Systems, School of Business, City University of Hong Kong, 83 Tat Chee Avenue, Kowloon, Hong Kong; bSchool of Management, Harbin Institute of Technology, 13 Fayuan Street, Harbin, People’s Republic of China; cDepartment of Logistics and Maritime Studies, Hong Kong Polytechnic University, Kowloon, Hong Kong; dDepartment of Information Systems, City University of Hong Kong, P7720, 83 Tat Chee Avenue, Kowloon, Hong Kong

Information and communication technology has been widely deployed in the provision of healthcare for decades. Teleconsultation, one of the new means of providing healthcare solutions, has been prevalently implemented in numerous countries. In principle, it is expected with great potential to improve the effectiveness and efficiency of healthcare service through wide accessibility and cost control. However, many teleconsultation systems have been installed but abandoned rapidly or used at a disappointing low level. This paper explores the antecedents of low usage in post-adoption of teleconsultation service in clinical practice. We identify specific theoretical attributes targeted on the research problem and extend the Technology– Organization –Environment (TOE) framework into a multi-dimensional analytical framework. We design a comparative case study and conduct deductive analysis to test our propositions using data from multiple sources. The proposed analytical framework and empirical findings not only provide theoretical contribution by articulating the TOE framework to reflect the specific and distinguished characteristics in teleconsultation services, but also provide implications for practitioners to develop better strategies for teleconsultation collaboration. Keywords: teleconsultation; telemedicine; post-adoption; TOE framework; media synchronicity theory

Introduction Worldwide, healthcare is receiving ever-growing concern and accounting as an important part of the economy. Great challenges to achieve cost reduction and quality improvement of medical service are faced in virtually every country. As in many other developing countries, China needs to accelerate the development of the healthcare industry in order to meet the gap between national economic growth and citizens’ living conditions. One of the biggest medical problems is the challenge of unbalanced, distributed medical resources. Most specialists in China work in wellresourced hospitals located in big cities, such as Beijing and Shanghai, whereas large parts of the population in rural areas have scarce resources (Zhang, Wand, & Xi, 2010). Information and communication technology-based innovation provides a great potential breakthrough for quality improvement and cost control. Telemedicine is “the use of electronic information and communication technologies to provide and support healthcare when distance separates the participants” (Ekeland, Bowes, & Flottorp, 1996). Diagnosis, treatment, monitoring, and remote learning purposes can be achieved by using telemedicine systems. Teleconsultation is “a particular type of telemedicine typically involving one healthcare provider – usually ∗

Corresponding author. Email: [email protected] Sajda Qureshi is the accepting Editor-in-Chief for this article.

# 2013 Commonwealth Secretariat


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a primary care provider seeking advice from another – usually a specialist or sub-specialist – who has specialized expertise regarding the health problem at hand” (Paul, 2010). Literally, telemedicine technology leads to a wider boundary for collaboration, through which geographically dispersed medical resources can be leveraged to be more efficiently utilized. In principle, it is possible for specialized medical resources to be assessed remotely and costs to be offset by reducing tertiary transfer. Unfortunately, such promising vision has not occurred in reality. Many telemedicine systems have been installed but abandoned soon after or been used at a disappointing low level (Yan, Guo, & Vogel, 2012). Our research thus aims to provide a comprehensive understanding of dynamic collaboration between specialized hospitals and general hospitals in teleconsultation. The paper proceeds as follows. The literature review briefly summarizes existing relevant research in teleconsultation. The next section presents the multi-dimensional conceptual framework, considering both previous theoretical foundations and current domain characteristics. The following section includes a deductive analysis to test propositions using data from comparative case studies. We then design a frequency diagram to reveal the overall situation as well as describe the respective distribution in organizational, environmental, and technological dimensions. Finally, theoretical and practical implications as well as discussion for future development are outlined. Literature review Teleconsultation Teleconsultation is conducted in a growing number of medical specialties, including cardiology, pathology, radiology, dermatology, orthopedics, otolaryngology, etc., the process of which can be synchronous or asynchronous. Synchronous service generally refers to real-time video-conferencing between specialists and general practitioners. Asynchronous service includes medical files exchange with store-and-forward technology. For instance, the electronic cardiology graph (ECG) of a patient is sent to a specialist through a particular system for consultation advice. Telemedicine has received attention from multiple disciplines: medical informatics, nursing, management, information systems, etc. It includes services, such as teleconsultation, remote medical education, remote surveillance, and so on. Prior research shows that, despite great expectations, the development of telemedicine systems and the adoption of telemedicine services have not achieved desired results. Among these, teleconsultation has been especially noticed for a low adoption and use rate (Al-Qirim, 2007; Obstfelder, Engeseth, & Rolf, 2007; Ruas & Assunçaõ, 2013). Some common obstacles, such as time intensive, expertise asymmetry, and poor image resolution, are reported as the barriers in clinical usage in previous literature (AlQirim, 2007; Olenik & Lehr, 2013). However, inconsistent findings in terms of effectiveness and efficiency are shown. Some studies conclude that teleconsultation is used for problem solving, but in actuality serves only as a tool for reassurance; however, others consider it with potential advantage for remote access, and communication could contribute beyond the reassurance utility itself (Bergmo, 1997; Braa, Hanseth, Heywood, Mohammed, & Shaw, 2007; Ekeland, Bowes, & Flottorp, 2010; Lamminen, Tuomi, Lamminen, & Uusitalo, 2000; Lehoux, Sicotte, Denis, Berg, & Lacroix, 2002; Sicotte & Lehoux, 2003). Therefore, a systematic and comprehensive model is called for in assessing teleconsultation service. Theoretical lens There is a plethora of research on IT adoption and usage, a research area which has become one of the richest streams in the IS field. The adoption process goes through the organizational


