Hospital Websites: From the Information Repository to Interactive Channel

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eCENTERIS - International Conference on ENTERprise Information Systems / ProjMAN eCENTERIS - International Conference on ENTERprise / ProjMAN International Conference on Project MANagement / HCist - Information InternationalSystems Conference on Health International Conference on Project / HCistand - International Conference on Health and Social Care MANagement Information Systems Technologies and Social Care Information Systems and Technologies

Hospital Websites: From the Information Repository to Interactive Hospital Websites: From the Information Repository to Interactive Channel Channel Mirjana Pejić Bacha,a,*, Sanja Seljanbb, Božidar Jakovićaa, Ante Buljanaa, Jovana Zorojaaa Mirjana Pejić Bach *, Sanja Seljan , Božidar Jaković , Ante Buljan , Jovana Zoroja

a Faculty of Economics and Business, University of Zagreb, Square of John F. Kennedy 6, 10 000 Zagreb, Croatia a Faculty of Humanities Social Sciences-Department of Information and Communication University of Zagreb, Ivana Lucica 3, 10 Faculty and of Economics and Business, University of Zagreb, Square of John F. Sciences, Kennedy 6, 10 000 Zagreb, Croatia b 000 Zagreb, Croatia Faculty of Humanities and Social Sciences-Department of Information and Communication Sciences, University of Zagreb, Ivana Lucica 3, 10 000 Zagreb, Croatia b

Abstract Abstract The aim of the research is to examine the content of hospital websites in three different countries and assess them as information repository an interactive online communication mean. Three countries were selected: candidate The aim ofortheasresearch is to examine the content of hospital websites in three different countries and (Bosnia-and-Herzegovina), assess them as information repository or as and an interactive communication mean. Three wereofselected: candidate (Bosnia-and-Herzegovina), recent (Croatia) establishedonline EU member country (Slovenia). Fivecountries dimensions the hospital websites were analyzed: Technical recent established memberAdmission country (Slovenia). Fiveservices, dimensions of the hospital items, (Croatia) Hospital and information andEU facilities, and medical Interactive on-linewebsites serviceswere andanalyzed: External Technical activities. ResultsHospital betweeninformation countries are the Kruskal-Wallis non-parametric test.on-line Hospital websites mostlyactivities. used as items, andcompared facilities, using Admission and medical services, Interactive services and are External Results between countriesand are less compared usingcommunication the Kruskal-Wallis non-parametric test.the Hospital websites mostly used as information repositories as online channels. In addition, country, whicharehad standardized information repositories and asauthority, online communication channels. In websites. addition, the country, which had standardized recommendations issued by the less public had more developed hospital recommendations issued by the public authority, had more developed hospital websites. © 2019 The Authors. Published by Elsevier B.V. © 2019 2019 The Authors. Published by Elsevier Elsevier B.V. This is an open accessPublished article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) © The Authors. by B.V. This is is an an open open access article under underofthe the CCscientific BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) (http://creativecommons.org/licenses/by-nc-nd/4.0/) This access article CC BY-NC-ND license Peer-review under responsibility the committee of the CENTERIS - International Conference on ENTERprise Peer-review under responsibility of the scientific committee of the CENTERIS -International Conference on ENTERprise Information Systems / ProjMAN – of International Conference on Project HCist - International Conference on Health Peer-review under responsibility the scientific committee of the MANagement CENTERIS - / International Conference on ENTERprise Information Systems / ProjMAN - International Conference on Project MANagement / HCist - International Conference on Information Systems / ProjMAN – International Conference on Project MANagement / HCist International Conference on Health and Social Care Information Systems and Technologies Health and Social Care Information Systems and Technologies. and Social Care Information Systems and Technologies Keywords: eHealth; public Health; hospital websites; public communication; information repository; interactive online communication Keywords: eHealth; public Health; hospital websites; public communication; information repository; interactive online communication

* Corresponding author. Tel.: +358-1-238-3464; fax: +385-1-230-8472. address:author. [email protected] * E-mail Corresponding Tel.: +358-1-238-3464; fax: +385-1-230-8472. E-mail address: [email protected] 1877-0509 © 2019 The Authors. Published by Elsevier B.V. This is an open access under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) 1877-0509 © 2019 Thearticle Authors. Published by Elsevier B.V. Peer-review under responsibility of the scientific committee of the CENTERIS - International Conference on ENTERprise Information Systems / This is an open access article under CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) ProjMAN – International Conference Project MANagement / HCist - International Conference on Health Social Care Information Peer-review under responsibility of theonscientific committee of the CENTERIS - International Conference onand ENTERprise Information Systems / Systems TechnologiesConference on Project MANagement / HCist - International Conference on Health and Social Care Information ProjMANand – International Systems and Technologies 1877-0509 © 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/) Peer-review under responsibility of the scientific committee of the CENTERIS -International Conference on ENTERprise Information Systems / ProjMAN - International Conference on Project MANagement / HCist - International Conference on Health and Social Care Information Systems and Technologies. 10.1016/j.procs.2019.12.155

