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 The Development of a Web Strategy n a Healthcare Organzaton: A Case Hstory 

Chapter.I

The.Development.of.a.Web.
Strategy.in.a.Healthcare.
Organization:
A.Case.History
Massmo Memmola, Catholc Unversty, Italy

Abstract

Many writers have described the advantages that the Internet can bring to a health-
care organization in terms of consistent improvements in efficiency and efficacy, the
reduction of access time to services, and an improved awareness of these. Bank-
ruptcy costs and devastating failures of investments in technology would have us
believe that the go-to Internet has taken place, at least in the healthcare field, with
a certain improvisation and without a thorough knowledge of the full potential that
the Internet offers. This chapter presents a way to define a Web strategy by aligning
a company’s corporate strategy, in which there is an acceptance and awareness of
the possibilities that the Internet offers by the principal company stakeholders, with
a general strategy of utilization of information and communication technology.

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 Memmola

Introduction

In recent years, there has been a veritable literary frenzy on the theme of healthcare
and the Internet. In these works, however, there has not been adequate attention paid
to the role that potential users of the site (patients, general practitioners, healthcare
personnel, students, private doctors, other healthcare organizations, etc.) could and
should play in the process of defining the Internet strategy.
To overlook these aspects while planning the information content and services of a
Web site would have the same consequences as failing to do a stakeholder analysis
while planning corporate strategy. This, in fact, allows the identification and analysis
of the importance of people, groups, or institutions that can influence, positively or
negatively, corporate activity, consequently determining the success or failure of a
strategy. The objective, in the final analysis, is to identify their expectations, needs,
and requirements so as to ensure correct alignment with the corporate strategic policy.
This process is much more important when you are about to change the logistics of
the production or provision of a product or service.
To put it more simply, you cannot hope to develop a high-profile Web strategy
when patients do not have access to the Internet or lack technological skills, when
the doctors of the organization are not interested and do not want to collaborate
in providing the various content for services to be offered by the site, or when the
general practitioners (GPs) do not regard the Internet as a tool that can improve
their working conditions or results.

Objectives.and.Research.Methodology

This study had the aim of determining the best methodological approach to take
for a healthcare organization to determine and develop its own Web strategy. In
particular, our intention was to look for useful knowledge that would allow us to
understand the following:

• How does one determine the best strategy for the “colonization” of the virtual
space made available by the Internet?
• How does one use the Internet to the best of its potential to provide informa-
tion, offer services, make transactions, and interact (in real time) with patients,
doctors, and whoever has an interest in any way in the organization?
• What will the impact be on corporate strategy and clinical, organizational, and
management processes?

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 The Development of a Web Strategy n a Healthcare Organzaton: A Case Hstory 

• How does one establish a presence on the Internet and how long will it
take?
• Which performance measurement should be applied and how does one evalu-
ate the benefits and success of the strategies chosen?

This research is part of a more wide research project (Baraldi & Memmola, 2006),
started in 2002 and still ongoing, aimed at determining how much and in what way
healthcare organizations can exploit the potential of the Internet to create value in
the eyes of the principal stakeholders. Analysis took place outside the organiza-
tion, evaluating, through the Web site, the final product of the Web strategy of each
healthcare structure.
However, to obtain a complete picture of the subject under investigation, it was
necessary to go inside the organization to share with those responsible for it the
preparation, determination, and eventual implementation of the Internet strategy,
critical aspects and development times, and the expectations and needs of the people
involved directly or indirectly.
The experimental research (Yin, 2003) was undertaken thanks to the cooperation
of a relatively small private healthcare organization (150 beds and about 300 em-
ployees).
The logistics that inspired the setting up of the project is briefly described in Figure
1, which shows the route to determining a Web strategy through the appropriate
alignment of the following:

• The corporate strategy of the organization (business strategy).

• The general strategy of utilization of information and communication technol-
ogy supporting corporate processes (ICT strategy).
• The degree of acceptance and awareness of the possibilities of the Internet by
The personnel (not only medical, but also technical and administrative).
• The degree of acceptance and awareness of the possibilities of the Internet
by patients, GPs, and other corporate stakeholders (outside acceptance of the
Internet).