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application adoption decision, to the individual application adoption decision, and then to the post-adoption area (Jasperson, Carter, & Zmud, 2005). Considerable research has contributed to the pre-adoption and implementation of IT, as seen from both the organizational and individual perspective; however, the influential factors are distinct in different pre-adoption and postadoption contexts. For this reason, we need more specific understanding of post-adoption variance (Jasperson et al., 2005; Kane & Labianca, Articles in Advance; Zhu & Kraemer, 2005). Telemedicine research is still lacking in theoretical foundation. Based on the review in the telemedicine domain, articles with theories account for only 5% out of 1615 articles from 1990 to 2005 (Gammon, Johannessen, Sørensen, Wynn, & Whitten, 2008). Many of these studies adopt existing theories from multiple disciplines: theory of reasoned action (Ajzen & Fishbein, 1980) and technology acceptance model (Davis, 1989) are adapted to investigate general determinants of telemedicine adoption. Theories, such as the IS success model (DeLone & McLean, 1992) and the innovation diffusion model (Rogers, 1995), are adopted to examine diffusion of telemedicine on the organizational level. There is another stream of theories that shares the belief that science and technology are socially embedded to influence technology adoption and use, namely actor network theory (Latour, 1999), Giddens’ structuration theory (Giddens, 1984), institutional theory (Scott, 1995), etc. As stated earlier, though, there is still a dearth of theory that illuminates influential factors for teleconsultation collaboration in post-adoption phase. In addition to the individual level of adoption, there is a growing recognition and call for a “broader umbrella” of research that integrates organizational, technological, and other factors to gain a holistic understanding (Furneaux & Wade, 2011; Kauffman & Techatassanasoontorn, 2011; Monteiro, 2005). The Technology – Organization – Environment (TOE) framework (Tornatzky & Fleischer, 1990) has been proposed for understanding innovative IT use in different business contexts (Kuan & Chau, 2001; Lee & Shim, 2007; Zhu & Kraemer, 2005). However, the TOE framework provides only an overall scope, and is therefore not a welldefined theory for particular research issues. Further, individual theories may lack the breadth of variables in the TOE framework and its classification. Consistent with previous research that combines appropriate attributes to the TOE framework, we propose a multi-dimensional analytical framework (Table 1) in order to enrich the understanding in our specific context with solid theoretical attributes (Mishra, Konana, & Barua, 2007; Zhu, Wu, & Peng, 2003). Theoretical framework Proposing preliminary theories with propositions, such as “sufficient blueprint,” is an essential step for positivist case study research (Yin, 2008). Although there is a growing trend of studies with theories, there is no solid theory for teleconsultation. We adapt and extend the TOE framework with appropriate theoretical attributes and then develop a multi-dimensional analytical framework. This high-level framework is proposed not only for understanding the dynamic collaborative endeavors among participants, but also for exploring potential solutions for reaching mutual agreement by examining the internal and external influences of participants (Gregor, 2006). Consistent with the TOE framework (Tornatzky & Fleischer, 1990), the framework comprises three dimensions: organizational, environmental, and technological. Under this general umbrella, we further identify specific theoretical attributes below and integrate them into each of the dimensions. Organizational context In general, organizational context refers to resources and characteristics of the firm. Originating in resource dependency theory (RDT), the concept of resource refers to “anything perceived as valuable by an actor (i.e. an organization), such as information, material, capital, or access to

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Table 1. Multi-dimensional analytical framework. Dimension

Issues

Reference

Organizational

† Business capital and operation † Organizational management † Specialist’s resource

Tornatzky and Fleischer (1990) Sorensen (2003) Agarwal, Guodong, DesRoches, and Jha (2010) Feldman and Horan (2011) Tillquist, King, and Woo (2002)

