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A Balanced Scorecard Approach in Assessing IT Value in Healthcare Sector: An
Empirical Examination
Article in Journal of Medical Systems · February 2012
DOI: 10.1007/s10916-012-9834-2 · Source: PubMed
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J Med Syst (2012) 36:3583–3596
DOI 10.1007/s10916-012-9834-2
ORIGINAL PAPER
A Balanced Scorecard Approach in Assessing IT Value
in Healthcare Sector: An Empirical Examination
Ing-Long Wu & Yi-Zu Kuo
Received: 2 September 2011 / Accepted: 9 February 2012 / Published online: 25 February 2012
# Springer Science+Business Media, LLC 2012
Abstract Healthcare sector indicates human-based and
knowledge-intensive property. Massive IT investments are
necessary to maintain competitiveness in this sector. The
justification of IT investments is the major concern of senior
management. Empirical studies examining IT value have
found inconclusive results with little or no improvement in
productivity. Little research has been conducted in healthcare
sector. The balanced scorecard (BSC) strikes a balance between financial and non-financial measure and has been
applied in evaluating organization-based performance. Moreover, healthcare organizations often consider their performance goal at customer satisfaction in addition to financial
performance. This research thus proposed a new hierarchical
structure for the BSC with placing both finance and customer
at the top, internal process at the next, and learning and growth
at the bottom. Empirical examination has found the importance of the new BSC structure in assessing IT investments.
Learning and growth plays the initial driver for reaching both
customer and financial performance through the mediator of
internal process. This can provide deep insight into effectively
managing IT resources in the hospitals.
Keywords IT value . Performance measure . Balanced
scorecard . Healthcare sector
Introduction
Recently, healthcare providers are in transition and facing
many challenges regarding escalating cost and more
I.-L. Wu (*) : Y.-Z. Kuo
National Chung Cheng University,
Chia-Yi, Taiwan, Republic of China
e-mail: ilwu@mis.ccu.edu.tw
pressure to deliver a high quality of care to patients [71].
Healthcare organizations basically indicate both humanbased and information-intensive properties while involving
a variety of employees, such as physicians, nurses, administrative staff, and technical personnel and requiring a large
amount of expertise, such as medical knowledge, management knowledge, and other technical knowledge [21]. More
specifically, when a new health insurance policy was initially implemented in Taiwan in 1995, the government is the
only provider for the medical insurance resources. A limited
insurance budget therefore intends to support the huge program and as a result, the medical payment for hospitals has
been reduced largely. Hospitals in Taiwan have been facing
severe challenges in terms of cost control and maintaining
quality of care. Thus, IT investments are imperative for
hospitals to improve operational efficiency and knowledge
management capabilities. The value justification of IT
investments has been considered as an important issue for
top management [15].
For over a decade, empirical studies in the IT value
literature have attempted to understand the benefits realized from IT investments. However, the results have been
inconclusive for finding little or no improvement in
productivity despite massive IT investments. This phenomenon for failing to conclude positive results from IT
investments in organizations refers to IT productivity
paradox in the literature [4, 13–15]. Inadequate measuring methodology may be the major reason for causing
the inconsistence. The performance measures traditionally were financial ones, such as ROI and ROA. Perhaps,
the most serious issue in IT performance measure has
been isolated and separated from other organizational
practices [14, 26, 47]. Thus, executives may receive
misleading signal of organizational performance in making important decisions.
3584
The balance scorecard (BSC) may be a feasible approach
to overcome the IT productivity paradox. The BSC, in
essence, is a hybrid performance measure system, which
considers various organizational practices in measuring organizational performance. It includes four performance perspectives, finance, customer, internal process, and learning
and growth, which are critical to an organization’s success.
The system strikes a balance between financial and nonfinancial measure and provides a set of forward-looking
performance indicators linking strategy to specific actions
[37, 63]. The four perspectives were originally built in a
cyclical structure for the relationship of mutual influence
[30].
While the literature for IT payoff has been most focused
on business sector, there is a critical need to examine IT
payoff in healthcare sector, as discussed above. Research on
the IT productivity paradox has concluded the inappropriateness of a focus on financial measure while it is isolated
and separated from non-financial measure, for example,
customer satisfaction. Moreover, there are two BSC structures defined for business and healthcare sector respectively,
which particularly indicate their different emphasis on financial or customer measure [59, 62]. In addition, most
studies on the BSC have been focused on the impact of
the overall organizational resources rather than the particular
IT resources [10, 12, 21, 29, 63]. Thus, this study proposed a
novel hierarchical structure for the BSC to examine IT
payoff in the healthcare sector. This structure considers
placing both finance and customer at the top (the same
level), internal process at the next, and learning and growth
at the bottom. Empirical examination was further conducted
for its practical validity.
Literature review
IT and healthcare sector
For two decades, healthcare sector has faced dramatic
changes in technology, demographics, labor market, public’s awareness, and compensation and benefit. This has
created enormous pressure for improving patient outcomes
in hospitals [42]. Next, the new health insurance policy in
Taiwan has effectively integrated many different insurance
programs, such as farmer, labor, government, and military
insurance program and has successfully reached the goal of
the effective management of medical insurance resources.
This policy has created a great impact on the competitive
environment of healthcare sector, including clinics, pharmacists, local hospitals, regional hospitals, and medical centers.
The major impact for various levels of hospitals lies in the
radical change of the medical payment systems. This policy
basically builds on the concept, fee for service (FFS).
J Med Syst (2012) 36:3583–3596
However, the early version of this policy has resulted in
the rapid rise of healthcare cost and further, financial deficit
for the year of 1998 to 2004. The government thus modified
the early version and introduced a new version, namely,
global budget systems, in an attempt to resolve the financial
unbalance while maintaining the quality of healthcare services. This policy will be continuously to make changes in
order to tightly control healthcare cost over time.