The final two points of this list particularly required the carrying out of a survey that
was different for each type of corporate stakeholder: patients, general practitioners,
and personnel (healthcare, technical, and administrative).
This method made available a mass of information particularly relevant for the
understanding of the best way a healthcare organization should develop an Internet
presence (Web strategy). The colonization of the virtual space the Internet provides
can be achieved, therefore, through an effective evaluation of the following:

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 Memmola

Figure 1. Research methodology

BUSINESS
STRATEGY

ACCEPTANCE OF

ACCEPTANCE OF
INTERNET

INTERNET
INSIDE

OUTSIDE
WEB-STRATEGY

ICT STRATEGY

• Corporate-strategy orientation.
• Information gained from the survey aimed at evaluating inside and outside
acceptance of the Internet.
• The impact on clinical, organizational, and managerial processes.
• Costs and benefits associated with the contents once activated.
• Performance measure mechanisms through the determination of the KPA (key
performance area) and the KPI (key performance indicator), which enable the
evaluation of the success of the accomplished initiative.

The model presented in these pages leads to a rationalization of the complex process
through which an organization determines the informative or service content of its
own Web site.
To explain the type of strategic approach used by a healthcare organization to de-
termine the contents of its Web site and to evaluate how and how much the poten-
tiality of the Internet is being exploited, we have used Angehrn’s model (Angehrn,
1997), known by the acronym ICDT (Information, Communication, Distribution,
Transaction).

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 The Development of a Web Strategy n a Healthcare Organzaton: A Case Hstory 

Figure 2. The ICDT model (Angehrn, 1997)

Virtual.Information.Space
(VIS)

Virtual.Communication.Space Virtual.Distribution.Space
(VCS) (VDS)

Virtual.Transaction.Space
(VTS)

[Angehrn, 1997]

The model (Figure 2) gets its name from the segmentation of the Internet’s virtual
space into four main sectors: the virtual information space (VIS), virtual communi-
cation space (VCS), virtual distribution space (VDS), and virtual transaction space
(VTS). This segmentation emphasizes that “the Internet has extended the traditional
market space by providing new spaces in which economic agents can interact by
exchanging information, communicating, distributing different types of products
and services and initiating formal business transactions” (Angehrn, 1997, p. 362).
Angehrn’s model has allowed us to build a map of the Internet presence of health-
care organizations aimed at providing a clear and immediate perspective of the Web
strategy pursued by the enterprise (Figure 3).
The Web site is ideally segmented into a series of minimum units of analysis (MUAs).
An MUA represents an area inside the site in which the contents (information or
services) are homogeneous and represent in this way a precise area of occupation
of the virtual space offered by the Web. This might not involve just one page of
the site but might be spread over several pages, or the same page may be shared by
other MUAs. In the VIS area, the MUAs that can be activated are mainly informa-
tive as, for example, those that provide general information about the organization:
its history, clinical specialties, waiting times, and any research being carried out.
In the VDS area, on the other hand, an MUA is normally dedicated to providing a
service such as online consulting, educating, or personalizing programs for health
monitoring. Each MUA is then placed in its own virtual area of competence (VIS,
VDS, VCS, VTS); the greater the level of technological sophistication (LOS) from

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 Memmola

Figure 3. Creation of the map of the Internet presence of a healthcare organiza-

tion

Web.Site
Web.Site

VIS

2.5

LOC 3.5 LOS

2.6

2.1 3.4
1.3

MUAs
3.3 2.2

MUAs 3.8
1.4 2.4
1.2

VCS VDS
3.2
1.1 5.1
3.7

3.6

LOS 4.1 LOC

6.1

VTS

the outside, the greater the level of personalization of contents (LOC), as evaluated
along the orthogonal axis of the figure.

Main.Findings

Research at MD Hospital, a small private healthcare organization (150 beds and

about 300 employees) in the north of Italy, began in the last 4 months of 2004 and
was completed in the first 2 months of 2005. Top management had just completed
the process of determining a strategy for 2005 to 2007, in which great emphasis had
been placed on the need to develop a suitable presence on the Internet that could
help communication and support, in some way, new corporate stances. However,
the strategic approach to the Internet was decidedly low profile (Figure 4a), with
a limited quantity of content of an informative nature, determined at the time of
registration of the domain some years earlier.
After we shared with top management the methodological approach by which the
development of the case under study would proceed, the first problem we met in-

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 The Development of a Web Strategy n a Healthcare Organzaton: A Case Hstory 

Figure 4. Evolution of the Internet positioning of MD Hospital due to alignment

with the business strategy

Part a)

Part b)

volved the composition of the group of work and, in particular, the assignation of
the ownership of the process of determining the Web strategy.
Aware that the Internet can bring about a really dramatic change in the genetic code
of any organization, including those of healthcare, and as a direct consequence of
the way business is carried out (or rather the way treatment services are provided),
we felt that active involvement by the top management (both head office and the
medical and administrative managers) was critical. Moreover, if they are the principal
actors of corporate strategy, why ask others (the information officer or a consultancy
firm) to be responsible for and to coordinate a process that should teach one how to
use the potential of the Internet to pursue this strategy?
Furthermore, enthusiastic sponsorship by senior levels of the organization makes
the employees realize, when they are eventually involved in the project directly or
indirectly, the importance of what is happening. Active participation by the staff is
a factor we believed to be of the utmost importance. To this end, starting with the
preliminary phases of the project, meetings were held with all the doctors and the
nursing and administrative staff in which the objectives and expected results of the
project were explained, in particular, the level and type of their involvement.