† Geographical location † Teleconsultation demands and clinical situation


Environmental

Technological

† Government support † Regulations on responsibility † Regulations on security † Intangible benefit/altruistic motivation † Social obligation

Sorensen (2003) Tornatzky and Fleischer (1990) Sorensen (2003) Agarwal et al. (2010) Feldman and Horan (2011) Xue, Padman, Ramsey, and Spirtes (2008)

† Institutional pressure † Teleconsultation hardware equipment † Transmission quality † Technical support † Synchronicity needs for different teleconsultations

Tornatzky and Fleischer (1990) Sorensen (2003) Agarwal et al. (2010) Feldman and Horan (2011) Dennis, Fuller, and Valacich (2008)

markets, and dependency is a state in which one actor relies on the actions of another to achieve particular outcomes” (Pfeffer & Salancik, 1978; Ulrich & Barney, 1984). We adapt the definition to the teleconsultation context, including human resource (such as medical specialists), technological infrastructure development, related business capital (such as affordable expense on purchase and maintenance of teleconsultation systems), as well as the expected profit from teleconsultation. The interdependency issue in teleconsultation is reflected in collaboration among hospitals (Agarwal et al., 2010; Feldman & Horan, 2011; Sorensen, 2003; Tillquist et al., 2002). RDT points out that successful collaboration is built on the mutual assumption that the outcome of a relationship is greater than that which can be achieved by the individual party. In other words, the motivation for collaboration depends on the exclusive mutual benefit of two parties. The ultimate goal is to achieve collaborative agreement: a linkage between companies to jointly pursue a common goal (Pfeffer & Salancik, 1978; Tillquist et al., 2002). Thus, the key issue is to identify sustained motivation determinants of collaboration, and then assess governance dependency through coordination of activities between two organizations (Feldman & Horan, 2011; Hergert & Morris, 2002; Huxham & Vangen, 2000). Accordingly, the teleconsultation demands, the clinical situation, as well as management support are included into subdimensions of the conceptual framework. Particularly in the healthcare context, unbalanced distribution of specialists’ resource and geographic dispersion among prosperous and rural hospitals form the initial motivation for collaboration. The critical issue then falls to feasible and effective management among participants to form sustainable collaboration. According to the statement of Minister of Health, the Chinese Government constantly makes an effort to close the gap between the need for healthcare services and the capabilities of the current Chinese health insurance and delivery system. In particular, there is an emphasis on the cooperation among different healthcare sectors (Qiang, 1 July 2005). Teleconsultation service normally involves multiple stakeholders from different organizations, including


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administrative hospital managers, professional physicians, third-party players, etc. Normative management is necessary for balancing different interests and conflict agendas among stakeholders. Heterogeneity and contextual differences need to be identified and addressed (Mosse & Sahay, 2005). Successful teleconsultation collaboration cannot be established without the specific coordination among participants in matching the demand and supply through comprehensive procedures, including arranging time and location for video-conference, assigning duties for each party from preparation to completion, conducting quality assurance for the information exchange process and outcome, etc. For instance, the non-specialists should prepare all examination results required by specialists after they have agreed on certain teleconsultation cases; explicit regulations need to be set and followed by participants; specialists should give consultation result within certain time and format, etc. This leads to our first proposition: P1: When normative organizational management is established and enacted based on mutual interests among participants, teleconsultation service is facilitated.

Environmental context Environmental context refers to the macro-industrial structure of the investigated research context (Tornatzky & Fleischer, 1990). In the Chinese healthcare market, about 90% are public hospitals, and therefore the government plays a central role in regulating the healthcare market (Hew, 2006; IDC, 2009). The regulatory environment is focused in this dimension. Governmental regulations can be formulated into different purposes. Considering the impact on innovative IT adoption and use, both supportive regulations and coercive pressure are relevant (Park, Lee, & Yi, 2011). There are generally three major income sources in public hospitals: charges for medical services, profit from medicine sales, and government funding. Regulations on financial and political support are important for telemedicine adoption and use. Rural and community hospitals face the challenge of attracting enough patients and gaining profit, and thus they are not able to afford the expenses on the infrastructure for teleconsultation without financial and political support. Specialized hospitals can use the funds to expend their teleconsultation service by upgrading service center equipment, hiring IT and managerial professionals, generally benefitting and community hospitals, etc. Regulations as coercive pressure are necessary to supervise and adjust the market. By definition, coercive pressure for hospitals mainly arises from government regulations and policies (Gosain, 2004). Prosperous hospitals with extensive specialist resources and the most advanced medical infrastructure have the advantage in the healthcare market. They often lack incentives to form teleconsultation service collaboration with rural hospitals, especially if there is not a quick return on their investment plan. However, as public hospitals, they are under coercive pressure to embrace social obligation and balance between profit-based operations and public welfare. Administrators in rural and community hospitals are bound to ensure the facilitation of teleconsultation service. Thus, P2: When government provides regulation for financial and political support and enacts coercive pressure for establishing social obligation among participants, teleconsultation service is facilitated.

