Research

Improving quality of service of home healthcare units

with health information technologies
Juan Gabriel Cegarra-Navarro, Anthony K.P.Wensley and Maria Teresa Snchez-Polo

Abstract
Deployment of health information technologies (HITs) provides home care units with the means to generate
improvements in accuracy and timeliness of information required to meet dynamic patient demands and provide
high quality patient care. Increasing availability of information can also facilitate organisational learning, which
leads to the invocation of processes that result in improved responses and decisions. This study examined
crucial links between HITs and quality of service provided through an empirical investigation of 252 patients in a
hospital-in-the-home unit (HHU) in a Spanish regional hospital. The study sought to test the relationship between
HITs and the quality of service using factor analysis and structural equation modeling (SEM) to investigate
how HITs mediate effects of organisational learning on quality of service. Findings support the notion that the
relationship between organisational learning and quality of service can be mediated by HITs. This study provides
HHU managers with guidelines for understanding the role of organisational learning processes with respect to
HITs and quality of service.
Key words (MeSH): Learning, Information Science; Information Management; Health Services; Health Information;
Quality Improvement; Hospital Home Care Services
Supplementary term: Organisational Learning
Introduction
Home healthcare units (HHUs) can improve quality of life
for patients in a variety of ways, ranging from a reduction
in the variety and severity of risks typically associated
with hospital admissions to a decrease in the level of
care the family needs to provide (Gideon et al. 1999).
To capture potential benefits (or the lack of) measures
of HHU should include performance standards (e.g. the
HHU responds to patient inquiries in a timely manner)
and measures to gauge the extent to which the HHU
follows internal procedures, directives, regulations or
technical aspects of the relationship between healthcare
delivery processes and patients (Lockamy & Smith 2009).
The composite measure of quality of service (QoS) fulfils
these two objectives because effective deployment of
services requires healthcare practitioners to use appropriate technologies and apply their knowledge to critical
healthcare delivery processes, which in turn influences
patients perception of value and satisfaction with these
services (Asubonteng et al. 1996).
Quality of service is determined, at least in part, by
development and application of health information technologies (HITs), which enable provision and maintenance
of care services. For instance, when services are provided
in a homecare setting, patients can access information
from the Internet and potentially contribute to their own
health care (Field 1996), and patient satisfaction may
increase along with quality of care.
However, for HITs to reach their full potential, they
must be implemented in line with medical process that
HHU practitioners routinely use. HITs that can provide
exchange of rich information may require significant
modification of existing routines or adoption of radically
30

new routines. Reardon and Davidson (2007) pointed out

that introducing HITs into the learning environment can
encourage collaboration and build on patients desire to
communicate and share understanding. This, in turn,
facilitates organisational learning because adapting to
and deriving benefits from change, whether instigated
through the adoption of HISs or otherwise, requires that
organisational learning take place. This perspective on
organisational learning is based on the work of March
(1991), who suggested that learning is a dynamic process
consisting of two sub-processes: (i) exploration of new
knowledge and skills and (ii) exploitation of existing
knowledge, skills and processes.
The aim of this paper is to raise awareness of
homecare practitioners of the necessity of connecting
previous learning with successful implementation of HITs.
The authors hope this study may assist home healthcare agencies to understand better the nature and role
of previous knowledge in the successful implementation of HITs as well as the potential benefits in terms of
improved quality of service delivery.

Conceptual framework
HITs can be viewed as both computer hardware and
software that deal with the storage, retrieval, sharing,
use of healthcare information, data, and knowledge
for communication and decision-making (Brailer &
Thompson 2004). Utilisation of HITs has potential to
enhance quality value of service delivery and support
multi-functional and inter-organisational communications
(Chaudhry et al. 2006). Bhatt, Gupta and Kitchens (2005)
identified groupware that capture, store, and manipulate
information, and HITs such as email and mailing lists

