Novel Strategies in Greek Health Service-the Influence of Networking

Introduction

The adoption and use of internet has allowed the Greek Health sector to innovate unique and novel strategies in developing their business plan. The change in the socio-demographic patterns and shortage in healthcare manpower has increased the need to adopt information technology. Internet provides an opportunity to “fundamentally reinvent medicine and health care delivery” (Coile, 2000, p.8). Internet has transformed both the medicinal practice as well as the business side of the healthcare industry. Studies show that healthcare is a high transaction cost based industry and the use of internet is expected to reduce the cost of transactions considerably (Coile, 2000). The healthcare industry is said to be lagging behind in the adoption of information technology based communication (Landro, 2001) and thus need to adopt this technology to benefit its functions. This essay is a proposal for the final paper which will deal with the strategies for adoption of internet in the Greek healthcare service industry.

Aim and Objective

There are various needs for the adoption of internet to facilitate business operations which are also applicable to introduction of internet in healthcare. Ritter and Walker showed that there are various strategic decisions that need to be taken in order to implement an internet based business (Ritter & Walker, 1999). So it is imperative to understand as to what situations which need to be considered while adopting a business strategy around the use of information technology or internet. According to Ritter (1999), there are five factors which influence the adoption of internet on which previous research has been conducted. First is the factors related to corporate strategy like long term planning, market segmentation, distribution channels, etc. second is the related to characteristics of the executive and their qualification. The third factor is the nature of the company and its inclination to innovate or risk taking attitude, etc. fourth factor is related to the character of external environment which affects the company’s operations like technology or competition. The fifth factor is related to the usage of internet as an innovative resource wherein it allows strategic business innovation.

In case of healthcare, the industry has an extensive use of data transaction and transfer (Coile, 2000) which will definitely be facilitated by use of internet. This enhances the usage on internet in the industry for even for the basic requirements. One such example will be patients trying to find out the latest availability if scientific treatment of a particular ailment, which can easily be downloaded from the internet instead of the customer contacting the healthcare facility for the information. In the proposed paper, I will demonstrate the factors which affect the decisions of adoption of internet in healthcare service in Greece.

So we come to the following objectives for the adoption of internet. the first aim of the proposed paper will be to try to understand the characteristics of the internet as an innovation and the how the internet’s relative advantage, compatibility, triability, and complexity affect the decision to or not to adopt the internet in the Greek healthcare services. Then as a second objective, the proposed paper will try to ascertain the relation between the adoption of internet and usage on the performance of the healthcare service. And the third objective will be to determine the areas of adoption of the internet trade where the electronic trade will facilitate business, i.e. to determine the areas where internet will facilitate the healthcare business and its operations.

Given these aims of the proposed paper, I will now provide a brief literature review of the research area which will be enhanced in the final paper.

Literature Review

Here I will discuss previous researches which have been conducted in the area and their view regarding the issue of adoption of internet to facilitate business operations.

Then we will demonstrate the healthcare sector’s experience with the internet.

Natesan (2005) found that internet affects six areas of the healthcare service which are “web enabling of medical records, web enabling of clinical computing systems, web enabling of medical information for health care providers, web enabling of medical information for the public, evaluation and accreditation of public health care websites and privacy issues on the web” (Natesan, 2005, p.247). He pointed out six areas which need to be looked for the adoption of internet. First is to enable medical records of a patient which assumes critical information for the development of this will help in driving down medical errors wherein centrally stored medical records can be accessed by all practitioners. The second area which will be helpful with internet is clinical information delivery like medical literature searching or medication delivery. The third usage will be enable medical information to be published of general public to access. But Natesan also believes that internet may cause problems for information validity and delicacy. But in the end, he concludes that even though the information theft is a major issue that is faced by healthcare services, the advantages of using internet are far greater than their disadvantages.

