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THE IMPACT OF USING E-HEALTH ON PATIENT SATISFACTION FROM A PHYSICIAN-PATIENT RELATIONSHIP PERSPECTIVE

This research is completed under patronage of Petra University Dr. Yasmin Sakka1, Dr. Dina Qarashay2 1Faculty of Administrative & Financial Sciences/Management, Information Systems Department/University of Petra 2Medical Health Center/University of Petra Received: 14 March 2020 Revised and Accepted: 8 July 2020

ABSTRACT: This study aims to determine how e-health impacts physician-patient relationship by evaluating patients’ perceptions in terms of trust, reliability, communication, service quality, time and cost, and control and improvement aspects of the relationship. The aggregate outcome of the study examines patient readiness to use electronic two-way communication between patient and physician in Jordanian healthcare sector. The theoretical model has been constructed post a review of related previous literature to identify the dependent and independent variables of the study. Data was collected by means of questionnaire survey of patients visiting private hospitals in Amman, Jordan using a simple random sampling method (N=344). The results of this research revealed that the perception of Jordanians of e-Health physician-patient relationship is significantly positive. This perception comes with the belief that e-Health will improve the relationship, save time and money and improve the quality of care.

I. INTRODUCTION There is a wealth of research data that supports the benefits of effective communication and health outcomes for patients and healthcare teams. The connection that a patient feels with his physician can ultimately improve their health mediated through participation in their care, adherence to treatment, and patient self-management. E-Health through variety of tools is gaining popularity globally as well as in Jordan due increased penetration of internet and the use of smart phones. Patients in Jordan readily accept receiving lab reports, x-rays, medical records as well as receiving doctor appointment confirmation messages through their smart phones or in other forms of electronic communication. This is largely true for the private sector and is little evidenced in the public healthcare sector. eHealth tools, therefore, are technologies that may include electronic medical records (EMRs), personal health records (PHRs), mobile apps, patient portals, information repositories, and many other internet- based programs or software used to help patients monitor and manage their health. Previous research on the topic of e-Health investigated a variety of issues such as use of social media, attitude of healthcare professionals, barriers of use and patients’ attitudes. This paper aims to investigate the level of trust and satisfaction in e-Health from the patients’ point of view. The researchers believe that patients’ acceptance based on essential factors affecting healthcare delivery, will shed a light towards the direction of promoting e- Health utilization. Physician-patient relationship is at the core and is the most important component of e-Health and thus needs to be understood more clearly for the total e-Health to work successfully. 1.1 Review of the Literature In a study by Huang, Edgar, Dunbar, Christina, (2013) found that the flow of information on hospital Facebook pages, and especially twitter pages, is dominantly one-way, nevertheless, hospitals, especially larger ones, have made great effort to interact with their Facebook visitors while marketing themselves. The more Likes and posts the hospital will attract, the more people will comment on the hospital posts, and the more the hospital will get recommended. In addition, the Study demonstrates that using social media, as a two-way communication channel seems to be much more effective for hospitals to connect to their visitors than using those as a one-way marketing tool. Also confirmed by Manderscheid & Wukitsch, (2014) that a national effort has promoted a shared vision for improving the health of all Americans in a very fragmented health care delivery system. This paper describe how effectively, Healthy People 2020, has developed in a changing environment, how the new digital communication strategy for Healthy People 2020 has changed the national landscape around this initiative, and