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support knowledge management process. (Appendix 1
includes a full list of HITs included in this study).
The growth in variety and capabilities of HITs has
provided many opportunities for HHUs to facilitate
communication and collaboration between colleagues,
patients and carers while patients are in the home environment (Lockamy & Smith 2009). HITs allow exchange
of information between non co-located hospital staff and
patients, resulting in potential improvements in delivery
of care, particularly with patients in a home-care setting.
Through the use of HITs patients are able to augment
their learning with respect to relevant healthcare issues,
generate new knowledge, and obtain feedback from other
users (e.g. practitioners and other patients). Taking the
Internet as one example, Robinson et al. (1998) argued
that it has not only facilitated healthcare information
acquisition by patients but it has also changed the nature
of patient-physician interactions and facilitated a variety
of cost-reduction strategies. For example, practitioners
can upload information about appointments as well as
new techniques or research protocols and data relating to
experiments that they are carrying out.
Although HITs can be effective tools to achieve a
HHUs objectives, there are difficulties associated with
using HITs in a home healthcare setting. Confidentiality
and security issues may present challenges for practitioners attempting to access sensitive patient information
stored on a remote server; and implementation of HITs
often requires modifications to existing routines and
processes or their replacement by new routines and
processes (Cegarra & Cepeda 2010). It is important to
remember that existing routines and processes have
typically co-evolved with paper-based information
systems and may have many characteristics contingent on
such systems (Winthereik & Bansler 2007); and information available in one setting may not be easily available in
another setting and routines will have to be adjusted or
augmented to reduce the incidence of adverse events and
medical errors. For example, a portable pulse oximeter
may not provide information with respect to the patients
carbon dioxide levels and the amount of oxygen being
used, so implementing routines that depend on richer
information provided by non-portable pulse oximeters in
a home healthcare setting will depend on other ways to
obtain the additional information (Campbell et al. 2007).
Applying new and existing HITs in new settings
frequently generates problems when information
provided or routines supported conflict with current
knowledge (Starbuck 1996), for example, patients
and practitioners may use different terms, their understanding of HITs and how they function may be different,
and each may operate from a different knowledgebase,
which can lead to inappropriate actions and potential
misunderstandings. Starbuck (1996) noted that using
new technology typically requires a change in peoples
knowledge, habits and routines, which requires that
they forget old knowledge, habits and routines and
replace them with new ones. Therefore, an organisa-

tional learning process that improves existing skills and

knowledge and extinguishes outdated routines and
knowledge is an essential requirement for organisations
generally, and HHUs in particular.
Organisational learning, at its heart, facilitates
creation and application of new knowledge and new
knowledge structures by reorienting organisational
values, norms and/or cognitive structures (Crossan, Lane
& White. 1999); it involves the acquisition, distribution,
interpretation and storage of knowledge that facilitates
a rapid improvement of business processes, tools and
methods whose improvements are critical to success.
Researchers distinguish between processes that support
the exploration of knowledge and those that support the
exploitation of knowledge. Bontis, Crossan and Hollund
(2002) and Mom, van Den Bosch and Volberda (2007)
maintained that the essence of exploration is to create
variety in experience, associated with broadening a
managers existing knowledgebase; while the essence
of exploitation is to create reliability in experience,
associated with deepening a managers existing knowledgebase. Put another way, knowledge exploitation
refers to the effective and efficient allocation of resources
into valuable and competitive organisational platforms
based on existing knowledge. While knowledge exploration retains knowledge within the organisation, in the
healthcare situation, typically the hospital, knowledge
exploitation may well release the knowledge into the
external environment. In the context of home healthcare,
provision of sub-activities associated with knowledge
exploitation include targeting output to a particular
target (patient, patients family, healthcare providers) and
producing output involving activities such as interpreting,
packaging and delivering information for the target
(Bohmer & Edmondson 2001). We would add that HHU
can further encourage the process of knowledge exploration by implementing some combination of formal or
informal meetings between internal and external parties
or by creating external communities of practice where
patients and practitioners interact and work together in
order to achieve mutually beneficial objectives. Through
the development of relational trust, common language
and confidence, organisational members are able to
articulate, share and internalise knowledge (Cegarra &
Cepeda 2010).
In the healthcare environment, organisational learning
impacts upon several elements of organisational experience that contribute to quality, such as nursing care,
job satisfaction, and patient safety (Aiken et al. 2002).
However, the knowledge resulting from the two aspects
of organisational learning that we have proposed (viz.
exploration and exploitation) might be stored in different
forms and locations, including HITs (Nonaka & Takeuchi
1995). There is an ongoing dynamic interaction between
knowledge created through exploitation and exploration
and the existing stock of individual and organisational
knowledge: improved understanding of one stage
becomes the precursor for the next (Klein & Myers 1999).