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1. Introduction eHealth services are often seen as complementary to traditional health services [1, 2]. However, many researchers discuss strategic relation between ICT factors (accessibility, usage, quality, trade, applications) and public health indicators [3]. eHealth can be defined as “the use of emerging information and communication technology (ICT) and especially the Internet to improve or enable health and health care” [4]. Ganesh (2004) [2] identified the main groups of eHealth applications, among which are consumer health sources (including websites addressing consumer needs, internet-based communication, electronic medical record and home care for elder citizens) and public health (including integration of health resources for decision making, surveillance of community health and disaster management). Use of eHealth technologies can enhance communication and information sharing among patients, health professionals, healthcare providers, and researchers in order to improve the quality and effectiveness of healthcare services [2; 5]. Van Limburg et al. (2011) [6] point out a need for a business model in order to determine implementation strategy in the development on eHealth technologies in order to generate common values supported by all stakeholders, by reflecting on value needs. Evaluation of websites is also performed also in the education domain, as in Stango and Carter (2017) [7] who presented a content analysis of websites of top rated social work educational programs. According to Pejić Bach et al. (2017) [8], presenting information of the proper institution to a wider audience can influence information access, the decision on service use, satisfaction with hospital service, institution evaluation, etc. Functional, interactive, and well-designed website can contribute to the credibility of the hospital and patient confidence. Information presented on hospital websites is important not only for patients but also for other stakeholders, like health system policy makers, hospital managers, providers of healthcare services. Several types of research have been made on hospital websites taking into consideration marketing issues [9; 10; 11] analyzed through various aspects (website accessibility, content, technology, and usability), while others are oriented to the relationship between the quality of hospital websites and satisfaction of patients [12; 13; 14]. There is also analysis regarding the culture’s impact, demographic factors, Internet use or culture’s impact [15] and interactive eHealth tools regardless the hospital type, ownership or ranking [16], while Bardach et al. (2015) [17] conducted research analyzing the relationship between commercial website ratings and traditional hospital quality. The aim of this paper is to examine content characteristics of hospital websites and to detect whether they serve more as an information repository or as an interactive online communication mean. According to our best knowledge, none of the previous researchers focused to the panel of countries with different administrative and economic development, as well as to the possible impact of standardization instructions issued by the public health authority. Therefore, we focus on three research goals: (i) RG1: To investigate if more interactive content is less present compared to more technical and informative content on hospital websites in all countries; (ii) RG2: To investigate if there is a relationship between the level of administrative and economic development and development of hospital website content; and (iii) RG3: To investigate if recommendations issued by the public authority have positive impact on the development of hospital websites. We use the duration of EU membership as a proxy for administrative and economic development. Therefore, three countries were chosen, differentiating regarding EU membership: candidate EU country (Bosnia-and-Herzegovina), recent EU member country (Croatia) and already established EU member country (Slovenia). These countries are suitable for our research goals since the Slovenian Ministry of Health (2016) has publicly announced invitation and recommendations on improvement of quality and security of health services with greater emphasis on the role of patients as users of health services [18], and similar initiatives are not present in Croatia and Bosnia and Herzegovina. The paper is composed as follows. After the introduction, the second part of the paper presents the related work, and the material and methods used in the research are outlined in the third part. In the fourth chapter, results are presented, followed by discussion and conclusion, giving highlights through recommendations and suggestions for future work. 2. Related Work Hospital websites are extensively used by patients, for information, research, and communication purposes. Therefore, web assurance strategies that include data, policies, and procedures are necessary to enable the transfer of information through the website. The goal is to assure information and communication for the user, including numerous aspects,