Technological context Decisions to adopt innovative IT depend on what technologies are available in the market, and how well they fit with a firm’s current technology in a cost-effective way (Xue et al., 2008). Features of technology, including existing and available ones, have been widely supported in


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previous literature, indicating that they have an important influence on the adoption and implementation of innovative IT in healthcare (England, Stewart, & Walker, 2000; Poon, Blumenthal, Jaggi, Honour, & Kausha, 2004; Rogers, 1995).Thus, we assess available IT in teleconsultation from the aspects of hardware equipment, transmission quality, and technical support. The available technologies in teleconsultation in China are summarized as follows: data transmission technology: telephones, GPRS-EDGE, 2G, 3G, digital subscriber line (DSL), integrated services digital network (ISDN), ATM, leased lines, and optical network; transmission media: content, voice, video-conferencing, 2D and 3D gray level and color images, and gray level and color videos; as well as terminals and instruments: televisions, personal computers, personal digital assistants (PDAs), and mobile phones (IDC, 2009). Media synchronicity theory (MST) expresses the mechanism of fit between technology features and the communication process. Media synchronicity is defined as a “state in which individuals are working together at the same time with a common focus” (Dennis et al., 2008). Two fundamental processes have been identified in MST: conveyance and convergence. The conveyance process is the “transmission of new information and the processing of that information by the receiver so he/she can create and/or modify his/her mental model of the situation,” while the convergence process is the “process of mutually agreeing on the meaning of the information.” The conveyance process suits communications with lower synchronicity due, in part, to high cognitive information process requests, whereas the convergence process fits with higher synchronicity because it focuses on the negotiating process with existing mutual understanding in the participants’ mental models. MST also points out that combined media, rather than single media, can be more suitable to achieving better communication performance. In teleconsultation, the adopted technology should fit with the communication process between collaborative hospitals. Synchronous service is suitable for complex situations which need more direct interaction and feedback with enough cognitive effort. Based on the theory, prior knowledge for mutual understanding is important, and thus general practitioners should prepare completed information of patients before real-time video consultations. In this way, the teleconsultation can focus on discussing and checking potential possibilities for diagnosis. In synchronous service, participants communicate via real-time video-conference systems in which instant and timely interaction is important. Sufficient transmission velocity, rich symbol sets, and multi-channels are needed in this convergence process. In contrast, insufficiencies, such as transatlantic echoes can cause problems and negatively affect ultimate outcomes. Asynchronous service with store-and-forward technology can be used for transmitting medical files. For specialties (such as cardiology, pathology, and radiology), the diagnosis can be done by examining medical images, for which real-time interaction is not necessary; however, accuracy and clarity of relevant medical files are required. Thus, P3: When the media synchronicity of the adopted technology matches the synchronicity that the communication process requires, teleconsultation service is facilitated.

Research design We conducted case studies guided by the theoretical framework to empirically test the propositions to explore the underlying dynamics of teleconsultation collaboration. As a comparison of sites would help to demonstrate the impact in different contexts (Zhu et al., 2003), we further applied a comparative case study design. Developed from the multi-dimensional framework, the interview questions covered key issues in technological, organizational, and environmental dimensions. Following the instructions of Yin (2008), we explicitly documented interview instruments, interview conditions and descriptions, and general guidance in our case study protocol. We also incorporated