Accordingly, the future success in the sector greatly
depends on the improvement of cost structure in hospitals.
Furthermore, while there are growing healthcare consumerism and more constraints on healthcare regulations, it is
difficult for hospitals to effectively manage different
requirements for different stakeholders. These situations
seem to justify the value and importance of IT in this sector.
Hospital information systems (HIS) have begun as a basic
technology for supporting hospital’s operations [40]. Recently, it has been extended to include advanced features
such as picture archival and communication system (PACS),
electronic medical record (EMR), telemedicine system, and
electronic procurement system. Next, most hospitals have
shifted their business focus from traditional clinical activities to the activities of strategic management. This would
promote the role of IT in supporting the activities of strategic management in hospitals [7, 44, 46, 60]. Executives in
hospitals have decided to significantly increase IT investments in recent years [62]. Thus, understanding the potential
value of IT is important and useful for practitioners in
deciding massive IT investments
IT productivity in business and healthcare sector
While there were growing amounts of financial capital
invested in IT, the issue on the justification of IT value has
increasingly become more important than before [9, 22, 41].
Over a decade, the literature has discussed IT value at
various levels, industry, firm, and individual [8, 13, 43].
Firm performance has attracted a large attention in business
sector [8, 34, 50]. The findings were divergent in how they
conceptualize key measures and their interrelationships [1,
43, 56]. One major reason for these mixed findings may be
due to inadequate methodologies applied in assessing IT
value [3, 13, 15].
Performance measures were traditionally in the form of
management accounting systems. This has resulted in focusing on financial measures (i.e. ROI, ROA, and profitability) [18, 47, 57]. In fact, financial measures hinder the
view of organizational growth and success [30, 67]. Financial measures report past performance and are not good for
predicting the future. Financial measures alone rarely provide managers with all the information that they need to
make sound strategic decision. Reliance on financial indicators often leads to a narrow, short-term focus and can be a
J Med Syst (2012) 36:3583–3596
3585
roadblock to adopting long-term opportunities or dealing
with future threats [63]. Many studies examining IT value
have revealed schisms between the use of organizational
practices and financial measures, and the use of quantitative
and qualitative measures [4, 5, 8]. These contradictory
results have caused the IT productivity paradox in firm
performance measure.
Over the last decade, IT expenditure has significantly
increased for the importance of IT role in healthcare sector.
The justification of IT value has become an important issue
for academicians and practitioners. However, little research
has explored IT value in healthcare sector. A study used
both profitability and quality as performance measures to
examine IT value with time lag in healthcare sector, profitability including net patient revenue per day and net patient
revenue per admission, and quality including mortality rate
and customer satisfaction [14]. The findings provided the
support of IT value for the improvement in both profitability
and quality performances. Another study examined the
impacts of IT investments and regulation changes on productivity over a period of 18 years in healthcare sector [45].
The conclusions have led to positive returns of IT investments despite regulation changes.
BSC in business sector
The BSC was initially developed by Kaplan and Norton [30]
from a research of the leading edge performance measurement in early 1990. They argued that traditional financial
measures or accounting systems, such as ROI and ROA,
offer a narrow and incomplete picture of business performance and that a reliance on such data hinders the creation
of future business value. The BSC intends to complement
traditional financial measures with additional three perspectives. The BSC allows managers to look at the business from
four important perspectives, as indicated Fig. 1. The BSC
provides answer to four basic questions: (1) How do customers see us? (Customer perspective) (2) How do companies look to shareholders? (Financial perspective) (3) What
must companies excel at? (Internal process perspective) (4)
How can companies continue to improve and create value?
(Learning and growth perspective)
While providing executives’ information from four different perspectives, the BSC considers various organizational practices and simultaneously minimizes information
overload by limiting the number of measures used. After
Kaplan and Norton’s study, a large number of companies
have already adopted the BSC for measuring firm performance. The early experience using the BSC has demonstrated meeting several managerial needs. First, the BSC brings
together, in a single management report, many of the seemingly disparate elements of a firm’s competitive agenda such
as becoming customer-oriented, shortening response time,
improving quality of products, reducing new product cycle
time, and managing strategy. Second, the BSC guards
against sub-optimization in a firm’s operation. By considering all the important measures together, the BSC indicates
whether improvement in one area may have achieved at the
expense of another [30–32].
After the initial experience of the BSC, many companies
have moved beyond their early vision for using the BSC as a
strategic management system. The BSC in originality
addresses a serious deficiency in reflecting a firm’s strategy.
Without a comprehensive understanding of a firm’s strategy,
executives can not create alignment with the four perspectives. The BSC further proposes a new framework for organizing strategic objectives into the four perspectives with
cause-and-effect link, as indicated in Fig. 2 [33–35]. The
new framework initially arranges financial perspective at the
top. While achieving financial success is not the primary
objective of many organizations such as non-profit organizations, this structure is rearranged with customer at the top
and finance at the next.
BSC in healthcare sector
While the BSC has many successful applications in business
sector [6, 22, 28, 33–35, 50], applying the BSC to healthcare
sector has some unique challenges [63, 71]. This is due
in part to involving many different stakeholders such
as patients and their families, employers, physicians,
employees, insurance company, and the public. The design
and implementation of the BSC in healthcare sector is much
more complex than business sector in terms of the
Fig. 1 The Balanced scorecard
(Adapted from Kaplan and
Norton [30])
F in a n c ia l p e r s p e c tiv e
H o w d o w e lo o k to
s h a re h o ld e rs ?
In tern a l p ro cess
p e r s p e c tiv e
C u s to m e r p e r sp e c tiv e
H o w d o c u s to m e rs s e e u s ?
W h at m u st w e e x c e l at?
L e a r n in g a n d g r o w th
p e r s p e c tiv e
C a n w e c o n tin u e to
im p ro v e a n d c re a te v a lu e ?
