Another cost is medication administered at the patient’s house at a daily cost of about €26 for a total of €1,618. Travel costs to and from the hospital (6.5 trips on average) are €84.
Telemedicine is the last option and it is mainly based on the tele-oncology cost analysis in the previous subsection. The total cost of tele-oncology assistance is the daily cost per patient (i.e., €101) times the number of days that the patient spends at home on average before death – for a total cost per patient of €6,200 . The clinical data show that the patient also requires on average of 3.55 days in the hospital. At the average daily hospitalization cost per patient (i.e. €465), the total hospitalization cost is to €1,650.
Added to this is medication administered at the patient’s home at the same daily cost as the previous options (€26), plus travel costs to and from the hospital (1.5 trips on average) for a total of €19.50.
Table 6 shows the full estimated costs for the three options available to patients:
telemedicine, day-hospital, and stay in hospital.
It is important to emphasize that the cost analyses of the telemedicine and day- hospital options do not take into account the opportunity cost of the time families dedicate to their sick relatives. As a consequence, with an average stay-at-home period of 62.65 days - with no external support - the day-hospital option turns out to be extremely costly. Relatives and patients face the burden of self-administered assistance both in monetary terms and terms of time. This likely imposes psychic costs - for example increased anxiety - on the people involved.
The next project we consider had a goal of paperless –that is, all-electronic - documentation, whilst at the same time meeting legal requirements for signatures. To do this, management opted for an electronic document management system which incorporates digital signature technology (as established by legislative decree DPR 28/12/2000 no. 445, art.1, paragraph 1, letter ‘ee’).
Four health care units participated in the project, one of which was the lead partner in the project. Its goal was to electronically transmit medical reports from/to a number of local health care departments and services, specifically: the diagnostic services department, various hospital departments, the social and health care districts and a selected number of general practitioners. After a successful trial period at the lead site the system was implemented at the other three health care units.
5. Blurring the line between control and social learning evaluation: Technology
services departments (Microbiology Lab, Clinical Chemistry Lab, Anti-Diabetes Centre, Radiology and Neuroradiology department, Anatomy and Pathologic Histology department) and in various hospital departments. We identified the following processes to which we could attach costs
x personnel assigned to the reporting function, x space allocated to filing of documents,
x technological tools used to support the reporting process, x medical reporting production costs (paper, labels, etc.).
Table 6. The three clinical options
Telemedicine Day-hospital Hospital Parameters
Cost Parameters Cost Parameters Cost
Overall stay in hospital
(number of days per patient)
3.55 €1,650 2.35 €1,092 40 €18,592
Day-hospital access (number of patients)
5 €1,072
Medication treatment at patient's house (treatment days per patient)
61 €1,587 63 €1,618 25 €646
Patient transportation (trips)
1.5 €20 6.5 €84 2.5 €33
Tele-oncology assistance
(number of days per patient)
61 €6,200
Total cost/patient
€9,457 €3,866
€19,270
Table 7 shows the savings in personnel and filing space used for reporting after the introduction of the ICT system. The last column gives the yearly operating costs of the ICT system1.
Investment in the ICT system includes system design, hardware, software, customised applications, advisory services and internal personnel permanently assigned to the project. These costs total €600,000. Table 8 summarizes savings and costs over a five-year time period. On the basis of these data, the project’s net present value (using as a discount rate the rate on five-year Italian treasury certificates:- CCT) is a negative value: € (55,414).
The negative value indicates that it is difficult to justify infrastructure projects like this solely on the basis of measurable costs and savings. In regard to intangible benefits, it is worth noting that once the trial period was over the project arranged for
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transmission of the digital medical reports to patients at their homes. This new service was offered through an agreement with the national postal service. Once the health care unit transferred the electronic data, the postal service printed the reports and delivered them to the home address of the patients.