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company brochures and relevant online materials as additional data sources. To access the organizational level of analysis, we selected hospital administrative managers associated with IT healthcare as our interviewees. The interviews were semi-structured with open-ended questions in order for participants to fully express their opinions. Each set of interviews lasted around one hour, the content of which was documented in text format. All in-person interviews were completed by one author for consistency of the interview strategy. The interviews were conducted and documented in Chinese, and translated into English after completion of the data collection. To avoid potential bias due to interviewer’s subjectiveness, all translations and analyses were conducted independently and cross-checked. Interviews were undertaken in Beijing, Shanghai, and Taiyuan from April 2011 to July 2011. The details on each case are discussed in the following sections. The three themes along with sub-themes were generated from the theoretical framework. We set up key words for each category and iteratively refined them during the data analysis. In addition to the frequency analysis to identify major factors, the explanation building strategy (Yin, 2008) was also adopted. Digging into the text to examine the logic was time consuming but critical to the accuracy of the results. Case background Previous literature has classified teleconsultation service into two types: point-to-point mode (P2P) and client/service (C/S) mode. P2P mode is an independent service between a specialized hospital and a general hospital. The C/S mode is a network structure composed of a center-based service provider and clients connected to a server. The Chinese healthcare system is distributed as the three-tiered structure: primary or first level refers to rural and community hospitals; leveltwo hospitals are city-level or medium-sized hospitals; third- or tertiary-level hospitals are national- or provincial-level hospitals with a rich resource of professional specialists. From our investigation, most teleconsultation services nowadays are conducted in a multi-layered structured network. For instance, a second-level hospital connects not only to some first-level hospitals, but also to some third-level hospitals, culminating as a three-layer structure for teleconsultation service. The fundamental difference is whether or not the teleconsultation service is outsourced to a third-party IT service provider. Applying the theoretical replication strategy (Pettigrew, 1989), we selected two comparable case settings: the third-party-operation service mode and the hospital-operation service mode. Each case included three levels of hospitals and was identical in the three dimensions of our theoretical framework. Case 1 represents the hospital-operation mode of teleconsultation service (Table 2). We selected a typical three-layer structural network and different levels of hospitals in each layer. The No. 2 Hospital of Taiyuan City (the capital city of Shanxi province) is a medium-sized hospital with roots in the middle layer of the three-layer structure. It connects up to the PLA General Hospital – a national-level hospital in Beijing, and links down to 30 district hospitals in counties around Taiyuan City. The PLA General Hospital was founded in 1953 with more than 150 clinical, medical, and technology departments. This specialized hospital housing many famous specialists is reputed to be one of the best general hospitals in China, and is ranked in the Top 3 by the Health Department of General Logistics Department in China. The teleconsultation between PLA General Hospital and No. 2 Hospital of Taiyuan City is through real-time videoconference between specialists and generalists for diagnosing complicated cases. The teleconsultation between community hospitals and No. 2 Hospital of Taiyuan City is non-real-time remote electronic cardiology graph (ECG). In Case 2, the three-layer structure selected is comparable to that of Case 1. The national level of hospital is Beijing Tiantan Hospital, the middle level is Fenyang People Hospital

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Table 2. Comparative case study design. Institution


Case 1

PLA General Hospital

No.2 Hospital of Taiyuan City Community Hospitals Case 2

Beijing Tiantan Hospital

Neusoft company (teleconsultation service center)

Fenyang People Hospital Shanxi Sunji hospital

Mode structure

Interviewee CEO

Director of IT department Director of Cardiology department Doctors and nurses Doctors and nurses CEO Doctors and nurses Doctors and nurses

Regional manager Sales manager IT department manager Project manager CEO Director of IT department Doctors and nurses CEO Doctors and nurses

located in Fenyang city in Shanxi province, and the county level is Shanxi Sunji hospital. The third IT service provider is Neusoft company and the consultation management center is located in Beijing Tiantan Hospital. All hospitals in Case 2 are subscribers of Neusoft company for its teleconsultation service. The Neusoft provides real-time interactive clinical consultation and non-real-time remote video consultation (remote diagnosis with medical experts reports based on patients’ image materials acquired from X-ray computed tomography (CT), magnetic resonance (MT), computed radiography (CR), and DR amongst others). Case analysis P1: When normative organizational management is established and enacted based on mutual interests among participants, teleconsultation service is facilitated.

Case 1 The No. 2 Hospital of Taiyuan City is a medium-sized hospital with a limited number of medical specialists. Administrators decided to attract more local patients through the teleconsultation


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service with specialists from the PLA General Hospital. For years, the PLA General Hospital has established teleconsultation services with different hospitals all over China, through which it provides professional consultations and training programs for its teleconsultation partners. The teleconsultation program not only brings in a considerable amount of revenue, but also promotes the “social image” among the public. In sum, both hospitals are motivated to use the teleconsultation service, as the two hospitals indicate: The CEO of No.2 Hospital of Taiyuan City: I hope we can get help on some difficult disease through teleconsultation from the PLA General Hospital. We have basic hardware equipment for doing distant video conference, so the expense is not a big deal for us. Also, we have complicated cases from time to time and our own doctors are not uncertain on diagnosing, so that we want to seek help from expertise in Beijing. The patient can be treated in our hospital instead transferred, and bring revenue for us. We also want to attract local patients to our hospital by their famous reputation.

(As reported) The PLA General Hospital: We have plenty of patients in our outpatient service, so that we don’t see teleconsultation mainly for profit, but for building our ‘social image’ more widely. In addition, by doing teleconsultation, lots of patients don’t need to travel long way to Beijing and our over-loaded inpatient situation can be alleviated.