3586
J Med Syst (2012) 36:3583–3596
Fig. 2 The BSC strategy map
(Adapted from Kaplan and
Norton [32, 34])
V is io n a n d s tr a te g y
F in a n c ia l
p e r s p e c tiv e
C u sto m e r
p e r s p e c tiv e
In te r n a l
p rocess
p e r s p e c tiv e
L e a r n in g &
g r o w th
p e r sp e c tiv e
characteristics of the multiple stakeholders. In order to effectively link organizational practices in hospitals, for example, outcome, quality, value, and cost, the BSC is an
integrated tool for measuring them [8]. The performance
of outpatient operations in Mayo Clinic was originally based
on financial perspective. Executives further proposed a new
performance measure system based on the BSC concept
[12]. This system includes the measures of customer satisfaction, internal process, quality of service, finance, and public
responsibility, and further, identified detailed performance
indicators for these measures. Bridgeport Hospital used the
BSC as a strategic planning tool to focus on the first priority of
the patients [23]. The CEO and management team can track
progress through the review of the scorecard’s metrics.
Zelman et al. [71] reviewed the BSC concept in healthcare sector. They briefly summarized some of their suggestions: (1) the BSC concept is relevant to healthcare sector,
but modifications are necessary to reflect the organizational
setting; (2) additional perspectives for the BSC include
quality of care, outcome, and accessibility; (3) an effort
C o st
s tru c tu re
H e a lth c a re
s e r v ic e
a ttrib u te s
A sset
u tiliz a tio n
N ew
re v e n u e
o p p o r tu n itie s
C u s to m e r
re la tio n s h ip
C u s to m e r
v a lu e
H o s p ita l
im a g e
O p e ra tio n s
m anagem ent
p ro ce ss
C u s to m e r
m anagem ent
p ro c e ss
In n o v a tio n
p ro c e ss
H um an
c a p ita l
O rg a n iz a tio n
c a p ita l
In fo rm a tio n
c a p ita l
should proceed for comparing use of the BSC as the major
framework among hospitals. Hospitals are a type of non-profit
organizations from social and public aspects. Voelker et al. [63]
proposed a new BSC structure for hospitals, as depicted in
Fig. 3. Customer perspective relocates at the top while financial
perspective is at the next. This is because financial performance
may be not often the primary goal of non-profit organizations.
Learning and growth perspective constitutes the base as the
foundation for the success in other organizational practices.
Next, this subsection intends to develop the measures for the
four IT-enabled performance perspectives in healthcare sector.
The subconstructs were defined mainly based on the structure
of the BSC strategic map, as indicated in Fig. 2. There are three
subconstructs for finance, asset utilization, new revenue opportunities, and profitability, three subconstructs for customer,
healthcare service attributes, customer relationship, and hospital image, two subconstructs for internal process, operations
management process and innovation process, and three subconstructs for learning and growth, human capital, organizational capital, and information capital. This research further
Fig. 3 The BSC for nonprofit
organizations (Adapted from
Voelker et al.[63])
M is sio n
S ta k e h o ld e r s
F i n a n c ia l
In te rn a l p ro c e ss
L e a r n i n g a n d g r o w th
H o w d o o u r s ta k e h o ld e r s s e e u s ?
H o w d o w e lo o k to th e p r o v id e r s o f
f in a n c ia l r e s o u r c e s ? W h a t c o n d itio n
m u s t w e a c h ie v e to f u lf ill o u r m is s io n ?
T o s a tis f y o u r c u s to m e r s , a t
w h a t p ro c e sse s m u st w e
e x c e l?
D o w e h a v e th e b a s ic
in f r a s tr u c tu r e in p la c e to
im p r o v e , c r e a te v a lu e ,
a n d a c h ie v e o u r m is s io n ?
J Med Syst (2012) 36:3583–3596
3587
however, a healthy financial condition is a pre-requisite for
long-term viability in a hospital. Incorporating other organizational practices, such as customer perspective, is necessary in a complementary manner. The BSC approach may
be appropriate to overcome this problem. Moreover, customer performance is normally recognized as the highest
concern in healthcare sector. However, the two BSC hierarchical structures, as indicated in Figs. 2 and 3, have their
individual emphasis on financial or customer performance
conducted an extensive literature review in healthcare sector
and also consulted with executives to define the measuring
items for these subconstructs, as indicated in Table 1.