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Further, as Darroch and McNaughton (2002) indicated,
successful implementation of technical innovations
requires concerted effort as well as experience in recognising and obtaining new knowledge. Otherwise, lack of
previous learning may lead individuals to duplicate work,
develop conflicting data exchange protocols and apply
incompatible business models (Rodgers, Chen & Chou
2002). The learning process provides a way to explain
and resolve problems associated with implementing and
using HITs (Robey, Boudreau & Rose 2000), and supports
HHUs to modify or develop new routines and knowledge
by providing necessary external and internal knowledge
(Rodgers, Chen & Chou 2002). Where some HITs have
potential to provide ways of classifying and preserving
what has already been learned, they can also be viewed
as providing secondary steps in learning (Sorensen &
Lundh-Snis 2001). This consideration allows us to frame
the first and second hypotheses relating to our research:
H1: The level of knowledge exploration impacts positively
on HITs.
H2: The level of knowledge exploitation impacts positively
on HITs.
The relationship between the use of HITs and quality
of service has received considerable attention in the
literature. Barlow et al. (2007) reported that although
almost 9,000 studies reporting on telecare trials and pilot
projects have been published, little strong conclusive
evidence has emerged pointing to factors that lead to
successful telecare implementation. Whitten and Adams
(2003) reported that considerable investments in HITs
have failed to boost performance in a healthcare setting,
and more successful projects relating to the development
of telemedicine applications possess a more formalised
organisational structure. Gagnon et al. (2006) pointed to
the relevance of a more contingent approach that emphasises the importance of investigating the context in which
HITs exists prior to implementation. Thus, empirical
studies provide mixed support for the hypothesis that the
use of HITs has a direct effect on performance.
We propose that the use of HITs allows patients to
gain a deeper insight into their situation and health
challenges, enabling them to make more informed
decisions. When patients visit a health-portal or e-portal
they are in a powerful position because they can exercise
control over data and information provided about
themselves, and decide whether or not to engage in the
relationship (Leben et al. 2006). Such actions lead to
improved response times, improved quality of care and
knowledge sharing and creation. We argue that HITs
can be important tools to help hospital administrators
to meet patient needs by providing access to more and
better information, aid in routine administrative tasks,
and provide models and simulations of effective learning
practices. HITs can also enable learner support networks,
both in face-to-face and distance learning environments,
and provide for interaction in real time or asynchronously
(Lockamy & Smith 2009). This leads to improved patient
service levels and a higher level of perceived quality
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(Asubonteng et al. 1996). As Barlow and Hendy (2009)

noted, the main beneficiaries of HITs are patients and
family carers, through the provision of independence,
security, confidence, quality of life, and ability to stay in
ones own home. The hypothesis we propose under this
framework is:
H3: The use of HITs will affect the patients assessment of
the quality of service provided.

Method
Sample and data collection
To test these three hypotheses, patients in a Hospital-inthe-Home Unit (HHU) in a Spanish Regional Hospital
with a capacity of 880 beds were considered. This
HHU covers all necessary medical services, including
orthopedic surgery, gynaecology, obstetrics, anaesthesiology, radiology and a clinical laboratory; coordinates
treatment; offers psychological and social services; and
provides in-patient, emergency, post-discharge and
alternative care, such as hospice home healthcare. It
was established in April 1998, with a few hospitals in
almost every other city in the Region developing similar
programs. Initially, this unit was founded to improve
hospital patient flow, creating greater acute care capacity.
Ethical approval was granted by the Research Ethics
Board of the participating hospital and the program was
approved by the hospitals HHU Board in February 2007.
We chose to study this HHU for two main reasons: (a)
despite patient satisfaction reported as high (see Sanchez
et al. 2007), evaluation of the underlying causes of these
high levels of satisfaction was underdeveloped (Bao et
al. 2007); (b) HHU is an ideal platform for implementing
telemedicine networks because two or more individuals
(e.g. patients, carers, doctors and nurses) work together
with different web-based technologies and complementary capacities, which are changing enabler factors (Yu &
Yang, 2006). Therefore, the HHU at this hospital was an
appropriate setting for an investigation of organisational
learning and its impact on HIT, with web-based interaction allowing for exchange of information within the
patients social context, which may make consultation
more effective for all participants (Sanchez et al. 2007;
Bao et al. 2007).
HHU professionals at this hospital offer a service that
is both high quality and compassionate; they turn homes
into healing environments where selected patients and
their families learn to provide appropriate care. Selection
criteria for patients participation in HHU care services
include a stable medical condition that can be managed
at home without unexpected emergency interventions,
availability of a carer, an appropriate standard of housing,
a telephone connection, and patient consent. Patients are
visited and intravenous drugs administered by the HHU
nursing team comprised of four nurses. Every patient
receives a written Emergency Plan explaining the 24-hour
telephone backup service, which is provided by an HHU
nurse and the HHU director. The HHU medical members

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(two internal medical doctors) undertake medical
supervision while the patient is at home and carry out
ward rounds every day. At the conclusion of treatment,
the patient, who has retained the full status of a hospital
inpatient throughout the period of HHU care, is formally
discharged.