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 how the further evolution of communication technology will continue to enhance the impact of this initiative at the state, country, local, and personal levels through the end of the decade . Another study by Muller & Khoo (2014) found that non-face-to-face physical activity interventions effectively promote physical activity in older adults. Physical activity is effective in preventing chronic diseases, increasing quality of life and promoting general health in older adults, but older adults are not sufficiently active to gain those benefits. Novel and economically viable way to promote physical activity in older adults is through non- face-to-face interventions . A paper presented at Annual Global Healthcare Conference by Huang, Edgar & Wang, Jing & Liu, Tianjiao. (2014). Interactive E-Health Tools for Patients on Chinese Hospitals’ Web Sites concludes that comprehensively implementing the most important interactive e-health tools on Chinese hospital websites today will help the hospitals provide quality healthcare regardless of the hospital’s institution type, ownership nature, and ranking. And developing a systematic on-line marketing and communication strategy, helps patients more easily find the information about hospital, access and understand their medical records, and have a user-friendly patient education about their symptoms and medical procedures . Another study by Olok & Yagos, (2015) found that the majority of health care professionals has positive attitudes toward e-health attributes (mean 3.5). The level of skills was predictor of ICT used among health care professionals (r=.522, p‹.001), however, attitudes towards e-health attributes didn’t contribute significantly in predicting e-health use. The findings suggest the need for hospital’s managements to strengthen e-health care delivery in northern Uganda . From the standpoint of De vear, Peeters, Barbers, Schellevis, Rademakers & Francke (2015) that the acceptance of e-health can be increased by informing people about the potential benefits of e-health and letting them practice with the application. Special attention should be paid to people with less education and people who have not used the internet before . Also, from point of view by Obasola, (2015) that the prevalence of the application of mobile phone for maternal and child health (MCH) care and the influence of the use information and communication technology (ICT) for delivering MCH information and services to target population. There is a need for more application of ICT for MCH care from pilot initiatives to interventions involving all stakeholders on a sub-regional scale. These interventions should also adopt an integrated approach that takes care of the information needs at every stage along the continuum of care. It is anticipated that the study would be useful in the evolution and implementation of future ICT- based programs for MCH in the region . Also confirmed by (Kampmeijer 2016) [11] that e-heath tools are not only used by older adults in diverse health promotion programs, but also outside formal programs to monitor and improve their health. The latter is hardly studied. The successful use of e-health/m-health tools in health promotion programs for older adults greatly depends on the older adult’s motivation and support that older adults receive when using e-health and m-health tools. A study by (Van der, Meij 2016) [26] concluded that in the majority of the studies, e-health leads to similar or improved clinical patient-related outcomes compared to only face to face perioperative care for patients who have undergone various forms of surgery. However, due to the low or moderate quality of many studies, the results should be interpreted with caution. A paper by (Chali, Kalegele 2018) [3] the authors propose a Data Exchange Component (DEC) that provides a platform to connect a mobile app with multiple eHRs. The motivation here is that utilization of mobile devices in healthcare is increasing every day. Deployment of the DEC in this manner is designed to leverage and capitalize on the high penetration of mobile phones (devices) in the healthcare delivery. This is due to the wide range of capabilities and uses of mobile devices especially mobile phones. The study concluded that achieving interoperability between two or more eHRs is still a challenge in both developing and developed countries. Yet, interoperability of eHRs continues to be an important aspect towards delivering good health care services. Efforts among health care stakeholders, practitioners, researchers, etc. are still directed toward achieving interoperability among eHRs. A study by (Jalghoum, and Khasawneh, 2016) [29], ―An Empirical Research of the Challenges to E-Health Initiative in Jordan‖. The study found that there was a huge impact on the development of the e-health in Jordan and consequently e-health leaders should come up with innovative strategies and change management techniques that can help in managing or reducing the effect of these particular issues in order to ensure a smooth and successful implementation the e-health initiative. In (Matar and Alnabhan, 2014) [14], ―Evaluating E-Health Services and Patients Requirements in Jordanian Hospitals‖ was based on survey results of hospital IT professionals and patients. The study found that the Jordanian have a positive attitude towards the existence of e-health services, a negative awareness regarding the technological background required for such services, and it draws a vital recommendation for adaptive e health services development considering the country requirement.