Coye, Jacks, Everett, and Akay (2001) studied the physician leaders and office-based practicing physicians regarding their use and facilities they were deriving from using internet in their administrative and clinical systems. Their aim was to study understand the medical practitioner’s use of internet and the barriers or promoters of technology adoption in healthcare services. According to their survey, more than 85 percent of the respondents were using internet enabled services and 35 of the respondents reported to use more than 5 internet enabled services. These services included both business and clinical applications. The reasons for adoption of the internet enabled services was clear from their survey were “reduced administrative costs, faster payments, and improved quality of care are the most important benefits derived from Internet-enabled applications” (Coye et al, 2001, p.67). 96 percent of the respondents expected internet to have positive impact of the business and clinical practice of the healthcare services. The research identified a few barriers to the adoption of internet which are “lack of industry wide standards for health information and the inability of current computer systems to exchange information across health care delivery networks” (Coye et al, 2001, p.67). The research was based on quantitative survey method. The sample was randomly selected from American Medical Association Group Practice File and the Physicians List. They surveyed a total of 215 practitioners and an online survey was conducted. They were asked questions regarding their internet usage, benefits of internet adoption, and barriers to the process of adoption, and organizational strategies which will enable adoption of the internet. The outcome of the survey show that the practitioners widely think that internet is a good option for it will ease away the “Existing paper-based systems frustrate both patients and physicians because they require complex administrative tasks and commonly result in incomplete or lost medical records.” (Coye et al, 2001, p.74). They believe that their study shows that usage on internet in the healthcare services should be a concern for the planner sand believes those who are not yet using it are not exploiting the opportunities the technology holds.

Diamond and Shirky argue that information technology (IT) adoption in healthcare services will not be facilitated by the assuming that IT will act as a “magical thinking” and will solve all the problems of healthcare services. (Diamond & Shirky, 2008). They believe this is one of the biggest barriers in adoption of IT in healthcare services. According to the authors all the stress on formulating policies for IT adoption, healthcare services have neglected the requirement to remove other barriers. So they suggest, “…it would require clear policy statements that will guide the design of technology” (Diamond & Shirky, 2008, p.389).

Frank (2000) believes that internet has the potential to result in substantial positive impact on medical care which will enable fastest possible medical care. He divides the internet based health care companies into three business categories: “content, connectivity and commerce” (Frank, 2000, p.8). The companies who provide these services try to capture various sections in the healthcare industry. Frank provides a list of benefits from the point of view of the medical consumers (i.e. the patients) which are “(1) Disseminate information, (2) Aid informed decision making, (3) Promote health, (4) Provide a means for information exchange and support—the community concept, and (5) Increase self-care and manage demand for health services, lowering direct medical costs” (Frank, 2000, pp.15-16). Frank is convinced that adoption of internet in health care functions will definitely help the industry both through increased business and through easier and correct diagnosis. This will also reduce the gap between the medical practitioner and the patient (Frank, 2000).

Bernstein, McCreless and Côté (2007) discusses five constraints which they feel affect the proper implementation of IT in healthcare service. They are “(1) budget, (2) supportive leadership, (3) project management, (4) implementation, and (5) end user involvement.” (Bernstein et al, 2007, p.17). The authors believe that these are the main constants for all healthcare company to check before implementing an internet based business strategy.

Kleinke (2000) argue that the internet will not drive the structural cost down, but rather raise them up. He does a case study analysis of the Vaporware.com to provide a study of the failed case of internet and IT utilization in the healthcare sector in the United States. He believes the adoption problems of IT are mostly economic, cultural, legal, regulatory, and organizational (Kleinke, 2000). The author argues that in medical diagnosis, there are various aspects which need to be considered and there cannot be a thumb rule for a particular case. So he states:

“As every practicing physician knows (or should know), when the survival of a human being is the “work product,” an information system that is not 100 percent reliable is 0 percent useful. This hard, unalterable fact has made building usable closed clinical IT systems extremely difficult. This same fact will make building a usable clinical IT system out of the slew of emerging “open” technologies—collectively described as “Internet-based computing”—next to impossible.” (Kleinke, 2000, p.64)

But the author does not neglect the benefits that internet provides to the customers as well as to healthcare business: “The Internet provides the first feasible way of transforming large data sets into provider and health plan performance information for consumer use.” (Kleinke, 2000, p.66) But the author argues against the popular notion that internet based business will drive down healthcare cost for he believes that customers are highly sensitive in regards to their health and they tend to choose the product which is prices higher than the others due to a perception of better quality than those which are low priced (Kleinke, 2000).