Table 7. Annual savings/(costs) from implementation of electronic document system (in €)
Organisational Unit Personnel Filing space Operating costs
Microbiology Lab. 41,026 3,000 0
Clinical Chemistry Lab. 76,924 3,000 0
Anti-Diabetes Centre 0 3,000 0
Radiology and Neuroradiology 0 3,000 0
Anatomy and Pathologic Histology 25,641 3,000 0
Hospital departments 0 0 0
Social and Health Care Districts 92,309 0 0
Common-shared costs 51,283 0 (2,000)
TOTAL 102,565 15,000.00 (2,000)
N.B.: the figures in brackets represent additional expenditures, while the other figures indicate cost savings
Table 8. Savings/(costs) during the five-year investment horizon (in €)
Year 1 Year 2 Year 3 Year 4 Year 5
Investment (600,000) 0 0 0 0
Personnel 102,565 102,565 102,565 102,565 102,565
Filing space 15,000 15,000 15,000 15,000 15,000
Operating costs (2,000) (2,000) (2,000) (2,000) (2,000)
Total (484,435) 115,565 115,565 115,565 115,565
N.B.: the figures in brackets represent additional expenditures, while the other figures indicates cost savings
We factor in the cost of producing and mailing the reports to patients’ homes in table 8. Operating costs include the costs for each medical report produced and mailed (we estimate an average of 272,000 reports per year).
The technical tools are the same as before, but there are additional costs related to the purchasing of a specific IT application, to the number of days used to integrate it to the system, then interface it with the ICT architecture. Thus, overall costs total
€606,960. Table 9 shows the cash flow over the five-year investment horizon adopted for the analysis.
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Table 9. Annual savings/(costs) (in €)
Organisational Unit Personnel Filing space Operating costs Reporting
Microbiology Lab. 41,026 3,000 0 0
Clinical Chemistry Lab. 76,924 3,000 0 0
Anti-Diabetes Centre 0 3,000 0 0
Radiology and Neuroradiology 0 3,000 0 0
Anatomy and Pathologic
Histology 25,641 3,000 0 0
Hospital departments 0 0 0 0
Socio-Medical Districts 30,770 0 0 12,930
Common-shared costs 51,283 0 (99,196) 0
TOTAL 225,643 15,000 (99,196) 12,930
N.B.: the figures in brackets represent additional expenditures, while the other figures indicates cost savings
Table 10. Savings/(costs) (in €)
Year 1 Year 2 Year 3 Year 4 Year 5
Technological
platform (606,960) 0 0 0 0
Personnel 225,643 225,643 225,643 225,643 225,643
Filing space 15,000 15,000 15,000 15,000 15,000
Operating costs (99,196) (99,196) (99,196) (99,196) (99,196) TOTAL (465,513) 115,565 141,447 141,447 141,447
N.B.: the figures in brackets represent additional expenditures, while the other figures indicates cost savings
These cash flows equate to a positive project net present value of €43,656. This positive net present value compared to the negative value calculated earlier shows the value of extending the analysis from operations within the front office alone to activities further down the information chain, in this case to getting the reports into the hands of the patients.
In addition to these quantified benefits, there are intangible benefits:
x improved and more efficient services provided to users (such as the reduction in reporting times);
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x improved quality of services, as fewer mistakes occur in sorting reports (according to the health care units’ estimates, mistakes occurred 10% of the time);
x improved image of the health care unit;
x improved accessibility to and effectiveness of operative processes (for example services available on-line to patients and other parties).
These benefits represent value added to the investment. Unlike quantified benefits however, the choice and use of appropriate indicators is not always an easy task. For example we evaluated reporting turnaround times through direct surveys and questionnaires administered to health personnel. We limited the survey and questionnaires to the interaction between the Clinical Chemistry Lab (LAB) and the Anatomy and Pathological Histology department (APH) in a sample of 13 wards of the hospital. The results of the randomly chosen sample of patients participating in the study are reported in table 11.
Table 11. Characteristics of the sample of patients participating in the study before and after the technological innovation
Characteristics before after
No. of patients 159 155
No. of patients with urgent requests only 9 6
Average no. of patients involved for each ward 12.2 11.9
No of wards 13 13
Total no. of requests 369 369
No. of urgent requests 124 120
No of requests to the LAB 346 357
% urgent 35.8% 33.6%
% programmed 64.2% 66.4%
No. of requests to the APH 23 12
% urgent 0.0% 0.0%
% programmed 100.0 % 100 .0%
Average no. of hospitalisation days 10.5 9.9
From this analysis we can see two significant and comparable values:
x the average waiting time between the submission of a request for a diagnostic exam and receipt of the medical report (S/R waiting time index)
x the average waiting time between the availability of a medical report in a ward and its use for treatment purposes (W/U waiting time index).