Although both hospitals had initiatives to use teleconsultation services, the actual usage of real-time teleconsultation service was low. We then assessed their managerial support on teleconsultation separately in order to find the obstacles. In No. 2 Hospital of Taiyuan City, there is no designated department or person responsible for teleconsultation. Although the hospital has an information technology service department, it mainly deals with issues, such as health information systems, electronic medical record, etc. Doctors consider themselves to be professionals in medical issues, but not in managerial issues. Most doctors are busy treating patients and do not have extra time for organizing and managing teleconsultation services. However, running a teleconsultation service requires considerable coordination. Participants need to set up applications, search suitable expertise, and negotiate available times. Explicit regulations with sufficient details should be set and followed by participants. Therefore, the first gap in regard to managerial and organizational issues is the lack of specific support on the coordination. Another important aspect in this regard is the preparation process. General practitioners should prepare all examination required by specialists after they agree on certain teleconsultation cases; specialists need to provide consultation results within certain time and format. The complete procedure should be strictly followed by participants, but the No. 2 Hospital of Taiyuan City did not form a managerial procedure to ensure it. To conclude, in Case 1 the inconvenience of organizing and managing resources of participating hospitals leads to a resultant limited lack of collaboration, and ultimately hindered teleconsultation. Case 2 The specialists’ resource allocation, the demands and expectations on teleconsultation, as well as the affordability of teleconsultation of Case 2 are similar between the Shanxi Sunji hospital and Beijing Tiantan Hospital. However, in Case 2, there is a clinical consultation management center for teleconsultation service provided by Neusoft company. The management center establishes standard procedures, enacting the detailed cooperating scheme and system maintenance, as well as the training – all of which ensures that resources for participants in teleconsultation service will be leveraged to support mutual agreement on collaboration. The evidence of usage of teleconsultation shows a considerable number of success cases. (As reported) The Director of department of neurology in Beijing Tiantan Hospital:

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Z. Yan et al. Before the video conference for teleconsultation, the panel doctor of Sunji hospital has to uploaded patients’ CT scans and description of medical history record to the system as required. At the beginning, he also briefly summarizes them to me. Then I give him my consulting advice and explained to him as . . . .Although the patient has missed the best recover period, I also suggested him to start the rehabilitation program for patient as early as possible and told him to pay attention to . . .


An “in charge” doctor in Shan Sunji hospital: “Thanks to teleconsultation and the advice from Dr. Ma (from Beijing Tiantan hospital), we clarify and confirm the patient’s problem. The whole consultation proceeded thirty minutes, and the consulting report released later.” Comparing the two cases, the comprehensive and normative management in teleconsultation service is critical to the successful collaboration. P2: When government provides regulation for financial and political support and enacts coercive pressure for establishing social obligation among participants, teleconsultation service is facilitated.

All hospitals in our cases agreed that financial and political government support is critical to IT adoption in healthcare, including teleconsultation. Hospitals, especially rural ones, face considerable operational pressure. Therefore, financial support from the government facilitates the teleconsultation implementation and adoption process. Director of information technology department in Fenyang Hospital: Ever year, big amount of money need to spend on IT systems and service in our hospital. The local ministry of health department will fund some money for it; however, it only can cover a small portion of our expense. If we can get more funding, we may consider hire some people or form a team to do teleconsultation. I think the results would be better.

Director of Cardiology department in No. 2 Hospital in Taiyuan City: . . . as the early stage of launching the dynamic electronic cardiology program, we were facing lots of difficulties. For instance, most community hospitals do not have the ‘box’ for capture patient’s dynamic electrocardiograph and we need to equip each box per hospital. The total expense on equipment for thirty community hospitals is really a big amount and luckily we get the Taiyuan government support on this purchase. Otherwise, we may not launch this program in a short time at this scale.

The lack of specific laws for teleconsultation is another concern for hospitals. The potential risks of being involved in a dispute or being charged in a lawsuit can diminish participation initiatives in teleconsultation services. On the other hand, enacting standard regulations and laws can reduce ambiguities and loopholes. Thus, suitable regulations would facilitate teleconsultation service. Prosperous hospitals are generally equipped with advanced medical information systems and professional specialists, and attract large number of patients. Some of them are even overcrowded in clinical services. It is logical that they are lacking incentives to form teleconsultation service collaboration with rural hospitals. In this case, government can exert pressures to supervise and adjust the market. The hospitals are therefore under the coercive pressure to embrace social obligation and balance between profit-based operation and public welfare. Director of information technology department in Fenyang hospital: . . . Yes, we heard of ‘Facilitating Regulations on Telemedicine Regulation 1991’, but it is the regulation, not the law. We were once involved in a dispute. We gave consulting advice through teleconsultation, but the local doctor didn’t interpret correctly and made wrong treatment for patients. However, we still had responsibility for that . . .

Director of information technology department in No.2 Hospital in Taiyuan City: Our hospital has been selected as one of 10 pilot hospitals in western China in the national telemedicine project 2010, so we have the social obligation to invest and launch the teleconsultation project.


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To be honest, we consider teleconsultation as a social obligation or a way to establish our social image as the leading public hospital, but we do not have tangible benefit from it.