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Lastly, the paper by (Jalghoum Y, Tahtamouni A, 2019) [30] concludes that all of the unique findings that emerged are directly related to human and cultural issues. These two aspects appear to have a huge impact on the development of the e-health in Jordan. II. PROBLEM STATEMENT Effective and efficient healthcare are the two major factors that drive healthcare payers (insurers, government, patients) and practitioners in the delivery of care systems. For patients’, effectiveness is determined by the quality and speed of health services’ delivery; efficiency reflects affordability and cost of services. Striking a balance between these two factors that yield both acceptance and satisfaction for all players in the healthcare ecosystem requires coordination among players and for the system to be less fragmented. In recent years, leveraging tools and technology through e-Health is becoming a solution to improve care delivery on case-by- case basis through utilizing high speed computers, and mobile devices to share patient information. Effective practitioner-patient communication is crucial to achieve better clinical outcomes reduces unnecessary waiting and visit time where both practitioners and patients can use to perform other valuable activities. Implementing e- Health successfully requires both an appetite for change and practical use of technology by both health practitioners and patients. The Saudi study (Adnan Mustafa AlBar and Md Rakibul Hoque 2018) shows there is significant influence of perceived usefulness and perceived ease of use of e-Health on patients’ attitude. The study was motivated by the fact that there is very little studied about the adoption process of e-health from users' viewpoints in Saudi Arabia. Patient satisfaction in an article by (De Rosis, Barsanti 2016) on evidence from an Italian survey showed results that age education and dissatisfaction with the healthcare system are the main determinant factors of e-health use. The behavior of sharing thee-health experience with general practitioners is more diffused among those patients who are more satisfied with physicians for the involvement in the decision-making process and suggestions on lifestyle. Understanding Jordanian patient satisfaction and associating it with determinant variables and demographics is essential to have a deeper view on e-Health and promote its future use as there limited information to date on the satisfaction levers of the Jordanian patient. III. PURPOSE STATEMENT The purpose of this correlational study is to test the applicability of electronic physician-patient relationship in the e-Health context to define the impact of communication practices between physicians and patients and to explore the extent to which both are willing to utilize e-Health. The study also aims to measure the impact of e- Health in terms of patient trust in physician responses, ease of health information and on-line access to physicians Furthermore, the study will assess participants views on improving efficiency of health services through electronic communication. The independent variable will be generally defined as electronic physician-patient relationship. The dependent variables will be generally defined as patient satisfaction and it engulfs the following variables: physician- patient trust relationship, reliability and affordability, service quality, time spent and cost, and control and improvement. IV. SIGNIFICANCE OF THE STUDY Outcome of this research will be shared with healthcare leaders in the private sector with the aim of creating awareness about e-Health and how it can help health institutions to be more effective and efficient and at the same time get better patient satisfaction through enhanced service delivery. Articles based on the outcome of the research will be sent to local newspapers and leading news websites to highlight the benefits of e-Health. Also recommend the results of the study to leaders in the public and military health sector. Motivate new research on the topic in scientific research in Jordan and conduct more research addressing issues relating to healthcare providers. Research Questions The research questions for this study are: RQ1: How communication practices between doctors and patients can impact patient satisfaction from the patient's perspective? RQ2: How patients perceive physician readiness to use electronic two-way communication between patient and physician in Jordanian healthcare sector? RQ3: How can e-Health improve physician-patient satisfaction in Jordanian healthcare sector, when using health services? Hypotheses H01: There is no satisfaction with e-Health systems among patients of the Private healthcare sector of Jordan.

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H02: There is no readiness among physicians to use electronic two-way communication between patient and physician in the Private healthcare sector of Jordan. H03: There are no significant differences in sample assessments for their levels of stratification and readiness with e-Health systems in the Private healthcare sector of Jordan according to their demographic and personal occupation. H04: There is no relationship between mutual communication (patient-physician) and patients’ satisfaction in the Private healthcare sector of Jordan due to the use of e-Health system. Identification of Variables Trust relationship: Involves confidence and reliance of patients on physicians to provide care for their health situation. Reliability: This variable is intended to obtain patient views on how reliable the systems that currently support e-Health Communication: Method of communication and how it impacts perception Service quality: Addressing patients’ needs in a satisfactory manner is signifies that the service is a quality by having expectations met or exceeded Time and cost: This variable indicate that less time is spent by patients waiting to obtain a service and patient perception that they obtained value for money. Control and improvement: The perception of patients that they have more control over their health and that e- Health is a step forward toward improving care delivery.