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such as access/ usability, accuracy, timeliness, authority, and security/ privacy. Randeree and Rao (2004) [19] analyzed 100 hospitals in the USA in order to investigate web assurance strategy, according to the factors of access, audience, accuracy, timelines, content, authority and privacy. Following their work, numerous researches have been conducted on hospital websites, but they are not easily comparable since they are mostly based on different methodologies. For the purposes of this paper, we used, researched, and reviewed 37 papers dealing with hospital web-site evaluation. In our survey, we limited ourselves to papers available in WoS and Scopus databases. We have compared and reviewed the methods used in reviewed papers to find common ground in order to make a better foundation for future work. Most of the researchers focus on the quality of the hospital websites. Moslehifar, Ibrahim and Sandaran (2016) [20] researched in the context of medical tourism where trust is a particularly important feature of quality information, by assessing top 10 medical tourism websites in Asia, ranked by Medical Travel Quality Alliance (MTQUA) in 2014. They focused on semantic features and source features divided into four categories: general information, accessibility of websites, functionalities, and availability of the information of websites. Liu et al. (2011) [21] focused their research on quality evaluation of 23 hospital websites in China, using criteria of content, function, design, and management and usage. De Song et al. (2015) [22] investigated whether hospital location, size, and level of care affect the rate and quality of hospital websites. Calvo-Calvo (2014) [23] assessed the quality of 53 Spanish website hospitals with more than 500 beds, using criteria of global quality, accessibility, usability, interactivity, updating, quality model and information given, concluding that large Spanish website hospitals are more informational spaces and do not facilitate the interaction, participation, and collaboration of hospital users. Jeddi, Gilasi, and Khademi (2017) [24] analyzed various models used in the quality evaluation of hospital websites. Among them, they identified essential criteria in the evaluation of all websites: accessibility, content, design method, security, and confidentiality of personal information, suggesting that the ease of use, graphics, attractiveness and other apparent properties of websites are considered as the sub criteria of user-friendliness, speed, and accessibility as sub criteria of efficiency. For example, Llinás et al. (2008) [25] have defined Friendliness, and user orientation as the quality of information, i.e. general information, logo, and location; Readability was defined by Flesch index Joaquín Mira et al., (2006) [26]; Availability was defined through web accessibility test. Lin et al. (2013) [27] defined Transparency as information about authorship, ownership, sponsors, government involvement; References as clear statement of information and hierarchy, availability of evidence for information; Feedback as general contact information; Easy navigation as availability of internal search engine, site map, provided links, general disclaimers, copyright information. Rafe and Monfaredzadeh (2012) [28] were using similar definitions to Maifredi et al. (2010) [29] and offered a hierarchy of the proposed framework content quality, design quality, organization quality, user-friendliness, performance quality, service quality, and technical points. Johnson and Norris Martin (2014) [30] analysed interviews of 15 participants to conduct research on a hospital website usability and credibility (language credibility, visual and technical), including visual and technical dynamism. Huerta et al. (2014) [10] also reviewed technological characteristics that they defined as successful design and a well-maintained website. The second group of researchers focuses on specific medical issues. Bramstedt and Dave (2013) [31] conducted website content analysis for 15 hospitals which participate in transplants in order to decide on kidney donation. Jin et al. (2011) [32] examined the extensiveness of information and content on robotic surgery on 400 randomly selected U.S. hospital websites. Chen and Liu (2010) [33] considered accessibility, range and depth of nursing information provided, across 50 top hospitals from five countries, choosing ten for each geographical region: Australia (Oceania), China (Asia), South Africa (Africa), UK (Europe) and the USA (North America). The third group of researchers concentrates on communication with the patients through different channels. Huang, Wang, and Liu (2014) [16] were interested in available information concerning the patients directly. De la Torre et al. (2014) [34] used Google PageRank and Alexa TrafficRank for measuring visibility and popularity and evaluating the degree of adaptation to the Web 2.0. Gallant et al. (2010) [15] were highly focused on ease of access in terms of using a website in another language and compared it with other in regards of information for foreigners and/or tourists. Fourth groups of researchers focused on hospital websites in specific countries. Maifredi et al. (2010) [29] performed an analysis of 1265 public and private Italian hospitals, aiming to study whether they are more sources of information or interactive websites. Salarvand et al. (2016) [35] performed cross-sectional analysis of all 59 public hospitals in Iran’s capital city, Tehran, by analysing 112 items divided into five sections: technical characteristics, hospital information and facilities, medical services, interactive online services, and external activities.

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Table 1 presents a systematic overview of the selected papers discussing hospital websites. While some, like Maifredi et al. (2010) [29], Moslehifar, Ibrahim and Sandaran (2016) [20], Salarvand et al. (2016) [35] or Moghavvemi et al. (2017) [36], have defined their work in a similar fashion and could be compared one to another, others like Gallant et al. (2010) [15] and Liu et al. (2011) [21] use similar, or completely different methodologies (e.g. Huerta et al., 2014) [10]. However, the methodology used by Maifredi et al. (2010) [29] is one of the best defined and most extensive, covering most of the categories discussed by other authors. Table 1. Review of papers according to the website dimensions, (Authors).