P3: When the media synchronicity of the adopted technology matches the synchronicity that the communication process requires, teleconsultation service is facilitated.

Based on previous summarization (Puentes, Bail, Wickramasinghe, & Naguib, 2007) and the current situation in China, the basic technology features in teleconsultation are summarized as follows. Data transmission technology: telephones, GPRS-EDGE, 2G, 3G, DSL, ISDN, ATM, leased lines, and optical network; transmission media: content, voice, video-conference, 2D and 3D gray level and color images, and gray level and color videos; terminals and instruments: televisions, personal computers, PDAs, and mobile phones. The available technology in teleconsultation in China can support communications with different synchronicity needs. Nevertheless, technology serves various functions in different departments in the medical domain. It is necessary to identify the characteristics based upon the nature of the specific medical department and then to analyze its synchronicity requirement.

Asynchronous case In Case 1, although the teleconsultation between the No. 2 Hospital of Taiyuan City and the PLA General Hospital was not well used, the particular consultation service in cardiology between the No. 2 Hospital of Taiyuan City and three community hospitals in Taiyuan was used extensively. Launched in 2009, the program already generated profit for both levels of hospitals. In addition, it brought social benefits for local patients and thus received government funds for extension. Director of cardiology department in No. 2 Hospital of Taiyuan City: Before launching the program, we formed a particular team to do the market research, from which we would like to know what situation in those community hospitals. The results showed that all community hospitals had equipped with the electrocardiogram machine and local doctors had capability to operate the machine and did the electrocardiogram for patients. However, many local doctors could not provide correct diagnosis and local patients were not trust with the community hospitals in turn...Since electrocardiogram is already a digital format and it is easy to be transmitted as long as they have computers connected to the internet . . .

This case shows that teleconsultation communication in cardiology can be done asynchronously when local hospitals have existing technology that can support this process. Consistent with the previous medical literature (Puentes et al., 2007), as well as findings from the pilot and main cases, departments (such as cardiology, pathology, and medical image) that require a high diagnostic level but a relatively low level of lab operation are suitable for asynchronous teleconsultation. Others, such as the dermatology, ophthalmology, etc., which need more direct interaction between physicians and patients, have difficulty giving complete consultations at different geographical locations. Teleconsultation could be considered as supplementary assistance or could serve as follow-up consultation service.

Synchronous case One of the critical factors in synchronous teleconsultation is the prerequisite of existing mutual knowledge for both participants. More specifically, generalists should prepare sufficient patient medical documents, such as symptom descriptions, test reports, medical histories, etc., and send them to specialists before the teleconsultation. Additionally, generalists should have enough medical knowledge to digest the consultation given by specialists. In our investigation, many

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synchronous teleconsultations were hindered due to the lack of prerequisite understanding and the unmatched communication process with medical diagnosing requests. On the other hand, more efficient cases with better result diagnoses occurred if sufficient managerial and operational procedures as well as regulations were applied to both participants in teleconsultation. This is indicative of the comparative examples in the two cases: Case 1. Director of information technology department in No. 2 Hospital of Taiyuan City:


The time is very limited in teleconsultation, but quite amount of it is wasted by asking and exchanging medical reports. Sometimes, we provide consultations based on potential symptoms that patients may encounter to, such as if . . . , then . . . ; else if . . . , then . . . unfortunately the doctors in the village hospital seems do not understand the instructions and cannot treat local patients correctly.

Case 2. Neusoft regional manager: We have formal procedures for interactive teleconsultation. For instance, the generalist (requesting party) needs to prepare complete test results and ancillary reports which approved by the specialist (supplying party) before the video conference. We also have strict time arrangement schedule and step-by-step procedures from start to end. To ensure the service quality, we also set up strict deadline to hand in diagnosing report with signatures to our system . . .

To provide an overall understanding, we systematically analyzed the data source. Guided by the theoretical framework, we set up key words for each category in each of the three dimensions and iteratively refined them by the explanation building strategy (Yin 2008). Unlike quantitative data analysis, narrative interview data are much richer and flexible in meaning; thus, solely using automatic computer-aided analysis does not adequately reflect a complete picture. Accordingly, apart from counting common key words, we also examined the interview documents literally to match the concept with identical meaning to suitable category. For instance, apart from “government,” “government funds,” and “regulation,” terms, such as “health reform” or “law,” were added to the government support under the environment scheme during the review process. Figure 1 provides additional detail. The frequency is measured by the times that certain concepts were mentioned in the interviews. The more often a topic is brought up, the more likely that it will be associated with some conflicts or concerns. Combined with the text, we can further ascertain the cause of certain problems or the area in need of help. In general, the antecedents

Figure 1. Concept Distribution in interviews.