Research model and hypotheses development
Although IT productivity with financial measure has often
led to inconclusive results, namely, IT productivity paradox,
Table 1 The BSC measures for IT value in healthcare sector
Perspectives
Objectives
Measures
Sources
Financial
Asset Utilization
Improve medical instruments or facilities utilization
Control occupancy ratio of beds
Increase turnover ratio of beds
Increase revenue from self-payment medical services
Increase revenue from new customer market
Increase revenue from community activities
Increase return on investment (ROI)
Increase revenue
Increase profit margins
Increase market share
[63]
[63]
[63]
[34, 35]
[34, 35]
[12]
[63, 64]
[10, 12]
[48]
[10, 12, 21, 43]
Improve availability of medical service
Improve accessibility of medical service
Improve quality of medical service
Improve patient satisfaction
Improve medical staff satisfaction
Improve administrative staff satisfaction
Improve payers satisfaction
Promote hospital reputation in customer survey
Promote hospital rank in customer survey
Increase hospital recognition rate in customer survey
[10]
[10, 39, 63]
[10, 52]
[10, 12, 21, 39, 48]
[10, 21, 23, 41, 63]
[10, 63]
[10, 29]
[10]
[23]
[10]
Improve administrative process
Improve medical service process
Improve after-medical-care service process
Avoid medical errors or incidents
Identify more innovative opportunities for hospital business
Develop innovative medical service
Design innovative administrative service
Improve employees’ skill
[10, 12, 21, 39, 63]
[10, 11, 14, 21, 39]
[21, 39]
[39, 63]
[27, 39, 69]
[48]
[10, 63]
[10, 34, 35]
Improve employees’ talent
Improve know-how capabilities of employees
Provide more opportunities for employees’ training
Improve sharing of work knowledge
Improve awareness of shared vision, objectives, and value
Improve availability of qualified leaders
[34, 35]
[11, 22]
[22, 48, 63]
[34, 35, 49]
[12, 34, 35, 49]
[12, 34, 35]
Improve
Improve
Improve
Improve
[34, 35]
[18, 20, 34, 35]
[34, 35, 48]
[19, 20, 34, 35]
New revenue opportunity
Profitability
Customer
Healthcare service attributes
Customer relationship
Hospital image
Internal process
Operations management process
Innovation process
Learning and growth
Human capital
Organization capital
Information capital
alignment of goal and incentives with strategy
quality of information
capabilities of knowledge management
accessibility of various information
3588
J Med Syst (2012) 36:3583–3596
and may not well fit into this situation. Rather than, many
studies on the BSC issue have indicated their focus on
placing both financial and customer performances at the
top in healthcare sector [38, 65]. Additional study made a
summary from 22 hospitals for presenting different performance focuses on financial, customer , or both when there is
a high proportion of hospitals indicating an emphasis of
placing both performances at the top [24]. Thus, both financial and customer performances were widely considered as
the major concerns simultaneously in the healthcare sector.
This study thus proposed a new BSC structure to evaluate
IT value in the healthcare sector with placing both financial
and customer perspectives at the top, as indicated in Fig. 4.
Specifically, this framework integratively comprises two main
parts. The first examines the impact of IT investments on the
four performance perspectives individually. The second investigates causal relationships among the four performance perspectives. However, much research for the BSC has focused
on the impact of the overall organizational resources in healthcare sector [29, 48, 63]. Little research for the BSC has
discussed the impact of IT resources in healthcare sector.
The following develops relevant hypotheses for the research
mode. As discussed previously, the BSC with the four performance perspectives has been widely applied in evaluating hospital performance [24, 38, 71]. Recently, a study on performance
measurement issue proposed a framework to explore the relationships between IT-enabled supply chain and the four BSC
performance perspectives [68]. This paper particularly argued
that IT investments on supply chain would help to enhance
learning and growth, internal process, customer performance,
and financial performance. Additional study also investigated
the similar issue in healthcare sector for the links between ITenabled capabilities and the four BSC performance perspectives
[65]. Accordingly, Hypotheses 1–4 are thus proposed.
Hypothesis 1. Higher IT investment will help to drive
higher learning and growth capabilities.
Hypothesis 2. Higher IT investment will help to drive
higher internal process capabilities.
Hypothesis 3. Higher IT investment will help to drive
higher customer performance.
Hypothesis 4. Higher IT investment will help to drive
higher financial performance.
The learning and growth perspective constitutes the basic
foundation for directing the future organizational success. It
basically comprises three components, human capital, organization capital, and information capital. While an organization well prepares for these capitals, the organization
would have the capabilities to mobilize and sustain process
changes required to meet the challenge of external environment [33, 35]. Next, researchers have reported that IT
resources in general and knowledge management (KM) in
particular may influence firm performance through the intermediate outcome of business processes [36, 54, 59].
Moreover, the main objective of KM lies in effectively
enhancing organizational learning and growth and eventually building a formal learning organization [53, 70]. Thus,
organizational learning and growth is closely related to IT
resources, and further indicates a potential link to internal
process capabilities. Finally, researchers showed that IT
resources often play the role of enabler in initiating process
redesign [61, 66]. Based on the above arguments, there is a
potential link between learning and growth capabilities and
internal process capabilities. Hypothesis 5 is thus proposed.
Hypothesis 5. Higher IT-enabled learning and growth capabilities will drive higher internal process
capabilities.
The internal process perspective captures critical business
activities and drives current operations of the organizations
in an efficient and effective way. While financial and customer performance are the ultimate goal in hospitals, the
improvements in the critical business processes are the
reliable indicators of future financial success and customer
satisfaction [12, 63]. Recently, research on the healthcare
BSC issue have proposed that internal process is the important antecedent for reaching both customer and financial
Fig. 4 Performance framework
IT investment
H1
H2
H3
H4
Finance
H7
Learning
and growth
H5
Internal process
H6
Customer
J Med Syst (2012) 36:3583–3596
performances with the support of IT driver [38, 65]. Moreover, researchers examining IT value revealed that IT
resources influence financial and non-financial performance
through intermediate business processes [36, 43]. In the netenabled organizations, IT resources not only improve individual processes, but also enable process synthesis and
integration across organizational boundaries, for reaching
the final goal, such as financial and customer performance
[2, 58]. Thus, the potential links may be argued between
internal process capabilities and customer and financial
performances. Hypotheses 6–7 are thus proposed.
Hypothesis 6. Higher IT-enabled internal process capabilities will drive higher customer performance.
Hypothesis 7. Higher IT-enabled internal process capabilities will drive higher financial performance.
Research design
This study conducted a large-sample survey research to
collect cross sectional data. A three-part questionnaire was
designed. The first uses a nominal scale, while the others use
a 7-point Likert scale, as indicated in Appendix.
Instrumentation
Basic information This part collected organizational characteristics, including type of hospital, annual revenue, number of employees, and experience in IT investment, together
with respondent’s characteristics, including education, age,
working experience, and position.
IT investment This part, in general, defined the components
of IT investment in hospitals, including computer hardware,
computer software, and human assets [13, 14, 45]. A total of
three measuring items were defined in this part.