✔ x

✔

Llinás et al., 2008 Chen and Liu, 2010 Gallant et al., 2010 Maifredi et al., 2010

x

Jin et al., 2011 Liu et al., 2011

x x ✔ x x

Brunnekreef and Schreurs, 2011 Rafe and Monfaredzadeh, 2012

✔

Lin et al., 2013

✔

Luers et al., 2013 Bramstedt and Dave, 2013 Huang, Wang and Liu, 2014

x

Calvo-Calvo, 2014

x

De La Torre Barbero et al., 2014 Huerta et al., 2014

x ✔

Meyer et al., 2014 De Song et al., 2015 Huerta, Walker, and Ford, 2016

x x

x x

Moslehifar, Ibrahim and Sandaran, 2016

✔

✔

x

✔

✔

Salarvand et al., 2016

✔

✔

✔

✔

✔

Moghavvemi et al., 2017

✔ 19

✔ 16

✔ 6

✔ 11

✔ 8

Total (of 25 reviewed)

x ✔

✔ ✔

✔

✔

✔ x x x

x ✔

✔ x ✔

✔

✔

✔ x ✔

x

✔

✔

✔

✔

✔ x x ✔

x

✔

✔

Joaquín Mira et al., 2006

Performance

✔

Transparency

Randeree and Rao, 2004

Accessibility

✔

Readability

✔

x

External activities

x

Norum and Moen, 2004

Interactivity

Sánchez and Fuentes, 2002

Admission and facilities information

Hospital information

Technical information

Authors, year

x

✔ ✔

x

x

x

✔ x

✔ ✔ x

x x

x

✔ ✔

10

15

4

2

Source: Authors’ work Notes: ✔ - characteristic is fully present, x – characteristic is partially present, (Authors)

3. Methodology Public hospitals in three countries are examined: candidate EU member (Bosnia and Herzegovina), recent EU member country (Croatia) and established EU member country (Slovenia). In addition, the Slovenian Ministry of Health (2016) has publicly announced invitation and recommendations on improvement of quality and security of health services with greater emphasis on the role of patients as users of health services [18], and similar initiatives are not present in Croatia and Bosnia and Herzegovina. Analysis of the previous research presented in Table 1 indicated that the methodology used by Maifredi et al. (2010) methodological approach is one of the most comprehensive [29]. There focused to four groups of indicators: Technical items of websites (19 items), Hospital information and facilities (22 items), Admission and medical services (25 items), Interactive online services (10 items), and External activities (13

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items). Items were measured using binomial variables (0-item do not exist; 1-item exists). Data was collected by surveying 100 public hospitals web sites in Croatia (53), Slovenia (25) and Bosnia and Herzegovina (22), in February of 2017 during the period of 4 weeks. When choosing hospitals to be included in this research, we have taken into consideration all public hospitals referred to by respective country ministries. Five categories indicated by Maifredi et al. (2010) are measured with the 89 items [29]. Hospital websites were evaluated by two independent researchers separately, indicating the presence or absence of items, and their results were similar (>90%). Kruskal–Wallis nonparametric test was used in order to measure if differences between the hospital websites in three different countries are statistically different across these five categories. 4. Results Table 2 summarizes the results by categories for the three compared countries. The average hospital web sites are less developed as interactive online services, focusing more on Technical characteristics and Hospital information facilities, showing the current orientation to one-way communication with the public. Last two categories (Interactive online services and External services) are directly connected to the use of technologies as a means of communication and increasing transparency of business conduct. Slovenia is the leading country in all 5 categories, followed by Croatia and with Bosnia and Herzegovina in the last position. Kruskal-Wallis test has shown a statistically significant difference in medians among the three countries for four categories at α<.05 for Technical items, and for all other categories at level α<.01. These results are not surprising when we take into consideration the fact that Slovenia is the EU member country for the longest time, Croatia is a new member country, and Bosnia, and Herzegovina is a candidate country. In addition, Bosnia and Herzegovina was the most war-affected area, which dearly influenced economic development. However, taking into account the recommendations by the Slovenian Ministry of Health (2016) [18], it is surprising that Slovenia has the greatest standard deviation in the categories of Technical items and Hospital information and facilities [18]. Bosnia and Herzegovina, as countries strongly affected by war ’90s and recently joined and not yet a member of EU, still do not have have web-strategy relating to the quality of web sites. Table 2. Comparison of countries according to categories – Descriptive statistics, (Authors)