Eysenbach (2000) has shown that internet has become a platform of interaction between the doctor and the patient. He uses a non-exhaustive review focus on the topic to understand the impact of IT on healthcare. He searched Medline for the terms “consumer” and “informatics” and other sources like the American Medical Informatics Association’s symposiums for 1998 and 1999 and the proceedings of the ninth World Congress on Medical Informatics of 1998 and AltaVista search engine (Eysenbach, 2000). He found that there are certain areas of research which has been done on the area which showed the following success of IT in transforming the traditional healthcare service: (1) “Health care in the information age” (p. 1713), (2) “Bringing medical knowledge to consumers” (p. 1714), (3) “Electronic health records accessible to patients” (p. 1715), (4) “Decision aids to support consumers’ choices” (p. 1716), and (5) “Quality control of health information on the internet” (p. 1718). Thus, he believes that information system has the potential to bridge the knowledge gap between the patients and the doctors. This view has been shared by other researchers who feel that healthcare will transform the business aspects of healthcare services (Goldsmith, 2000). Apart from bridging the gap of knowledge transfer from doctor to patient, internet is thought to be helpful in licensing, long distance monitoring, and e-pharmacy (Goldsmith, 2000). But unlike Kleinke (2000), Goldsmith believes that technology’s impact on healthcare cost will be neutral (2000).

From the literature review, it is apparent that there are various issues that have been discussed regarding the adoption barriers of internet and the benefits of the technology. There are studies which have tried to ascertain the performance benefits that the internet has helped healthcare service to gain. There are gaps in beliefs and findings of different researchers regarding the cost reduction effect of internet on healthcare. Further, there are various strategies that the healthcare services have adopted in utilizing the internet and technology to benefit their operations. But there is not substantial research which will provide the comprehensive understanding of the whole situation.

Research Questions

Given the literature review and the gap in the present literature on healthcare services’ adoption of internet, I propose to work on the following questions. The literature suggests that internet adoption has certain barriers but the range of barriers differ from research to research (Bernstein et al, 2007). There are various constraints which cause hindrance in the adoption of internet as an innovation in healthcare services due to various reasons. In the proposed paper, I will try to ascertain the barriers which are the sector faces for adoption of internet. So the first question is regarding the barriers to the adoption of internet in the healthcare service.

Then it is important to understand the strategies wherein internet can be used innovatively. Internet is said to help in making consumers make the right choice (Eysenbach, 2000). Natesan (2005) identified six areas wherein application of internet has helped in the operations. But there may be more innovative areas where use of internet will improve the situation considerably. Internet also helps in business operations like licensing, etc. easier. Thus, it must be seen as to what are the novel areas where internet is being applied and used. This question will deal with the ways and means of applying internet as a technological aid to the development of the business and clinical operations in healthcare service. So the second question is related to the application of internet in healthcare services.

There is a gap in the understanding regarding the performance benefit of internet and the cost effect it has. Some researchers believe that internet will effectively increase the cost of healthcare (Kleinke, 2000) some believe that they reduce the cost (Frank, 2000) while others believe that its effect is neutral (Goldsmith, 2000). This implies that the effect of internet on the performance of the healthcare service and the cost reduction effect are widely debated upon in the literature. So I will try to find out the performance and cost effect of the usage on internet in the Greek healthcare service.

So the proposed research questions are:

1. What are the barriers or hindrances in adopting internet as an innovation?
2. Where can internet be used to the healthcare services operations in order to get optimum performance?
3. What is the performance benefit of the usage of internet? Are there any cost benefits that can be received from adoption of internet?

Ethical Considerations

As the study of the internet adoption in healthcare is closely related to the sector’s business and clinical strategy, it is imperative that the information must be kept guarded closely which is not desired to be made public. As there are various areas that go unnoticed, the ethics committee will be responsible to review the method and the information. Further, no information will be provided in the proposed paper which has not been gained from an authentic source.

Research Methodology

A research methodology is an important part for establishing how a research can be conducted. A research methodology is a plan as to how a study should be conducted. There are various research methodologies which are in use. First is quantitative, qualitative or combined research method can be used. In this section I will discuss and disadvantages of using the before mentioned research methodologies and finally will justify the research methodology I choose for the proposed paper.

Quantitative Research Methodology

A quantitative research method may be defined as the process of collecting numeric data and using that data to show what those, observations reflect (Babbie, 1992). The one of the important factors of quantitative research methodology is data collection which is done through various processes such as interviews, questionnaire surveys, tests/measures, and observations (Easterby-Smith et al, 1991). Questionnaires have been used as a survey method for data collection in the research of internet adoption in healthcare was done by Coye, Jacks, Everett, and Akay (2001).