Balanced scorecard This part mainly based the BSC strategic map on developing the subconstructs for the four perspectives [34, 35], as indicated in Fig. 2. Then, a
comprehensive literature review and consultation with practitioners in healthcare sector was conducted to define the
measuring items for these subconstructs, as presented in
Table 1. Financial perspective includes three subconstructs, asset utilization, new revenue opportunity and
profitability, and each containing three items, three items,
and four items, respectively. A total of ten measuring items
were defined in this construct. Customer perspective consists of three sub-constructs, healthcare service attributes,
customer relationship and hospital image, and each containing three items, four items, and three items, respectively. A
total of ten measuring items were defined in this construct.
3589
Internal process perspective comprises two sub-constructs,
operation management process and innovation process, and
each four items and three items, respectively. A total of
seven measuring items were defined in this construct.
Learning and growth perspective contains three subconstructs, human capital, organization capital and information capital, and each containing four items, four items, and
three items, respectively. A total of eleven measuring items
were defined in this construct.
Sample design
This study primarily discusses the contribution of IT investments in healthcare sector. Experience in massive IT investments is the basic requirement for qualified hospitals to serve
as potential survey respondents. Thus, larger hospitals would
be more likely to have the experience. Three types of hospitals, medical center, regional hospitals, and district hospitals,
were qualified for this research. A total of 496 hospitals were
chosen according to the 2007 listing published by the Taiwan
Joint Commission on Hospital Accreditation. Furthermore,
the main focus of this research was to understand the issue
of IT-enabled hospital performance. This issue was considered
an organization-wide concept and was often the major concern of senior management. Executives or vice executives
were the managerial personnel more likely to be familiar with
the issue and were thus selected as the major respondents.
Next, in order to improve survey return, follow-up procedure
was conducted using phone call or letters for the nonrespondents after 2–3 weeks.
Scale validation
Initial pretest was conducted for the scale. The scale was
carefully examined by selected practitioners and academicians in this area, including translation, wording, structure,
and content. Initial reliability and content validity of the
scale should be acceptable. After the questionnaire was
finalized, 496 questionnaires were sent to the respondents
by regular mail. 173 questionnaires were responded, with
missing data or data entry errors deleted, resulting in a
sample size of 158 for a response rate of 31.9%. Table 2
depicts the sample demographics. The seemingly low response rate raised the concern about non-response bias.
Non-response bias can be best addressed by confirming that
there is a sample size sufficient for statistical analysis.
This study thus conducted a power analysis to confirm
the sufficiency of the sample size. When the research model
can be considered as four multiple regression models for the
four dependent variables (performance perspectives) associated with their independent variables, the power (1-β) in
regression models refers to the probability of detecting a
regression coefficient at a specified significant level for a
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J Med Syst (2012) 36:3583–3596
Table 2 Sample demographics
Hospital types
Medical center
Regional hospital
District hospital
Annual revenue
<100
100~500
500~1000
1000–1500
1500–2000
>2000
Number of employees
<100
100~500
500~1000
1000~1500
1500~2000
>2000
Working experience
<10 years
10~15 years
15~20 years
20~25 years
>25 years
Education level
High school
College
Graduate
Ph.D.
Gender
Female
Male
Age
<30
30~40
40~50
50~60
>60
Position
Executive/Vice executive
IT manager
Other manager
Frequency
Percent (%)
12
50
96
7.6
31.6
62.8
50
55
42
31.6
34.8
26.5
6
3
2
3.9
1.9
1.3
39
56
23
18
13
9
24.7
35.4
14.5
11.5
8.2
5.7
61
30
33
18
16
38.6
19.0
20.9
11.4
10.1
6
72
3.8
45.6
65
15
41.1
9.5
40
118
25.3
74.7
14
29
51
54
10
8.8
18.3
32.2
34.2
6.5
90
50
18
56.9
31.7
11.4
specific sample size. This study defines significant level (α)
as 0.05. The test results showed that all regression coefficients in each of the four regression models reach a power of
0.80 at least. This indicates that there is a sufficient number
of observations for statistical analysis.
In addition, common method bias results from the fact
that the respondents provide the measures of explanatory
and dependent variables by a common rater [47]. In this
study, subjective measures were used for two relationship
structures, that is, IT investments and four performance
perspectives, and the four performance perspectives. The
two structures are all associated with the explanatory and
dependent variables. There is a risk for common method
bias. Harman’s single factor test is one of the most widely
techniques to address the issue of common method variance
[51]. This method includes all items from all of the constructs for a factor analysis to determine whether the majority of the variance can not be accounted for by one general
factor, that is, more than 50% variance accounted for. The
results reported the explanatory and dependent variables
extracted as different factors from the survey data. No single
factor accounts for the bulk of covariance (less than 50%
variance accounted for), leading to the conclusion of the
inexistence of common method bias.
Furthermore, confirmatory factor analysis (CFA) with
AMOS software was used for scale validation, as described
below. First, a measurement model was examined for a
model fit based on the criteria: chi-square/degrees of freedom (χ2/df) less than 3, adjusted goodness-of-fit index
(AGFI) larger than 0.8, goodness-of-fit index (GFI), normed
fit index (NFI) and comparative fit index (CFI) larger than
0.9, and root mean square error (RMSE) less than 0.10 [25].
Second, reliability was assessed using the indicator of composite reliability and construct validity using the indicators
of convergent and discriminant validity. Convergent validity
uses three criteria: item loading (l) larger than 0.7, composite reliability larger than 0.8, and average variance extracted
(AVE) larger than 0.5. Discriminant validity uses the criterion: each construct’s AVE larger than its squared correlations with other constructs [17].