Measures
We used Churchills (1979) approach to questionnaire development, combining scales from several
other relevant empirical studies with new items to
make an initial list of 26 items (four measuring range
of knowledge exploration; four measuring knowledge
exploitation; 13 measuring the existence of HIT, and five
relating to quality of service). Appendix 1 provides an
overview of the final 26 questions.

Knowledge exploration and knowledge exploitation

Based on Mom et al. (2007), we adopted a broader
notion of organisational learning. While the Knowledge
Exploration Scale (ER) determines the extent to which
the HHU supports activities that encourage individuals
to learn new skills or knowledge by tracking changing
markets and sharing market intelligence with patients
and other external agents (Mom, van Den Bosch &
Volberda 2007), the Knowledge Exploitation Scale (ET)
focused on utilisation of knowledge embedded in the
HHU to develop plans and response to implementation of
plans (Bontis, Crossan & Hulland 2002).

Customer perceptions of service quality

SERVQUAL, a multi-item scale first proposed by
Parasuraman, Zeithaml and Berry (1985), was used to
measure customer perceptions of service quality across a
wide variety of service environments, including healthcare in the USA (Carrillat, Jaramillo & Mulki 2007).
The version of the scale used was based on the work
of Carrillat, Jaramillo and Mulki (2007) and adapted to
the context of the study by the authors. The scale consists
of five statements to measure performance across five
dimensions that indicate whether or not patient expectations have been achieved: (i) physical facilities; (ii)
service performance ability; (iii) prompt and helpful
service; (iv) ability to inspire trust and confidence;
and (v) caring individual attention. Based on patients
answers to these questions, we created a new variable
with a minimum value of zero and a maximum value of
five. (See Appendix 1 for details).

The HIT Scale

Measures relating to the existence of the HIT Scale
consisted of 13 items adapted from a scale designed by
Bhatt, Gupta and Kitchens (2005) to measure features of
technologies associated with communication modalities
(e.g. fax, email, voicemail). Respondents were asked to
represent the current status of HIT from their point of
view on a dichotomous scale of 13 items (See Appendix
1). From answers respondents supplied, we found a new
variable with a minimum value of zero and a maximum
value of 13; where zero was not at all and 13 was to a
very large extent.

Reliability and validity of measures

Research models and hypothesised relationships were
empirically tested using structural equation modelling
(SEM), supported by EQS 6.1 software (Bentler 1988).
EQS was selected because of the characteristics of our
model and sample. Our data are non-normal and other
techniques of structural equation modelling (e.g. the
covariance-based model performed by LISREL or AMOS)
cannot be applied in these circumstances (e.g. see
Diamantopoulos & Winklhofer 2001). Using EQS entails a
two-stage approach (Bentler 1988). The first step requires
assessment of the measurement model, which allows
relationships between observable variables and theoretical concepts to be specified. This analysis is performed
in relation to attributes of individual item reliability,
construct reliability, average variance extracted (AVE),
and discriminant validity of indicators of latent variables.
In the second step, the structural model is evaluated, to
test the extent to which causal relationships specified by
the proposed model are consistent with available data.