Types of Quantitative Research

Quantitative research is of different types. First is descriptive research. A descriptive research approach provides an exact portrayal of the account of the characteristics of an individual or a group’s (Burns & Grove, 2005). This is usually used to:

• discover something through the research,
• providing description,
• determining the number of times something occurs,
• categorizing information (Burns & Grove, 2005).

A descriptive study is conducted when there exist little information regarding the observable fact. This research method often uses questionnaires, psychological measurements to describe a situation.

Correlation research is based on the methodical examination of relationship between two or more variables which has been identified through secondary research. The relationship can be positive or negative and the degree of strength of the relationship can be determined through this process. But they fail to determine cause and effect. They are used when the nature of the relationship has to be determined.

Quasi-experimental research is conducted when it is important to identify a relationship, examine the significance, clarify why, and/or combine these of a causal relationship (Burns & Grove, 2005). They are usually used to see the effect of medical intervention in the patient’s outcome (Burns & Grove, 2005).

Experimental research is an “objective, systematic, controlled investigation” in order to predict and control an occurrence (Burns & Grove, 2005, p.27). This is a method used for the study of the causality. These researches have highly controlled settings as in laboratory.

Advantages and Disadvantage

Now I will discuss a few advantages and disadvantage of quantitative research. Quantitative method is widely used for its objectiveness. Quantitative methods are systematic and are based on positive perspective. Further, quantitative research is replicable as it is possible to collect the same data in another situation or place and get some other outcome which can be compared. But quantitative research methodology has been criticised for its positivism (Tashakkori & Teddlie, 1998). Further arose a question of internal and external validity which was thought to be not present in the quantitative method by some psychologists. Further quantitative method has been criticised for being limited to hypothesis testing. Further it is also called a simplistic process wherein data related to the research question are gathered which are then analysed with little concern for the historical background of the situation (Grbich, 1999). Further as quantitative analysis are related to “cause, effect and objectivity” they fail to be an appropriate method of research for events which are dynamic (Grbich, 1999). This shows that the quantitative method is not a full proof method for acceptance.

Qualitative Research

Qualitative research is described as alpha numeric examination of the observations with the aim to discover the hidden meaning beneath it and a pattern of relationship, if any (Burns & Grove, 2005).

Types of Qualitative research

First is the phenomenological research which is the process of studying the event to describe the experience as lived by the participants of the study and in interpreted by the researcher. As the study is based on humanistic experiences, there is no singular experience common to all, on the contrary there are various experiences, each distinct for different human beings (Burns & Grove, 2005, p.27). It is a complex research process as it is lived by the researcher and participant.

Grounded theory is a process of inductive research which is used to discover the problems exists in a social scene and how persons handle them. The methodology emphasizes the use of “observations and intuitive relationships among variables” (Burns & Grove, 2005, p.27).

Ethnographic research method has been developed from the field of anthropology and is used to understand cultures. It is mostly used to determine the character of the cultures or subgroups and analyze their behaviour.

Historical research is a process of narrating the different aspects of an incidents and describing the process and the event which has occurred in the past. Data is collected from the “records, artefacts, or verbal aspects” (Burns & Grove, 2005, p.27). This is used to study the past, the mistakes, or the rights of the past events and the reasons or the success or failure of the event can be recorded.

Advantages and Disadvantage

Qualitative study is said to be more dynamic and suitable for studies which are occurring and are still in the process of change. They are useful in order to understand the reason for the development of the theory from the present understanding or studying prior historical data. But the advantages of the method are that they fail to be objective and are difficult to be replicated. So generalization is difficult in a qualitative research method. Qualitative researches are also known as constructivist approach refuse positivism (Johnson & Onwuegbuzie, 2004). Further these researches are value bounded and it is very difficult to differentiate between cause and effect. Johnson & Onwuegbuzie (2004) further identifies that qualitative research encompases a “a dislike of a detached and passive style of writing, preferring, instead, detailed, rich, and thick (empathic) description, written directly and somewhat informally” (p. 14). Thus there exists extensive literature on the differnce between quaniltative and quantitative research methods.

Combined Method

There exists extensive debate regardig the validatdity and supremacy fo one of the research method (Tashakkori & Teddlie, 1998) but it has again been criticised by scholars who believe that the two metthodologies are compatible (Johnson & Onwuegbuzie, 2004; Casebeer & Verhoef, 1997). So these group of scholars believe that even thoguh the two paradigms are different, there lies certain elements of similarities which can provide fruitful research: “The goal of mixed methods research is not to replace either of these approaches but rather to draw from the strengths and minimize the weaknesses of both in single research studies and across studies.” (Johnson & Onwuegbuzie, 2004, p.15).