In Table 12 the two indexes are calculated and compared before and after the introduction of the ICT system. A distinction is made both between the reports produced by the LAB and by the APH and, for each category, between those referring to urgent requests and those referring to non-urgent ones. Overall, a reduction in waiting time is reported.
The remarkable reduction in S/R waiting time is also confirmed by the answers to the questionnaires submitted to the staff working in the departments involved. These show a consistent perception of reduced waiting times. Reduced waiting time improves treatment. For APH, values are less significant. The diagnostic process is generally
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time-consuming (for technical reasons). The number of requests for the sample chosen is also very low. On the basis of these results management of the unit decided to keep a record of the reporting times. This can be done by extracting data from the log files produced by the new document management system.
Table 12. Reduction in waiting time before and after the technological innovation (values are in hours + minutes)
LAB APH Phase Indicator
Urgent Non-urgent Urgent Non-urgent S/R waiting time 5.17 17.02 - 173.97 before
W/U waiting time 1.03 6.44 - 4.73
S/R waiting time 2.0 10.8 - 98.0
after
W/U waiting time 0.6 6.3 - 14.7
Finally, since the sponsor of the project is a public body, we decided to evaluate external benefits, that is, the social benefits produced by the new system, especially by home delivery of medical reports. We identify the benefits as reduced travel costs and increased time for patients who no longer need to physically pick up their reports at the health care unit. We estimated an average distance from patient home to the unit which we multiplied by the average cost per kilometre (obtained from Italian AAA) to calculated travel costs. We estimated time saved at one hour multiplied by the average hourly wage (from ISTAT statistics) to calculate the value of time saved (see Table 13). The resultant savings are about €4 million.
Table 13. External benefits for the local community (in €)
Type of benefit Cost per report Annual reports Annual benefits
Reduced travel costs 3.46 272,000 941,120
Increased time 11.51 272,000 3,130,720
TOTAL 4,071,840
Conclusions
Our analysis of these two cases shows that ICT investments have a range of impacts. We need multiple measures to identify the full range of costs and benefits.
There are two issues that require particular attention:
x intangible benefits which mainly fall into the effectiveness sphere, but often cannot be quantified in monetary terms;
x synergies among different investments which can be sources of long term benefits (e.g., use of the postal service)
In addition, since we are evaluating a public sector service, e-government should improve the quality of life of citizens, regardless of whether the improvement can be
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quantified. The first case is an example of control orientation evaluation, mainly focused on objective values. The evaluation is based on standard financial measures.
However, it is worth remarking that the analysis did not take into account:
x costs of assistance to patients’ families during an extremely difficult period x longer-term improvement in the effectiveness of treatments
x measurable improvements in the efficiency of processes
x cost implicit in the time that patients’ families devote to assisting patients.
This last item is difficult to measure. Benefits consist of improved quality of life for terminally-ill patients, reduced anxiety and increased well-being of both patients and family.
The second case evaluates the impact and the intangible benefits accruing from the introduction of a technological innovation. The cost-benefit analysis provides useful tools (e.g., survey, questionnaire) to evaluate social benefits and treatment quality for example. However, neither the first nor the second case takes into account perceptions of the beneficiaries of care.
It is important to emphasize that formal and informal approaches are equally legitimate means of assessment, depending on the evaluative role and shareholders’
information needs. In particular, formal approaches are a common part of organizational culture. However, formal approaches need to be used together with informal approaches, especially for projects led by public or non-profit organizations, to overcome the limits of their restricted focus [14]. Further research is needed to quantify intangible benefits, thus gaining stakeholders’ consensus on their value.
Despite the limits of our study, the resulting information seems useful for prioritising investments and identifying the best alternative consistent with ICT strategy. Evaluative study supports strategic alignment and forces ICT public investments to adhere to the principle of ‘value for money’. Not only does this help to determine whether ICT investments are feasible, it also helps to manage innovation by highlighting the organizational impact and identifying opportunities for improvement.
Finally, it is evident that any kind of evaluation requires resources (in terms of time and costs) and information. Information cost represents one of the crucial problems of the evaluation process. It is one of the most important reasons for promoting a participatory approach. The mediating role of complementary factors in the relationship between ICT and its positive impacts [16] makes it difficult to identify information needed for effective evaluation. Participatory evaluation can help in this regard. This leads decision-makers toward solutions whose implementation is more likely to find stakeholders’ support.