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 Memmola

Aligning.Web.Strategy.with.Business.Strategy

It is fundamental for any strategy guide to explain and detail strategic objectives as
best as possible, and to express them clearly in writing and share them with those
who have responsibility in the organization and on who depends, in the final analysis,
the attainment or not of these objectives.
Recent literature on balanced scorecard systems and, more generally, multidimen-
sional performance measurement stress the necessity to translate the strategy into
action, but it has only highlighted this necessity (Kaplan & Norton, 2004). The
moment an organization decides to determine its Internet position, the removal of
any ambiguity regarding its future direction becomes, in the opinion of this writer,
imperative for the success of the project. If, in fact, you accept the assumption that
the Internet is a lever available to top management to pursue and determine cor-
porate strategy, how can you hope to use this tool efficiently and effectively if it is
not clear for what you have to use it?
It is also indispensable to clearly identify and then share the objectives of the Web
strategy, or rather, how the potential that the Internet offers should be used to sup-
port the corporate strategy of the organization.
Therefore, the first phase of the project involved identifying, given the aim ex-
pressed in the corporate strategic plan, which contents, information, or services to
activate in each of the areas in which the Internet’s virtual space occupies (VIS,
VDS, VCS, VTS).
To this end, Tables 1, 2, 3, and 4 show the results obtained relating to the most rel-
evant content. (For the VIS area, content relating purely to the organization such as
a general description of the organization, its history, or how to get to it have been
omitted.)
Each table shows, for each area, the contents proposed for activation and the strategic
aims that can be supported in a complementary or alternative way. For example,
activation of a service that informs patients in real time about waiting times for the
various types of treatment helps to facilitate access to services and greater transpar-
ency of levels of efficiency of the organization, and it creates value for the patient.
In the VDS area, activation of online consultation helps to make patient-doctor
relationships more loyal through greater interaction, branding, and so forth.
At the end of this phase, the map of Internet presence was drawn up in light of the
information emerging from the corporate strategic plan (Figure 4b).

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 The Development of a Web Strategy n a Healthcare Organzaton: A Case Hstory 

Table 1. Alignment of business strategy and Web strategy in the VIS area

SITE.CONTENTS STRATEGIC.AIMS
• Evaluation of inside expertise
Clinical Specialities
• Branding
• Greater attractiveness of MD’s offering
Waiting Times • Facility of creation of new contacts
• Support for international development strategy
Scientific Information • Transparency of levels of efficiency of organization
• Creation of value for patients
• Facilitation of access to MD’s services
MD/Tour Virtual Architecture
• Creation of value for specialist doctors and for GPs
• Greater participation and loyalty of GPs
• Increase of specialized contacts
Training/Congresses • Improved image of MD as an advanced organization
• Improved image as specialized organization from a scientific point
of view

Table 2. Alignment of business strategy and Web strategy in the VDS area

SITE.CONTENTS STRATEGIC.AIMS

Online Consultation
• Creation of value for patients
Education
• Participation and loyalty of GPs and patients
Health-care Glossary • Branding
• Greater interaction
Personal Health Scorecard
• Improved image of MD as specialized organization
Drug Information • Continuous patient support during treatment
• Evaluation of internal expertise
First Aid & Self-care Guide
• Greater awareness of MD’s offering
Health Lifestyle Planners

Aligning.the.Web.Strategy.with.Inside.and.Outside...........
Acceptance.of.the.Internet

Aligning the Web strategy with the business strategy is far from enough. Literature
unanimously agrees on the need to subject any creation process of the strategy to
confrontation with the environment in which the organization works. Environmental
analysis is, in fact, the corporate process that gives top management the information
necessary to clearly understand the principal trends that condition the environment

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0 Memmola

Table 3. Alignment of business strategy and Web strategy in the VCS area

SITE.CONTENTS STRATEGIC.AIMS

• Development and sharing of medical/scientific knowledge

Virtual Medical Rooms
• Sharing of best practices
• Facilitated interaction between doctors/specialists and GPs
Forum • Loyalty of GPs
• Creation of value for patients
• Participation and loyalty of GPs and patients
• Branding
Chat Line
• Greater interaction
• Improved image of MD as advanced organization