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of low utility are generated by various aspects across all three dimensions. In the organizational dimension, consistent with our analysis, quite a high number of primary- and second-level hospitals are struggling with the financial deficiencies and lack investment funds for teleconsultation systems. Managerial issues are paramount, and more effort needs to be put into solving these. Geographical location and specialist resource are mentioned often, representing the fundamental gap between prosperous hospitals and rural hospitals. In the external environment, financial funds are critical for the setup phase as well as sustainable development of teleconsultation service. Hospitals in all tiers claim the importance of government support. In the technological dimension, different departments of hospitals have different means of carrying out consultations, and the teleconsultation approach should fit with the communication requirement. In the cases in cardiology, pathology, radiology, and other asynchronous teleconsultation, high quality of document transference is of utmost importance. Synchronous teleconsultation, one the other hand, requires consistent and reliable Internet access as well as a platform with supplemental features that support document exchange and other interaction tools. Conclusion and implications This paper presents a multi-dimensional conceptual framework not only to understand dynamic teleconsultation among distant participants in order to understand the antecedences of actual usage in post-adoption of teleconsultation service, but also to provide reasons for actual low usage in clinical practice. Theoretically, this study extends the TOE framework together with RDT, institutional pressure, and MST to aid in understanding collaboration dynamics in teleconsultation. This could serve as a basis for developing theory on how technology and organizational factors affect healthcare outcomes in a virtual process. Practically, our propositions provide suggestions to develop and maintain long-term collaboration among hospitals. Special management should be established based on mutual benefit among different stakeholders to achieve sustainable collaboration. Central and local government need to consistently put in effort to provide not only financial support, but also laws and regulations to facilitate the development of teleconsultation service. Appropriate technology (in terms of media synchronicity) should be provided to facilitate teleconsultation communication processes. In addition, the issues from the framework and the frequency diagram can assist practitioners to prevent or alleviate low utility problems or help design strategic business and managerial plans for teleconsultation service. The view of future teleconsultation service can be inferred as a well-circulated ecosystem. With the help of specialists through teleconsultation service, rural and community hospitals can increase their proficiency and achieve better clinical performance. Local physicians can learn from experts, gaining more practical experience in order to improve their professional skills. Seen from the organizational level, the first and second level of hospitals can attract more patients, while tertiary hospitals no longer need to be overwhelmed with non-essential outpatients and can focus on treating difficult cases. We hope our research can help hospital administrators and other decision-makers identify and resolve current barriers and propose strategies for better and long-term development of teleconsultation service. There are, of course, limitations in the current study, given its explorative nature. Although cases are strategically selected with detailed background information provided, there is still a need for more empirical investigation to generalize the research findings. In the future, we plan to conduct more case studies to collect data from hospitals with different economic and cultural backgrounds. Further research could also examine how to accommodate resources and policy (identified in our propositions) to encourage continued long-term teleconsultation collaboration.

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Acknowledgement The authors are also grateful to Dr Stella Tian, Mr Xinyang Wang, and Dr Xiaoming Yang for their help on data collection.


Funding This study was partially funded by NSFC 71101037, NCET-12-0146 and the “Hong Kong Scholars Program.” Supplemental data Supplemental data for this article can be accessed http://dx.doi.org/10.1080/02681102. 2013.854730.

Notes on contributors Miss Ziyu Yan is currently a Ph.D. student in the Information Systems Department, City University of Hong Kong. She attained her degree of Master of Science in Electronic Commerce at the City University of Hong Kong. Miss Ziyu Yan is a current member of the SIG-Health Group and her research interest is in IT-related healthcare issues. Her works have been published in conference and workshop proceedings, such as the Americas Conference on Information Systems, Pacific Asia Conference on Information Systems, and China Summer Workshop on Information Management. Dr. Xitong Guo is an Associate Professor of Management Science and Engineering at the Harbin Institute of Technology. He received his Ph.D. in Information Systems at the City University of Hong Kong and Ph.D. in Management Science at the University of Science and Technology of China. His current research focuses on e-Health, collaborative process management, IT-enabled innovation, and social computing. His work has been published or accepted in referred journals and conference proceedings, such as Journal of Management Information Systems, Decision Support Systems, Electronic Commerce Research and Applications, and the International Conference on Information Systems. Douglas R. Vogel is Professor of Information Systems and is an Association for Information Systems (AIS) Fellow as well as AIS President. He received his Ph.D. in Information Systems from the University of Minnesota in 1986. Professor Vogel has published widely and directed extensive research on group support systems, knowledge management, and technology support for education. He has recently been recognized as the most cited IS author in Asia-Pacific. He is currently engaged in introducing mobile devices and virtual world support for collaborative applications in educational and health systems. Additional detail can be found at http://www.is.cityu.edu.hk/staff/isdoug/cv/.

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