Stephen Darlington
treat that group than if they have opt‐in or opt‐out rights. Effectively dealing with epidemics such as SARS is a case in point.
5. Satisfaction with e‐health systems seen as success or failure
The factors that may impinge on satisfaction measures would include: improved information management leading to better medical service delivery, cost efficiencies, positive service delivery transformation, whether overall expectations are met and participation fully realized( loyalty as opposed to exit). Satisfaction may involve patients fully disclosing relevant medical information( responsibility) to healthcare providers in the expectation that by doing so they will receive the most appropriate care. Addressing patient privacy concerns is key to reducing the likelihood that“ patients will continue to keep information to themselves”( Townsend 2012). E‐health also has the potential to transform service delivery with the result that service delivery will be improved. Indicators that the transformation of service delivery has been successful are changed stakeholder expectations of increased institutional efficiency and effectiveness and a measureable improvement in both. Achieving these outcomes is the theoretical basis for ascertaining e‐health system success and an indicator of the legitimacy of e‐government systems in general.
Dissatisfaction with e‐health systems may be indicated by: service delivery staying the same or deteriorating, unresolved rights issues that negatively impact stakeholders loyalty, negative stakeholder expectations regarding the efficiency and effectiveness of the e‐health institutional system, and dissatisfaction expressed through voice( complaints, arguments and litigation) and exit. Therefore, incentives and disincentives, how they are interpreted and valued, need to be explained( Hodgson 2006: 6) in order to more fully identify the components of success or failure. Power‐relationship ratios may also be determined in part by the rights incentives and disincentives inherent within the institutional e‐health system. This is an area requiring further research.
Satisfaction may be enhanced by the widespread adoption of e‐health institutional norms and values that appropriately balance stakeholder rights and system utility. E‐health legislation creates legal rights that result in healthcare provider obligations. E‐health institutional rules then develop as an interpretation, often explicit, of legislative intent. Once these rules are followed by most stakeholders most of the time they become customary( Hodgson 2006: 3,6,7,18,21). If combined with complimentary social norms then rules and norms combine to reinforce institutional legitimacy. People thus obey laws not simply because of the sanctions involved but also because legal systems can acquire the force of moral legitimacy and the moral support of others( Hodgson 2006: 5). When citizens habitually obey laws, follow rules and procedures, and show satisfaction with an institutional system then it could be argued that the institutional power relationship ratio favours the citizen while broadly supporting government policy.
6. Determining stakeholder rights
My main argument is that power‐relationship ratios determined by a chosen balance of rights versus utility could explain e‐health system success or failure. The theoretical basis for e‐health system success is the Rawlsian concept of the role of institutions being to“ secure fair background conditions against which the actions of individuals and associations – that are all part of society as a whole – take place”( Rawls, cited in Lehning 2009: 95). By doing so e‐health systems can enhance service provider and citizen interaction by effectively balancing citizen concerns over choice and service quality( Huijboom et al. 2009: 21) with the demand for, and cost of, health services. In part, this operationalizes“ key factual and visionary trends” identified by Huijboom et al.( 2009) including the“ simplification of processes and organisation” that reduce the administrative burden for citizens and businesses, and good governance concepts including responsiveness, consensus, equity and inclusion through democratic participation. To do so requires e‐health systems that enable citizen’ s capacity and competence to be capably expressed or used. This is both an institutional process of ableness and a societal process of norm building that reflects stakeholder values leading to appropriate power relationship ratios that balance stakeholder rights and e‐health system utility.
A successful balance between rights and utility will be identifiable in part when e‐health institutional rules and procedures become conventional and are widely seen as legitimate. Hodgson’ s( 2006) concept of the social nature of citizen interaction with institutions such as e‐health is valuable in that it allows public sector service provider efficiency and effectiveness to be measured through the rights lens of stakeholder engagement and satisfaction with the institutional system of rules and norms. Thus, Australia’ s PCEHR allows patients to make
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