Table 4. Alignment of business strategy and Web strategy in the VTS area

SITE.CONTENTS STRATEGIC.AIMS

Online Appointment Booking • Creation of value for patients

Payments For Treatment • Participation and loyalty of GPs and patients

Distance Refertation • Greater interaction

• Improved image of MD as advanced organization and
Complaints And Suggestions
closer to users’ needs
Customer Satisfaction • Facilitated access to organization

Useful Forms • Improved efficiency in undertaking of operative mecha-

nisms

(the main economic-social factors, analysis of competitors and expectations of

consumers, technological advances, regulations, etc.) and consequently formulate
strategic alternatives (Piggot, 2002).
With a substantially analogous logic, the next step should be development of the
Web strategy. Presence on the Internet determined from information emerging from
a corporate strategic plan must be confronted with the level of knowledge of the
Internet inside and outside the organization; in other words, it is necessary to check
the validity of the choices made by confronting expectations, needs, and the level
of the technological skills of the employees, patients, and any other stakeholders
deemed relevant in this process.
To state the obvious, it would be perfectly useless to create a high-profile strategy if
most patients do not have access to the Internet or do not intend to use the Internet
to educate themselves or out of interest during their treatment. Similarly, one would

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 The Development of a Web Strategy n a Healthcare Organzaton: A Case Hstory 

not set up a consultation service online if the doctors refused, for various reasons,
to collaborate in providing the service.

Aligning.the.Web.Strategy.with.Outside.Acceptance.of.the.
Internet:.The.Patients

Evaluation of the level of acceptance and knowledge of the Internet by patients was
undertaken using a questionnaire in the last 2 months of 2004.
The research involved outpatients, too, as all patients have the same questions.
There were, however, different means of medication. Inpatients received medica-
tion on the basis of direct interviews in the ward by the office of internal relations
on several occasions. Outpatients received medication after completing a question-
naire at reception.
Each questionnaire was in two parts: the first to determine the patient’s profile regarding
his or her level of acceptance and awareness of the Internet, and the second to obtain
the necessary information to check the feasibility of the Web strategy pre-selected
for him or her. This procedure was the same for the questionnaires completed by
the other stakeholders investigated (general practitioners and personnel).
The relatively high redemption rate, with an average value of about 60%, resulted
in the composition of a sample of analysis deemed to be statistically significant with
respect to the average population of patients who had access to the organization
in the 2 months the study lasted. Particularly, the questionnaire was completed by
52% of outpatients (729 out of a total number of 1,402) and by 67% of inpatients
(1,112 out of a total of 1,663).
The sample studied comprised a quota of outpatients of 40% (729 out of a total of
1,841 questionnaires received) and a larger group of inpatients, which was 60%
(1,112 questionnaires out of a total of 1,841). In the sample investigated, there was a
high incidence of patients over the age of 60 (about 26%) and a larger more relevant
cluster of patients aged between 30 and 60 (about 57%). Regarding the educational
profile, patients having an average to high background (high-school diploma or
degree) made up 43% of the sample; the remaining patients had a middle-school
diploma (26%), had an elementary-school education (25%), or did not answer the
question (about 6%).
As expected, the younger and more educated patients were more technology savvy:
81% of patients under 30, 65% of those between 30 and 60 (Figure 5a), and around
8 out of 10 patients with a high-school diploma or degree (Figure 5b) stated that
they used a personal computer (PC) and regularly used the Internet.
The use of technology literally collapses in the “weaker” bands both for age (only
2 patients out of 10 over 60 years old said that they used a PC or the Internet) and

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 Memmola

Figure 5. Internet use by patients of MD Hospital

YES NO

100%
90%
80%
70%
60%
50% Part a)
40%
30%
20%
10%
0%
N.D. under 30 30 - 60 years over 60
years years
YES NO

100%
90%
80%
70%
60%
Part b) 50%
40%
30%
20%
10%
0%
N.D. Elementary Middle School High School Degree

education (with a percentage that varies from about 15% for those with elementary-
school education to 46% for those with a middle-school diploma). It should be pointed
out that these groups, as already mentioned, made up over 50% of the sample.
Focusing attention on only the more educated patients (those with a high-school
diploma or degree), the Internet was mainly used to look for information or for
electronic post services.
The Internet was used to a lesser degree to look for information about healthcare,
probably due to a lack of awareness of the role that the Internet can play in choos-
ing a medical specialist or healthcare organization in which to be treated, which is
still the case for Italian patients. There was a particularly low level of interest in
e-commerce services and online interaction (forums, chat lines). The former, it can
be reasonably assumed, lies in the risks involved in making online transactions. In
the second case, the result was probably influenced by the rather advanced age of
the analysis sample (the use of this type of service is widespread among younger
Internet users) and on the particularly widespread use of other communication
technologies such as the mobile phone.