A second-order measurement model was formulated
for the scale. Their indices showed a slightly poor
model fit. GFI (0.81) and AGFI (0.78) were below the
criteria. The testing results further indicated two items
from learning and growth construct and one item from
each of the other three constructs with loading below
0.7. Modifying the prior model with deleting these
items would improve the model fit [54]. The reevaluated results indicated a model fit, χ2/df (591.85/
33401.772), AGFI (0.81), GFI (0.91), NFI (0.90), CFI
(0.92), and RMSE (0.062). The results for composite
reliability and construct validity are shown in Table 3.
Item loadings, composite reliabilities, and AVEs are all
larger than 0.7, 0.8, and 0.5 respectively. Next, AVEs of
the subconstructs are all larger than their squared correlations with other subconstructs. Thus, reliability, convergent validity, and discriminant validity were all in an
acceptable level.
J Med Syst (2012) 36:3583–3596
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Table 3 Reliability and convergent and discriminant validity for the BSC scale
Subconstruct
Item loading
Composite reliability
AVE
Squared correlation
AU
NR
P
HS
CR
AU
NR
P
HS
CR
0.70–0.85
0.75–0.75
0.75–0.82
0.77–0.83
0.76–0.79
0.83
0.81
0.80
0.84
0.82
0.75
0.70
0.73
0.73
0.72
–
0.14
0.23
0.05
0.16
–
0.21
0.09
0.25
–
0.15
0.35
–
0.21
–
HI
OM
IP
HC
OC
IC
0.70–0.77
0.71–0.79
0.71–0.78
0.70–0.80
0.70–0.76
0.89–0.91
0.80
0.81
0.80
0.81
0.80
0.90
0.71
0.71
0.71
0.73
0.71
0.81
0.15
0.20
0.30
0.07
0.35
0.08
0.31
0.08
0.14
0.12
0.37
0.23
0.18
0.17
0.21
0.25
0.11
0.08
0.18
0.14
0.27
0.31
0.09
0.21
0.18
0.05
0.30
0.18
0.27
0.21
HI
OM
IP
HC
OC
IC
–
0.31
0.07
0.31
0.24
0.18
–
0.22
0.16
0.08
0.29
–
0.31
0.06
0.14
–
0.19
0.18
–
0.12
–
Asset utilization (AU), New revenue (NR), Profitability (P), Healthcare service (HS), Customer relationship (CR), Hospital image (HI), Operations
management process (OM), Innovation process (IP), Human capital (HC), Organization capital (OC), Information capital (IC)
Analysis of the structural model
Structural equation modeling (SEM) with AMOS software
was used to examine the causal structure of this model. The
first was to examine a model fit of the structural model. The
second was to determine path coefficients (β) for the hypothetical relationships and coefficients of determination (R2).
The model-fit indices showed a poor model fit, χ2/df 1060/
33703.1, GFI00.83, NFI00.85, and CFI00.83. The testing
results suggested a new mode with an extra path added
directly from learning and growth to customer. That is, the
original model, as indicated in Fig. 4, was proposed as a full
model with indirect link of learning and growth to customer
through the mediator of internal process. In contrast, the
new model can be depicted as a partial model with both
indirect and direct links of learning and growth to customer.
The new model indicated a good model fit, χ2/df0610/
33701.81, GFI00.91, NFI00.91, and CFI00.92. The path
coefficients and coefficients of determination for the modified model are reported in Fig. 5. Hypotheses 2, 3, and 4 are
Fig. 5 Standardized solutions
of the structural model Value
on path: Standardized
coefficient R2: Coefficient
of determination, *: p<0.05,
**: p<0.01
all significant at 0.05 level (β00.28, 0.26, and 0.21). Hypotheses 1, 5, 6, and 7 are all significant at 0.01 level
(β00.48, 0.53, 0.57, and 0.48). The additional hypothesized
path is significant at 0.05 level (β00.23). Thus, Hypotheses
1–7 are all accepted at the two levels. IT investments explain
41% of variance in learning and growth. IT investments and
learning and growth jointly explain 58% of variance in
internal process. IT investments, learning and growth, and
internal process jointly explain 68% of variance in customer
performance. IT investments and internal process jointly
explain 51% of variance in financial performance.
Findings and discussions
First, IT investments indicate different degrees of significant
impacts on the four performance perspectives (Hypotheses
1–4). Among them, learning and growth perspective is the
most significant and can be explained by 41% of variance
(R2 0 0.41). The findings have partially confirmed the
IT investm ent
0.48**
0.28*
0.26*
0.21*
R 2 =0.51
Finance
R 2 =0.41
Learning
and grow th
R 2 =0.58
0.53**
0.48**
Internal process
0.57**
R 2 =0.68
C ustom er
0.23*
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theoretical assumption for defining the new BSC structure in
the research model. That is, learning and growth perspective
constitutes the basic foundation of performance achievement for driving the further success of the other performance perspectives due to IT investments in organizations.
The followings discuss the impact of IT on the four performance perspectives respectively.
For learning and growth perspective, IT plays an important role in well improving employees’ skill, knowledge
sharing, and accessibilities to important information. The
reasons behind this can be explained as below. Learning
organizations have been recognized as an important management concept in organizational practices, in particular for
the healthcare organizations with knowledge-intensive property, and have long been the major concern of senior management for maintaining competitiveness in healthcare
sector. This is because customers are becoming smart, powerful and highly informed for healthcare services in the
Internet era and as a result, their requirements change frequently in terms of the new stimulus of the society. KM
capabilities play a critical role in facilitating organization’s
learning to improve employee expertise for meeting the
changes of customer requirements. IT in general and KM
in particular are thus the important antecedent of learning
and growth capabilities.
For internal process perspective, the findings are consistent with those of prior business research. IT is the major
driver of business process reengineering (BPR) and has
strategic potential in reshaping organizational structure.
The results show that IT significantly improves the performance of all hospital processes, including administration,
clinical care, customer service, and innovation processes.