Data analysis and results

Hypotheses were tested simultaneously using structural equation modelling (SEM), supported by EQS 6.1
software (Bentler 1988). SEM used 252 cases. Referring
to hospital records, we pre-selected all patients admitted
to the home care unit during 2007, which resulted in
300 patients being contacted by the HHU and asked to
participate in the study, 252 of whom agreed to participate (response rate=84%). In March 2008, we conducted
telephone interviews using a simple structured questionnaire.
Items on the proposed model were evaluated with
exploratory techniques to assess reliability and dimensionality of measures. Initially, each construct was
assessed using item-to-total correlation and exploratory
factor analysis. The decision to retain items was based
on Hair et al.s (1998) recommendation with regard to
statistical criteria (loadings and regression weights),
which resulted in two items being dropped (ER3 and
ET4). Thus, psychometric properties of measures
improved the original proposal. To achieve a more robust
evaluation of the quality of measures, a confirmatory
analysis was performed using the covariance matrix as
input via the robust maximum likelihood method. In
addition, fit indices that are less sensitive to non-normal
data (Satorra-Bentler 2, comparative fit index and
incremental-fit index) were used to interpret the model
fit. The Satorra-Bentler 2 difference test was employed
using available software (Crawford 2007) to provide a
significance test of the relative goodness of fit between
nested models.
With regard to the measurement model, we began
by assessing individual item reliability. The fit statistics
for the resulting eight items, which are summarised in
Table 1, indicate a reasonable data fit. The fit index of
the Root Mean Square Error of Approximation (RMSEA)
is below .08, and the Goodness of Fit Index (GFI), the

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exceed this condition (see Table 2). Discriminant validity
was found to be robust, with confidence intervals ( 2
standard errors) around estimated correlations between
any two latent indicators never including 1.00 (Anderson
& Gerbing 1988).
Hypothesis tests resulting from structural equation
modelling analyses are summarised in Table 3, where
the explained variance of endogenous variables (R2) and
standardised path coefficients are shown. The fit of the
model is satisfactory (GFI=.942; CFI=.892; IFI=.901),
suggesting the nomological network of relationships fits
our data, another indicator of support for validity of these
scales (Churchill 1979). The hypotheses were evaluated
by examining R2 values and size of structural path coefficients. All hypotheses presented were significant and
verified.
The hypothesised link between level of knowledge
exploration and HITs (H1) was supported (=.675 at a
level of p=.032); and knowledge exploitation was found
to have a positive and strong influence on HITs, which
provided support for H2 (=.200 at a level of p=.032).
With respect to H3, the effect of HITs on quality of
service was fully verified (=.853, p=.030). According
to variance explained by each construct, explorative
and exploitive constructs explained 6.1% of the HITs
construct, and HITs explained 25.5% of quality of service.

Comparative Fit Index (CFI) and the Incremental Fit

Index (IFI) are above the common standard of 0.9 (Hair
et al. 1998). These results suggest the use of a single
variable with a minimum value of zero and a maximum
value of 13 to measure the existence of the HIT, and the
use of another single variable with a minimum value of
zero and a maximum value of 5 to measure quality of
service. For selected explorative and exploitive measures,
Bagozzi and Yis (1998) composite reliability index and
Fornell and Larkers (1981) average variance extracted
index are higher than the evaluation criteria of .7 for
the composite reliability and .5 for the average variance
extracted. These results suggest the use of three items
(ER1, ER2 and ER4) to measure knowledge exploration
(pcSCR=.871, pcAVE=.702) and another three (ET1, ET2 and
ET3) to measure knowledge exploitation (pcSCR=.850,
pcAVE=.664).
The constructs correlation matrix, shared variances,
means and standard deviations are shown in Table 2.
Examination of these results shows that all constructs
are reliable. On average, each construct is more strongly
related to its own measures than to others (Fornell
& Larcker 1981). The AVE should be greater than .5,
meaning that 50% or more variance of the indicators should be accounted for (Fornell & Larcker 1981).
Explorative and exploitive constructs of our model

Table 1: Confirmatory factor analysis and scale reliability

Note:
a
b
na

CONSTRUCT

VALUE

t-VALUE

RELIABILITY
(SCRa, AVEb)

ER1: Co-operation and search in social networks for new possibilities

with respect to services or processes
ER2: Co-operation and search in social networks for the renewal of
outdated services or processes
ER4: Work meetings with patients and carers searching for new
possibilities with respect to services or processes

.561

7.227

SCR=.871

.763

3.898

AVE=.702

.461

8.692

ET1: Homecare goals are communicated to patients and their families

ET2: Policies and procedures aid practitioner work
ET3: Homecare operational procedures allow your homecare
practitioners to work efficiently
Health information technology HIT:
Quality of service QS:

.735
.894
.525

6.223
2.787
12.308

SCR=.850
AVE=.664

1.000
1.000

na
na

The fit statistics for the measurement model were: Satorra-Bentler 2(14)=40.95; 2/d.f= 2.925; GFI=0.955; CFI=0.921; IFI=0.924; RMSEA= 0.076;
Scale Composite Reliability (SCR) of pc= (i)2 var () / [(i)2 var () + ii] (Bagozzi and Yi, 1998);
Average variance extracted (AVE) of pc= (i2 var ())/[i2 var () + ii] (Fornell and Larcker, 1981).
The asymptotic covariance matrices were generated to obtain the scaled chi-square (Satorra & Bentler 1988) and robust estimation of standard errors;
not applicable.