Technical items of websites (max 19 items)

Hospital information and facilities (max 22 items) Admission and medical services (max 25 items) Interactive online services (max 10 items)

External activities (max 13 items)

CRO SLO BiH Total CRO SLO BiH Total CRO SLO BiH Total CRO SLO BiH Total CRO SLO BiH Total

Average no. of items

Std. Deviation

% of max no. of items per category

Kruskal-Wallis H

7,19 7,80 6,95 7,29 8,30 11,68 7,14 8,89 7,64 9,80 5,05 7,61 3,28 4,28 2,00 3,25 4,11 5,12 1,82 3,86

1,374 1,581 1,397 1,452 2,145 2,193 2,100 2,711 3,574 2,677 2,886 3,590 1,574 1,514 1,309 1,684 3,215 2,774 1,842 3,062

37,8% 41,1% 36,6% 38,4% 37,7% 53,1% 32,5% 40,4% 30,6% 39,2% 20,2% 30,4% 32,8% 42,8% 20,0% 32,5% 31,6% 39,4% 14,0% 29,7%

7,240**

36,994***

21,759***

20,978***

16,731***

Source: Authors’ work

Results of this research are focused to public hospitals in three countries, which all had working websites, while Maifredi et al. (2010) included 1265 public and private Italian hospitals, regardless the development, availability of web-sites or orientation [29]. They found that 64.3% of public hospitals and 56.10% private hospitals had their own

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working web sites. Although our results are preliminary (smaller number of hospitals, selection criteria and a smaller number of evaluators), in continuation, we present the main differences with their research. Maifredi compares three types of facilities: public hospitals (PubHs-1), health authorities (PubHs-2), and private hospitals (PrHs) [29]. Since in our work we focus only to publish hospitals in Croatia, Slovenia and Bosnia, and Herzegovina, our results are comparable only to public hospitals from the research conducted by Maifredi et al. (2010) [29]. Figure 1 presents the average % of items per categories present at hospital websites in examined countries. As regarding the Technical items of websites, Italian public hospitals have in average 49.1% of the items present at their hospital websites, and they outperform all three countries (Slovenia - 41.1%, Croatia - 37.8% and Bosnia and Herzegovina – 36.6%). However, regarding the Hospital information and facilities, Slovenia has in average 53.1% of the items present at their hospital websites, and it outperforms Italian public hospital websites (50.0%), as well as Croatian (37.7%) and Bosnian (32.5%). In addition, Italian public hospitals have in average 40.6% of items present in the group related to Admission and medical services, and again outperform all three countries (Croatia – 30.6%, Slovenia - 39,2%, Bosnia and Herzegovina – 20.2%). On the other hand, Slovenian hospitals outperform other countries in the categories of Interactive on-line activities and External activities. 60,0% 49,1%

50,0%

41,1% 36,6% 40,0% 37,8% 30,0%

53,1%

50,0% 39,2%

37,7% 32,5%

40,6%

32,8%

30,6% 20,2%

20,0%

42,8%

39,4% 31,6%

32,4%

23,6% 20,0% 14,0%

10,0% 0,0%

CRO SLO BiH IT CRO SLO BiH IT CRO SLO BiH IT CRO SLO BiH IT CRO SLO BiH IT Technical items of Hospital information websites and facilities

Admission and medical services

Interactive on-line services

External activities

Figure 1. The average % of items per categories present at hospital websites (Source: Authors' work; Maifredi et al. (2010)).

5. Conclusion The content analysis of hospital websites in three countries (Slovenia, Croatia, Bosnia, and Herzegovina) was conducted with three research goals, using the methodology proposed by Maifredi et al. (2010) [29]. First research goal was to investigate if more interactive content is less present compared to more technical and informative content on hospital websites in all countries. Our results revealed that hospitals use web sites largely as a one-way channel of communication. Results of the research show that, although there are differences among countries, hospital web sites serve more as a repository of information, showing traditional contact details, than for interactive online communication, which suggests the existing business model. Although tourist countries, information on foreign languages exist on 30% of hospital web-sites in Croatian and BiH and 40% in Slovenia, while information for foreigners exists in 28% in Slovenia, 1,9% in Croatia and 0% in BiH. Hospital web-sites are mainly not adapted for people with disabilities, do not have a virtual tour, information on hospital quality indicators, the web-site search option is available in about 50%. Regarding interactive online services, the average result is the lowest for all three countries, comparing to other five categories, presented on 32,8% of Croatian, 42,8% of Slovenian and 20,0% BiH hospital web-sites.