This implies that IT role in healthcare sector is more important than other sectors. However, there is little research for
the exploration in healthcare sector. For customer perspective, the findings, in general, indicate that IT is an effective
tool in enhancing customer satisfaction. Prior research argued that IT, including system, information, and service
quality, has positive impact on customer satisfaction in
business sector. Over the last decade, IT tools, such as
HIS, PACS, electronic medical record, and e-procurement
system, are prevalent for providing the support to the management of healthcare organizations. However, empirical
investigation for IT-enabled customer performance has been
relatively rare in healthcare sector. More importantly, IT
shows positive impact on various customer performance
indicators, such as healthcare service, customer relationship,
and hospital image.
Financial perspective shows the lowest performance
achievement among the four performance perspectives from
IT investments (β00.21). The reasons behind this can be
explained as below. Customer perspective is often the ultimate
goal of non-profit organizations, for example, healthcare
J Med Syst (2012) 36:3583–3596
organizations. However, a healthy financial condition is also
a prerequisite for long-term viability of hospitals. This allows
the hospitals obtaining the resources necessary to provide high
quality of services, satisfy stakeholders’ needs, and fulfill their
mission. The IT productivity paradox associated with financial measures may be another possible reason to explain this.
As non-financial performance, such as learning and growth,
internal process, and customer, may be significantly improved
after a regular period of time, financial performance may
require an extended period of time to fully achieve it. This
implies that IT may play more important role in driving
customer than financial performance in healthcare sector.
The followings discuss the findings for the new BSC
structure among the four performance perspectives, that is,
the paths of learning and growth to internal process (H5),
internal process to customer (H6), and internal process to
finance (H7). For the path of H5, learning and growth
capabilities explain the major portion of 58 % of variance
in internal process (β00.53, R2 0 0.58). The reasons behind
this can be described as below. IT is the major driver to
improve learning and growth capabilities, such as employee
skills, know-how capabilities, new idea generation, and
worker’s knowledge sharing, through KM capabilities. IT
is the important component in building KM capabilities.
Examples of IT tools include database technology to support
codifying explicit knowledge and communication technology to support personalizing tacit knowledge. On the other
hand, IT tools, such as database and communication technologies, can effectively improve two major dimensions in
business process, that is, mediation and collaboration [61,
66]. Thus, the integration of IT and human resources to
create a learning organization enables hospitals to continuously redesign internal processes in improving the process
performance. There are many critical internal processes in
hospitals, such as administration, clinical service, supply
chain, inventory management, customer relationship processes, and so on.
For the path of H6, internal process explains the major
portion of 68% of variance in customer performance
(β00.57, R2 0 0.68). The reasons behind this can be explained
as below. As discussed above, the redesign of management
processes focuses on the enhancement of collaboration level
among workers. Important management processes in hospitals
include clinical service arrangement, manpower assignment,
equipment allocation, bed utilization, drug management, decision making of senior management, etc. IT applications,
such as group support systems, scheduling management systems, drug inventory management systems, and decision support systems, can effectively enhance the collaboration level
in management processes. This would increase the quality of
healthcare service and satisfaction of stakeholders, including
patients, physicians, medical staff, administrative staff, and
public.
J Med Syst (2012) 36:3583–3596
For the path of H7, internal process explains the major
portion of 51% of variance in financial performance
(β00.48, R2 0 0.51). The reasons behind this can be described
as below. In fact, business processes can be classified into two
types based on activity characteristics, operational and management processes. Moreover, the redesign of operational
processes basically focuses on reducing the degree of mediation and management processes on enhancing the degree of
collaboration. IT applications, such as HIS and supply chain
technology, can effectively reduce the degree of mediation in
operational processes, such as administration, customer service, and procurement processes. Consequently, this would
increase efficiency of these processes and in turn, decrease
operational cost in achieving financial performance.
For the added path, learning and growth capabilities
directly affect customer performance in a significant level
(β00.23). This finding is new and important in healthcare
sector. This indicates a phenomenon for a partial mediating
role of internal process in achieving customer performance
as opposed to the traditional BSC hierarchical structure [55].
Prior research argued similarly that the influential structure
among the four performance perspectives may vary with
certain degrees in different industries [33, 63]. The reasons
behind the new finding may be explained as below. Healthcare sector has knowledge-intensive property for heavy
emphasis on the expertise of physicians and nurses in effectively treating their patients. The medical knowledge required for them is often in a tacit form and meanwhile, IT
applications, such as KM, are the effective tool to support
learning and growth capabilities in a way to enhance their
tacit knowledge. This type of knowledge is specific in the
mind of medical personnel for the need of patients and
would directly reflect on the effective care of patients. This
would cause immediate and direct impact on the psychological perception of patients and in turn, patient satisfaction.
Accordingly, learning and growth capabilities would create
direct effect on customer performance in addition to indirect
effect through the mediator of internal process.
Conclusions and suggestions
This research proposes a new relationship structure among
the four BSC perspectives and has empirically concluded
some important findings. First, significant achievements
have been found for all four performance perspectives from
IT investments. Specifically, learning and growth perspective is the most significant one. Second, there are significantly positive relationships among the four performance
perspectives, that is, learning and growth to internal process,
internal process to both customer and finance. Moreover, a
direct link was found for learning and growth capabilities
and customer performance. This finding is important for
3593
practitioners using the BSC in healthcare sector. In sum,
the newly defined BSC structure, while used for assessing
IT value in the hospitals, is in a position to effectively
integrate intangible and tangible IT assets/resources to eventually realize their performance.
The implications for practitioners are as noted below.