This methodology is identified throguh the use of both the qualitative and wiantitative methodologies. This emthod identifies the similarities in the traditional methodologies which has been used. According to Casebeer & Verhoef “Careful review of the full spectrum of both major research paradigms will confirm that both methods can be used in less “usual” ways, i.e. it is possible to quantitatively describe observable events in the real world and to collect qualitative evidence within pre-specified, experimental situations.” (Casebeer & Verhoef, 1997).

This method has gained acceptance in various research fields. Sociologists and nursing researches widely use this methodology. As has been suggested by Corner, “the use of different research methods within a single study can provide a richer and deeper understanding of the area under investigation than would otherwise be possible” (cited in Casebeer & Verhoef, 1997). Recently medical research has also started using both the metraditional methods together (Casebeer & Verhoef, 1997).

Types of Combined Methods

Combined methods are divided into five catagories (Tashakkori & Teddlie, 1998). First is the Triangulation technique. This the method of using more than one type of quantitative method. This process is further divided into four parts:

1. data triangulation,
2. investigator triangulation,
3. theory triangulation,
4. methodological traingualtion (Tashakkori & Teddlie, 1998).

It is the methodological triangualtion that uses both quantitatibe and qualitative method. Then there is monomethod studies which uses only one type of research emthod.

Then there si the mixed model research method which is defined as the “studies that are products of the pragmatist paradigm and that combine the qualitative and quantitative approaches within different phases of the research process.” (Tashakkori & Teddlie, 1998, p.19). these are further divided into sequential study, parallel/simultaneous studies, equivalent studies and dominant-less studies (Tashakkori & Teddlie, 1998).

Advantages and Disadvantages

As the mixed research model is evolved through the disadvantages of quantitative and qualitative research method, it is important to understand the various areas where in the method can be applied. Further it is important to understand the areas wherein the two traditional methods will be applied to reap full benefit of their combinations. A mixed research method comprises of the following steps:

1. determine the research question;
2. determine whether a mixed design is appropriate;
3. select the mixed method or mixed-model research design;
4. collect the data;
5. analyze the data;
6. interpret the data;
7. legitimate the data;
8. draw conclusions (if warranted) and write the final report.” (Johnson & Onwuegbuzie, 2004, p.21)

Proposed Methodology

Given the extensive discussion on the three different kinds of methods of conducting research, it is important to understand which method will be useful for the proposed research. The research methodology that I propose to use is a mixed research methodology. In the following section, I will enumerate the reasons behind my choice of methodology wherein I will use a case study approach to study approach to determine the problem.

Information system research methodology has been dominated by mixed strategy wherein case study approach has been extensively used (Benbasat et al, 1987). Qualitative research methods have been used extensively used in studying the study of adoption of internet in healthcare where mostly the scholars have provided their analysis of the situation as they have seen through their experience or through interviews or secondary research. Very little research has been done on the area of internet adoption in healthcare which will help in analyzing the situation objectively.

I propose to do a mix of qualitative and quantitative research. In the qualitative research section, I will follow the historic data of the healthcare services and try to determine the areas where the internet has been adopted and the existing usages of internet in the Healthcare services in Greece. In this part, I will do an extensive secondary research on the healthcare industry of Greece, try to ascertain the benefits that healthcare has achieved through internet and then do constructive interviews to ascertain the complete picture. The interviews will be based on one organization were I will conduct my quantitative study. This organization will be my case study for the proposed paper.

From the qualitative research, I will gain adequate information regarding the organization’s present adoption status of internet and the barriers to it. The quantitative research section will follow a questionnaire survey in the designated organization or sector. The survey will be directed to understand the profile of the respondents, the usage of internet for them and the internet services which they are presently using. The next section of the questionnaire will discuss the benefits that the sector has gained from the usage of internet. The perceived benefits of internet usage have to be captured through the questionnaire. Then the questionnaire will discuss the barriers which the sector faced in adopting the internet for its business and clinical purposes.