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Second research goals were to investigate if there is a relationship between the level of administrative and economic development and development of hospital website content. Slovenian (established EU member) and Croatian (recent EU member) hospitals web sites present more in-depth information compared to Bosnian and Herzegovina (candidate EU member) hospitals. The best results are achieved by the hospital websites in Slovenia, followed by Croatia and Bosnia and Herzegovina, across all five sections. Research results were compared with the research conducted by Maifredi et al. (2010) [29], and it was discovered that Italian public hospitals outperform all three countries in the areas related to technology, hospital information and facilities, and admission and medical services. This result is even more striking if it is taken into account that this research was conducted in 2017, while research on the sample of Italian hospitals has been conducted in 2008. The third research goal was to investigate if recommendations issued by the public authority have a positive impact on the development of hospital websites. When analyzing all 89 characteristics in five aspects, Slovenian hospital web sites have the best scores. One of the possible reasons could be recommendations of the Ministry of the health of the Republic of Slovenia (2016), developed rules for ordering and managing waiting lists and publicly announced priorities in strengthening the public health care, including in priorities eHealth area of work [18]. Slovenia has published an invitation to a public hearing for improvement of quality and security of health services with greater emphasis on the role of patients as users of health services and their participation in decision-making bodies. According to resources in the document, some elements are already part of other regulations, related to the Patients' Rights Act and the Regulation on Public Health Operations. In these documents, it is proposed to develop information support of quality indicators in order to perform a quality evaluation at various levels and to regulate evaluation of health technologies. Our results show an intention of all surveyed countries to shift their focus from traditional business model towards a more modern Internet-based business model that can be used to help communicate and educate new generations and give to public adequate information and communication possibilities. Process of this shift seems to be an everlasting battle with new challenges, especially when there are no regulations or recommendations on quality standards. Differences obviously exist, but similarities are still high, especially in some elementary aspects. Some areas are strongly ruled by Slovenia probably due to compliance with European Union practices and technological advances and recommendations of the Ministry of the health of the Republic of Slovenia [18]. Hopefully, this trend will continue and bring more hospitals to new types of business model and make them more accessible to domestic and foreign patients. New technologies could be used to increase transparency, lower costs of business and ease access for users to services, but also to increase health concerns and inform the public of good practices and lower needs for not necessary health services. Results of this research should be considered taking into account the following limitations. First, we focus on the relatively small sample of public hospitals in three countries, while omitting private hospitals from the research. Second, the different period of similar research is a barrier for comparison between different countries. Third, this research did not focus on social media, although its relevance in health care communication is increasing. Therefore, future research directions should focus on the larger sample, including private hospitals and focus on the more interactive channels of communication, such as social media. References [1] Jung, Mary-Louise and Karla Loria. (2010) “Acceptance of Swedish e-Health Services.” Journal of Multidisciplinary Healthcare 3: 55-63. [2] Ganesh, Jai A.U. (2004) “E-health – drivers, applications, challenges ahead, and strategies: a conceptual framework.” Indian Journal of Medical Informatics 1: 39–47. [3] Wu Sarah Jinhui, Wullianallur Raghupathi. (2012) “A Panel Analysis of the Strategic Association between Information and Communication Technology and Public Health Delivery.” Journal of Medical Internet Research 14(5): e147. [4] Pagliari, Claudia, David Sloan, Peter Gregor, Frank Sullivan, Don Detmer, James P. Kahan, Wija Oortwijn, Steve MacGillivray. (2005) “What is e-health (4): A scoping exercise to map the field.” Journal of Medical Internet Research, 7(1): e9. [5] Eysenbac, Gunther. (2008) “Medicine 2.0: social networking, collaboration, participation, apomediation, and openness.” Journal of Medical Internet Research 10(3): e22. [6] van Limburg, Maarten, Julia van Gemert-Pijnen, Nicol Nijland, Hans C. Ossebaard, Ron Hendrix, Erwin R. Seydel. (2011) “Why Business Modeling is Crucial in the Development of eHealth Technologies.” Journal of Medical Internet Research 13(4): e124. [7] Stango, Gina M. M. and James R. Carter. (2017) “A Guided Review of Top-10 Rated Social Work Education Program Websites: Diversity in the Digital Age.” SAGE Open July-September 2017: 1–7.

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