First, while the IT productivity paradox was often caused
by using financial data, using both financial and nonfinancial measures to assess IT value, such as the four
BSC perspectives, can overcome this problem. Specifically,
the three non-financial performances, learning and growth,
internal process, and customer, were found to have significant improvements due to IT investments. This indicates
that their roles are important in assessing IT value while
they are regularly ignored in organizational performance
practice. Moreover, financial performance may require an
extended period of time in its creation process (a time-lag
effect) to fully realize. Both findings can provide possible
reasons to explain the phenomenon of the IT productivity
paradox. Second, while customer and financial performance
were both achieved well through internal process in IT
investments, this implies that hospitals should try to provide
unique mix of various IT-supported healthcare services,
including patient relationship, convenience, and image, to
improve both performances. Third, learning and growth
capabilities indicate a direct impact on customer performance. Applying IT to support an organization’s learning
and growth capabilities, such as KM, would be an important
channel to the increase of customer satisfaction. Finally, the
defined framework as a type of performance measurement
system further provides a strategic management tool to
effectively plan and implement massive IT investments in
the hospitals.
The implications for academicians are as below. The
literature has just literally discussed use of the BSC in
assessing the performance of the whole organizational
resources in healthcare sector. There was a lack of the
discussion in using the BSC to assess IT value in the
literature. This new BSC structure has offered substantial
evidences in explaining the problem of the IT productivity
paradox in the literature. Researchers argued that intangible
assets, such as knowledge resources and learning and
growth capabilities, regularly create an indirect impact on
final performance through the mediator of internal process
capabilities in business sector [43]. This research, in contrast, indicates a difference for the direct impact of learning
and growth capabilities on customer performance in healthcare sector. This would indicate an important contribution in
the literature. A second-order measurement model used in
the research has provided more insight for capturing the
explained variances of the four performance perspectives.
Specifically, the measuring items defined for all of the
subconstructs have indicated high levels of reliabilities and
3594
J Med Syst (2012) 36:3583–3596
validities, as indicated in Table 3. Furthermore, the newly
defined BSC structure has demonstrated high practical validity in assessing IT value in healthcare sector.
Next, this research just initiates a starting point and raises
several new questions for further research. First, this research
aims primarily at developing a research framework and further
examining it by empirical data. Future research with case
studies can offer another view to longitudinally observe the
usefulness of this framework in practice. Second, healthcare
sector is recognized as a special type of service sectors. Future
research can examine other similar types of service sectors to
see if the study results are supported. Third, while time lag is
an important factor in determining performance realization, in
particular, financial performance, future research may consider time lag as a moderator or control variable for financial
performance. Finally, since this study focuses on a single
national setting, future research could involve other countries
to understand their differences and similarities.
Although this research has presented some important
results, a number of limitations may be inherent in it. First,
the response rate was lower than desirable, despite the
various efforts to improve it. This may be due to, in practice,
a lack of experience in using the BSC as a performance
measurement system. However, the sample size is sufficient
with high power for current statistical analysis. In the future
survey, 5 contact protocols proposed by Dillman [16] can be
used to improve the response rate. Next, while executives or
vice executives were the major respondents in the survey,
however, IT managers and other managers also occupied a
significant proportion of 31.7% and 11.4%. IT managers are
also the managerial personnel likely to be familiar with the
activities and can provide different or additional information
for the survey. Although this would create different points of
view from executives, however, it could increase the diversity of data sources from multiple informants and thus, the
variances in the variables of interest.
Acknowledgement
interest.
The authors declare that they have no conflict of
Appendix
Basic information
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
Hospital type
Annual revenue (NT$ millions)
Number of employees (Persons)
Working experience
Education level
Gender
Age
Position
IT investments
(1) There are massive investments in computer hardware in
my hospital.
(2) There are massive investments in computer software in
my hospital.
(3) There are massive investments in IT personnel in my
hospital.
BSC performance
1. Financial perspective
(1) Use of IT can help improve utilization of medical
equipments and facilities.
(2) Use of IT can help increase occupancy rate of beds.
(3) Use of IT can help increase turnover rate of beds.
(4) Use of IT can help increase new revenue from selfpayment medical services.
(5) Use of IT can help increase new revenue from new
customer market.
(6) Use of IT can help increase new revenue from
community service.
(7) Use of IT can help increase return on investment.
(8) Use of IT can help increase sale revenue.
(9) Use of IT can help increase profit margins.
(10) Use of IT can help increase market share.
2. Customer perspective
(11) Use of IT can help improve availability of medical
service.
(12) Use of IT can help improve accessibility of medical
service.
(13) Use of IT can help improve quality of medical
service.
(14) Use of IT can help improve patient satisfaction.
(15) Use of IT can help improve medical staff
satisfaction.
(16) Use of IT can help improve administrative staff
satisfaction.
(17) Use of IT can help improve payer satisfaction.
(18) Use of IT can help promote hospital image and
reputation.
(19) Use of IT can help promote hospital rank in customer survey.
(20) Use of IT can help promote hospital recognition of
medical service.
3. Internal process perspective
(21) Use of IT can help improve administrative service
process.
(22) Use of IT can help improve healthcare service
process.
J Med Syst (2012) 36:3583–3596
(23) Use of IT can help improve after-medical-care
service process.
(24) Use of IT can help avoid medical errors or
incidents.
(25) Use of IT can help identify more innovative opportunities for hospital.
(26) Use of IT can help develop innovative medical
service.
(27) Use of IT can help design innovative administrative
service.
4. Learning and growth perspective
(28) Use of IT can help improve skill of employees.
(29) Use of IT can help improve talent of employees.
(30) Use of IT can help improve know-how capabilities
of employees.
(31) Use of IT can help provide more opportunities for
training of employees.
(32) Use of IT can help improve knowledge sharing of
employees.
(33) Use of IT can help improve awareness of shared
vision, objectives, and value.
(34) Use of IT can help improve availability of qualified
leaders.
(35) Use of IT can help improve alignment of goal and
incentives with strategy.
(36) Use of IT can help improve quality of information.
(37) Use of IT can help improve knowledge management capabilities.
(38) Use of IT can help improve accessibility of various
information.
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