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 The Development of a Web Strategy n a Healthcare Organzaton: A Case Hstory 

The analysis revealed a very low level of use of electronic post services to interact
with medical specialists, with medical doctors in general, or with healthcare orga-
nizations in general.
In the first section of the questionnaire, we wanted to investigate the efficacy of the
previous Web strategy of the organization, and obtained, inevitably, rather disappoint-
ing results: Few patients stated that they knew of the Web site of the MD Hospital
or had visited it (only about 17% of patients who made up the sample); when they
had, the main reason was to look for information about the organization.
The second section of the questionnaire was, instead, more practical, regarding the
approach to the new Internet presence of the organization. To this end, the tables
shown in Figures 6, 7, 8, and 9 report the results of the investigation not only for
patients but also for the other stakeholders taken into consideration. A green square
indicates a high level of interest in the content, a yellow triangle is low interest, and
a red circle is limited or even zero interest.
For the contents of the VIS area, patients said that they were very interested or quite
interested in getting information about access times for various treatments (in 63%
of cases) and, for individual clinical specialties, a list of services available (58%)
and the members of the medical team (51%). Patients were less interested in being
able to contact the medical specialists by e-mail (34%) or to read their curricula
vitae (CVs; 32%).

Figure 6. Report on the evaluation of inside and outside acceptance of the Internet:
VIS area

VIS.Area.Contents.Report.
(Virtual Information Space)
Minimum Unit of Patients Staff Commitment GPs
Analysis Activation Development Maintenance

VIS Area Contents (Virtual Information Space)

Clinical Specialties
+ List of clinical services

+ Medical Team

+ Curriculum Vitae

+ Contact medical staff by

e-mail N. A. N. A. N. A.
+ Publications N. A.
+ Research N. A.
Training/Congresses N. A.
Projects and business
initiatives N. A. N. A.
Annual Report
N. A. N. A.
Waiting Times

MD/Tour Virtual Architecture

N. A.

(N. A. = Not asked)

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 Memmola

For the content of services able to be activated in the new portal of MD Hospital,
patients showed considerable interest in the VDS area, stating they were very inter-
ested or quite interested in being able to do the following (Figures 7 and 8):

• Book appointments online (63%).

• Have distance refertation of their diagnostic investigations (59%).
• Use the educational services for pathologies (58%).

There was slightly less interest in the following:

• Programs for monitoring or improving patients’ state of health (53%).

• Online consultation (57%).
• How to use the principal drugs (52%).

Figure 7. Report on the evaluation of the inside and outside acceptance of the
Internet: VDS area
VDS.Area.Contents.Report.
(Virtual Distribution Space)

Minimum Unit of Analysis Patients Staff Commitment GPs

Activation Development Maintenance

VDS Area Contents (Virtual Distribution Space)

Online consultation

Educational N. A.
Personal Health Scorecard N. A.
Health Lifestyle Planners N. A.

Telemedicine N. A. N. A.

Scientific Information N. A.

Drug Information N. A.

(N. A. = Not asked)

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 The Development of a Web Strategy n a Healthcare Organzaton: A Case Hstory 

Figure 8. Report on the evaluation of inside and outside acceptance of the Internet:
VTS area
VTS.Area.Contents.Report
(Virtual Transaction Space)

Minimum Unit of Analysis Patients Staff Commitment GPs

Activation Development Maintenance

VTS Area Contents (Virtual Transaction Space)

Booking/Paying appointments
on line
Distance refertation

Look for a doctor

N. A.

Complaints and suggestions N. A.

Training courses
N. A. N. A. N. A.

(N. A. = Not asked)

In contrast, there was much less interest in the interactive online services in the
VCS area such as the forum and the chat line (18% of responses) as is shown in
Figure 9.

Aligning.the.Web.Strategy.with.Outside.Acceptance.of.the.
Internet:.General.Practitioners

Using the Web to increase the involvement of GPs is one of the principal aims of
the strategic plan of MD Hospital.
This is no surprise. The general practitioner plays an important interface role between
the National Health Service and patients, directing them and in many cases guid-
ing them in their choice of specialist and/or the organization in which they might
resolve their health problems.
The questionnaire was given to doctors during training courses organized at MD
Hospital and sent by e-mail. Intentionally, the sample was prevalently composed of

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