Source Building Model (Independent Variable : Electronic Patient – Physician Relationship from: De Rosis et al. (2016), Huang et al., (2014), Obasola, et al.(2015), De Veer, et al. (2015), Olok, et al. (2015), Van der Meij, et al. (2016), Chali, et al., (2017). Source construct model (dependent variable: Trust Relationship, Reliability, Communication, Service Quality, Time Spent & Cost, and Control and Improvement from: Black AD, Car J, Pagliari C, et al. (2011), Ossebaard et al. (2016), Mane R, Kulkarn R (2012), Rekila, (2013), Nicholas (2015), Blanson Henkemans, et al. (2013), Bergmo (2015). Design Data was collected by means of questionnaire survey of patients visiting private hospitals in Amman, Jordan using a simple random sampling method. This sampling method was chosen as the researchers intend to generalize the findings. The questionnaire included all elements of the study variables, then data was analyzed using One- Sample- T-Test and Two- Independent- Sample- T-Test. The aim of the study is to investigate the impact of using e-Health system on patient satisfaction from the perspective of Patients in the context of private healthcare sector of Jordan. Private hospitals of in the Capital city Amman were targeted as a study population, as these capital hospitals achieved good ICT progress and utilize some form of e-Health systems; therefore, the assessment of patients in these hospitals would provide useful feedback that will help in addressing the aims of present study.

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Nine hospitals were purposively selected out of (43) hospitals that are officially listed in the official website of Ministry of Health operating as private hospitals in Amman. The researchers selected (9) hospitals based on the level of advancement in adopting e-Health systems and the ability of researchers to obtain hospitals’ official permission to collect data.. The included hospitals are: Al Bayader Hospital, Istiklal Hospital, Arab Medical Center, Istishari Hospital, Jordan Hospital, Abdali Medical, Farah Medical Campus, Dar Al-Salam Hospital and Shumaysani Hospital.

V. ASSUMPTIONS AND LIMITATIONS Assumptions Survey questions are clearly understood, and that e-Health term is a clearly understood terms and staff who carried out the survey were trained by the researchers. Additionally, questions were in both Arabic and English language in order not to excluded English-speaking Jordanians and non-Arabic speaking residents. Greenhalgh T (2010) argues that eHealth ―interventions‖ may lie in the technical and scientific world, but eHealth dreams, visions, policies, and programs have personal, social, political, and ideological components, and therefore typically prove fuzzy, slippery, and unstable when we seek to define and control them. Greenhalgh T, Russell J (2010), states a key quality criterion in such studies is reflexivity—consciously thinking about issues such as values, perspectives, relationships, and trust. These traditions reject the assumption that a rigorous evaluation can be exclusively scientific. Rather, they hold that as well as the scientific agenda of factors, variables, and causal relationships, the evaluation must also embrace the emotions, values, and conflicts associated with a program. Limitations As the study is conducted in the private sector results may not be generalized to patients visiting public sector hospitals; although, some patients who are insured by the government receive private care treatment or is paid out of pocket. Additionally, the study included the University of Petra community that may bias the age demographics. Participants and Settings Patients visiting the selected hospitals provided the unit of analysis, and simple random sampling approach was adopted as this approach included participants by chance and randomly while maintaining that each element of the population has equal chance to be included in the sample (Sekaran & Bougie, 2016). Consequently, (392) questionnaires were distributed among the (9) hospitals and (327) questionnaires were retrieved, (65) questionnaires were returned blank which renders (83%) response ratio. Considering that many patients refused to cooperate due to their health condition, researchers aimed to increase the sample size for the purpose of generalizing results by targeting citizens from different geographical areas in Amman namely, Community 1, 2 and 3 which represent the three major areas of Amman. Moreover, participants from Petra university - due to researchers’ relationship with this university- were also included considering as the university provides health insurance to staff and students to access different services provided by private healthcare sector. Hence, their assessments will be useful to the study. Following that (30), (30), (50) and (50) questionnaires were distributed in Community 1, 2 and 3 and University of Petra respectively and retrieved as (29), (22), (43) and (50) respectively. In total researchers distributed (502) questionnaires and retrieved (421) questionnaires and (81) questionnaires were returned blank, accordingly; in total response ratio was (84%). After collecting the final sample, questionnaires were checked for its statistical validity through checking inconsistent answers, high missing data and answering patterns (Extreme agreement or Extreme disagreement) and accordingly (25) questionnaires were excluded from the sample and the final sample included (344) participants from the total population. Table (1) provides summary for the questionnaire distribution, retrieving and excluding.