Endnotes
1. The costs to produce medical reports remained the same: reporting previously done by Diagnostic Services was later done by the Social and Health Care Districts or by hospital departments, which are part of the same health care unit.
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References
[1] M. Castells, The Rise of the Network Society, Blackwell Publishers, Oxford, 2000.
[2] E. Borgonovi, Principi e sistemi aziendali per le amministrazioni pubbliche, Egea, Milan, 2002.
[3] S. Roach, Macro-realities of the information economy, National Academy of Science, New York, 1986 [4] T. Landauer, The trouble with computers: usefulness, usability and productivity, MIT Press,
Cambridge, 1995.
[5] Q. Hu and R. Plant, Does IT spending impact firm productivity and performance?, University of Miami Paper, Florida, 1998.
[6] K. Kraemer and J. Dedrick, IT and economic development: international competitiveness, in W. Dutton (ed.), Information and Communication Technologies, Oxford University Press, Oxford, 1996.
[7] E. Brynjolfsson and L. Hitt, Paradox lost? Firm-level evidence on the returns to information systems spending, in L. P. Willcocks and S. Lester, (eds.) Beyond the IT productivity paradox, John Wiley and Sons, New York, 1999.
[8] S. Shang and P.B. Seddon, Assessing and managing the benefits of enterprise systems: the business manager’s perspective, Information Systems Journal,12 (2002), 271-299.
[9] J.F. Rockart, Chief executives define their own data needs, Harvard Business Review,57 (1979), 81-93.
[10] R. Curtice, Strategic value analysis, Perentice Hall, Englewood Cliffs, 1985.
[11] F. Nuti, La valutazione economica delle decisioni pubbliche, Giappichelli Editore, Torino, 2001.
[12] M. F. Drummond, B. O’Brien, G.L. Stoddart and G.W. Torrance, Methods for the economic evaluation of health care programmes, Oxford University Press, New York, 1997.
[13] S. Hamilton, and L.N. Chervany, Evaluations Information Systems Effectiveness – Part I: Comparing Evaluation Approaches, MIS Quarterly,5 (1981), 55-69.
[14] V. Serafeimidis and S. Smithson, Information systems evaluation as an organizational institution – experience from a case study, Information Systems Journal,13 (2003), 251-274.
[15] C. Changchit, K.D. Joshi and A.L. Lederer, Process and Reality in Information Systems Benefit Analysis,Information Systems Journal,8 (1998), 145-162.
[16] M. Ko and K.M. Osei-Bryson, Using regression splines to assess the impact of information technology investments on productivity in the health care industry, Information Systems Journal,14 (2004), 43-63.
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Citizen Adoption of e-Government in the UK: Perceived Benefits and Barriers
David GILBERT, Pierre BALESTRINI, Ailsa KOLSAKER and Darren LITTLEBOY
School of Management, University of Surrey, UK
1. Introduction
In response to the prevailing discourse of consumer-centricity many organizations have sought to realign their structures and processes to focus upon meeting customer needs.
Customer Relationship Management (CRM) is employed widely by companies eager to develop and maintain fruitful, and profitable, relationships with their customers. CRM activities are increasingly Internet-based, as companies exploit the potential of the technology to communicate directly and interactively with consumers as well as handle and mine data, customize products and personalize offerings [1]. Whilst there exists a growing body of empirical evidence about consumers’ perceptions and evaluations of electronic service delivery generally [2, 3, 4], hitherto there has been little evaluation of this specifically in relation to the delivery of e-government services. Official reports, such as the annual European Commission report (see [5]) concentrate upon the provision rather than usage of public services (for a critique of this approach see [6]).
Yet understanding citizens’ perceptions, attitudes and intentions is of particular importance if the government is to achieve widespread acceptance and usage of its electronic services. Without an understanding of why UK citizens would choose to use electronic service delivery channels rather than more traditional service delivery methods, government organizations are likely to fall further and further behind e- delivery targets. Against this background we investigate citizen usage intentions based upon perceptions of benefits and barriers and based upon these results assess whether e-government services are likely to be successful in terms of citizen usage.