The survey result will be evaluated through factor analysis of the data collected. Here it must be kept in mind that barriers or usage of internet may be enhanced not only due to organizational factors but also due to individual factors. This has to be kept in mind while working on the questionnaire. The questionnaire will also evaluate the adopter’s decision and the criteria for choosing internet as an innovation. The business and clinical benefits that the internet can provide to the sectors will be asked in the questionnaire.

Further in order to determine the performance growth with the use and adoption of internet has to be correlated to the degree of usage of internet to the operational, financial, and performance success of the sector. This can be done through the data on internet usage and the perceived level of adoption to the financial performance over the years of adoption, number of patients treated, cost aspects, etc. can be correlated which will provide the level of acceptance of the internet and the success of using it. This can be validated through the study of the perceived benefits of the internet of the respondents with that of the financial and operational data. This process is important to be done in order to understand the performance benefit of the internet adoption in the Greek healthcare sector.

Conclusion

Why both the qualitative and quantitative research methods are proposed to be used in the research process? The reason is due to the use of qualitative tool in the information system research in the literature is rich and has been validated as one of the most accepted tool (Benbasat et al, 1987). Further, quantitative research is a well accepted methodology for measuring the benefits and barriers of internet adoption (Coye et al, 2001). This is so because it provides the objectivity and positivism that the research method presents. The combination of the two methodologies will be used to identify the factors which are the benefits, barriers, and usage of internet and quantitative method will validate the factors that we draw from the qualitative research.

This research method is apt for the proposed study, as it will provide a case of the healthcare industry with a micro-view on a particular company. The case study analysis will provide the background and the details of the process of internet adoption and the usage in the organization, while the quantitative analysis will provide the objective view of the benefit of using the internet and the usage wherein they are put to. This will validate the findings of the qualitative research.

Reference

Babbie, E., 1992. The practice of social research 6th ed. Belmont: CA: Wadsworth Publishing Company.

Benbasat, I., Goldstein, D.K. & Mead, M., 1987. The Case Research Strategy in Studies of Information Systems. MIS Quarterly, p. 369-387.

Bernstein, M.L., McCreless, T. & Côté, M., 2007. Five Constants of Information Technology Adoption in Healthcare., Hospital Topics Vol. 85 no. 1, p. 17-25.

Burns, N. & Grove, S.K., 2005. The practice of nursing research. St. Louis, Missouri: Elsevier Health Sciences.

Casebeer, A.L. & Verhoef, M.J., 1997. Combining Qualitative and Quantitative Research Methods: Considering the Possibilities for Enhancing the Study of Chronic Diseases. [Online]. Web.

Coile, R.C.J., 2000. The Digital Transformation of Health Care., The Physician Executive, p. 8-14.

Coye, M.J., Jacks, G., Everett, W.E. & Akay, L., 2001. Medical Group Adoption of Internet Services., Journal of Ambulatory Care Manage 24(4), p. 67–75.

Diamond, C.C. & Shirky, C., 2008. Health Information Technology: A FewYears Of Magical Thinking?, Health Affairs vol. 27 no. 5, p. 383-90.

Easterby-Smith, M., Thorpe, R. & Lowe, A., 1991. Management Research: An Introduction. London: Sage Publications.

Eysenbach, G., 2000. Recent advances: Consumer health informatics., British Medical Journal vol. 320, p. 1713-1716.

Frank, S.R., 2000. Digital Health Care—The Convergence of Health Care and the Internet., Journal of Ambulatory Care Manage 23(2), p. 8–17.

Goldsmith, J., 2000. HowWill The Internet Change Our Health System?, Health Affairs vol. 19 No. 1, p. 148-57.

Grbich, C., 1999. Qualitative Research in Health. London: SAGE.

Johnson, R.B. & Onwuegbuzie, A.J., 2004. Mixed Methods Research: A Research Paradigm Whose Time Has Come., Educational Researcher Vol. 33 No. 7 , p. 14–26.

Kleinke, J., 2000. Vaporware.com: The Failed Promise Of The Health Care Internet., Health Affairs, p. 57-71.

Landro, L., 2001. What’s Ahead for Healthcare. The Wall Street Journal, p.R14.

Natesan, D.C.N., 2005. The Impact of the Internet on Health Care Services., The Journal of American Academy of Business Vol. 7 No. 2, p. 247-53.

Ritter, T. & Walker, J., 1999. Are you ready for business on the internet?, Business Communications Review Vol. 29, p. 26-31.

Tashakkori, A. & Teddlie, C., 1998. Mixed Methodology. London: SAGE.