Table (1): Summary for Questionnaire Distribution, Retrieving and Excluding Distribute Response Total Location Retrieved Blank Excluded Valid d % Sample Al Bayader Hospital 30 23 7 77% 1 22 6.40% Istiklal Hospital 17 17 0 100% -- 17 4.90% Arab Medical Center 27 26 1 96% 2 3 0.90% Istishari Hospital 80 69 11 86% -- 69 20.10%

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Jordan Hospital 35 26 9 74% 2 24 7% Abdali Medical 50 44 6 88% 7 37 10.80% Farah Medical Campus 24 24 0 100% 4 20 5.80% Dar Al-Salam Hospital 42 27 15 64% 2 8 2.30% Shumaysani Hospital 37 21 16 57% 2 19 5.50% Petra University- 50 50 0 100% 2 34 9.90% Students Community 1- 30 29 1 97% -- 29 8.40% Community 2- 30 22 8 73% -- 22 6.40% Community 3 - 50 43 7 86% 3 40 11.60% Total 502 421 81 84% 25 344 100%

Instrumentation The questionnaire-survey provided primary data for present study, and to code the gathered data; the Social Package for Social Sciences [SPSS] version (25) was used. Different statistical tools were used including descriptive statistics to provide frequencies and percentages for the sample profile. Mean and Standard deviation (Std.) to identify levels of agreement on the questionnaire items, Independent Samples T-Test and One -Way Analysis of Variance–ANOVA with Fisher LSD posttest to identify significant differences in sample assessments according to their demographic and personal occupation. One Sample T-Test to identify the significant level of agreement, and finally Pearson Correlations along with Simple Linear Regression to investigate correlation and variance achieved in Patient Satisfaction due to the use of e-Health System. VI. CONCLUSIONS AND RECOMMENDATIONS Conclusions This research focused on patients’ satisfaction regarding the use of e-Health services and their perception of physician-patient relationship when utilizing healthcare electronically. It also found that the majority of patients are satisfied and accept utilizing e-Health believing that physicians do accept e-Health and would respond professionally to patients’ health concerns. The research found that there is no gender, economic class and address bias towards a satisfactory physician- patient electronic relationship. As for age and education groups there are differences with respect to study variables; nonetheless, these differences do not change patient satisfaction with e-Health prospects. In terms of education level, results showed that PHD holders have less satisfaction levels for the reliability aspect e-Health compared to other education levels. Additionally, the research established that two-way communication directly influences patient satisfaction in the use of e-Health. This influences the relation of trust and reliability; meaning the higher the communication is, the higher the level of satisfaction is. The results of this research revealed that the perception of Jordanians of e-Health physician-patient relationship is significantly positive. This perception comes with the belief that e-Health will improve the relationship, save time and money and improve the quality of care. Managerial Implications The results of this research revealed that there is a significant positive relationship between patient satisfaction and increased communication through e-Health. Healthcare executives should consider the positive impact of e- Health in delivering care and increasing patient satisfaction and at same time achieve more efficiency. Therefore, it is recommended that executives become more concerned with increasing their investment in technology and increase the levels of e-Health utilization. According to the results, all the dimensions of Patient Satisfaction have positively and significantly correlated with e-Health and use of Online/Offline communication. It is also recommended that health executives concern themselves with each dimension of patient satisfaction specially when it comes to service quality and reliability. According to the findings, patients’ readiness to utilize e-Health, it should be an opportunity by health executives which would increase both the effectiveness and efficiency of healthcare

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Recommendations Considering that the study respondents are patients, the results are not sufficient predictor of to the physician- patient e-relation success. The physician side needs to be researched as well. However, from a patients’ perspective being ready to accommodate the use of e-Health makes it an important factor contributing to the future development of e-Health aspects. This research found positive patient expectations of physician reactions towards e-Health, follow-on research needs to confirm this aspect from physicians and health practitioners’ point of view.

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