Table 2: Descriptive statistics and correlation matrix

M

SD
ER

1.
2.
3.
4.

Knowledge exploration (ER)

Knowledge exploitation (ET)
Health information technology (HIT)
Quality of service (QS)

5.157
4.015
2.433
3.258

1.216
1.769
3.162
1.315

.702
-.104
.032
.302 ***

CORRELATION MATRIX
ET
HIT

.042
.664
.220 ***
.068

.000
.054
na
-.124 **

QS

.113
.006
.015
na

Note.

*** <.01; ** <.05; Mean = the average score for all of the items included in this measure; SD = Standard Deviation; Inter-correlations are presented in the lower and
shady triangle of the matrix. Shared variances are given in the upper triangle of the matrix. The bold numbers on the diagonal are the square root of the Average
Variance Extracted; na = not applicable.

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Table 3: Model statistics
LINKS

PATH COEFFICIENTS

Exploration of knowledge HIT (direct effect)

Exploitation of knowledge HIT (direct effect)
HIT Quality of service (direct effect)
Exploration of knowledge Quality of service (indirect effect)
Exploitation of knowledge Quality of service (indirect effect)
Note:

.675 **
.200 **
.853 **
.576 ***
.171

t-VALUES

R2

2.134
2.144
2.170
3.830
1.161

6.1%
6.1%
6.1%
6.1%
25.5%

SOBEL TEST STATISTIC a

1.934 *
.508

*** p <.01; ** p <.05; * p <.1; a Sobel Test Statistic computed via http://www.danielsoper.com/statcalc/calc31.aspx (accessed May 8, 2010)

We also measured the effect of each dimension

of organisational learning on quality of service. We
estimated Sobels Critical Ratio (Sobel 1982) to test the
indirect effect of independent variables on the dependent
variable by way of the mediator. If the effect of independent variables differs significantly from zero, indirect
mediation is assumed (Preacher & Leonardelli 2003).
Table 3 shows that although knowledge exploitation in
the model had a positive influence it was not significant (t-value of .508). However, knowledge exploration
reached a t-value of 1.934, suggesting a positive and
significant influence at level of (p<.1). Thus, knowledge
exploration has a significant and greater impact on
quality of service (=.576) than knowledge exploitation
(=.171, ns).

Discussion
In testing H1, our results support the proposition that
in order to foster the utilisation of HITs, HHUs need
to provide and support explorative activities. This is
consistent with conclusions reached by Mohamed,
Stankosky and Murray (2006: 112) when they suggested:
information technology must be accompanied by social
networks, such as communities of practice and other
human interventions to create the requisite synergetic
effects. This means that, through knowledge exploration
activities, HHUs foster a dynamic capacity where teams
and their members are able to search out, integrate and
codify new knowledge. By using this dynamic capacity,
HHUs generate commitment and confidence among
patients and can reduce development time for new
services or redesigned processes to implement HITs.
Guided by interactions with patients, HHU managers
may consider it faster and easier to develop an electronic bulletin board that leverages current relations
with patients rather than change the voicemail system to
capture similar information.
Results for hypothesis H2 also support the notion that
knowledge exploitation plays a major role in facilitating
utilisation of HITs. As per Curry and Stancich (2000)
these results suggest that although communication
and collaboration for knowledge creation in organisations requires appropriate technology infrastructure,
it also requires a high level of commitment to technologies among stakeholders (e.g. patients), whose
representations of knowledge are influenced by cultural
background, goals, experience and values. When HHU
employees have problems using current technologies,

they turn first to colleagues and peers for relevant information (Cegarra & Cepeda 2010). What this could mean
for utilisation of HITs is that exploitation processes are
useful for discovery of the usefulness of HITs in real time
(live) and to provide knowledge about possible applications of current technologies (Lin & Lee 2005).
With regard to H3, results show a bi-directional association between HITs and quality of service, indicating that
HITs provide support to patient responsiveness and action
by retaining a broader range of potential responses,
which provides more options for patients when they
respond to variety presented by HITs. HITs allow patients
to exercise better control over processes, and to enter,
capture, classify and record valuable information and
knowledge. This information can also improve organisational performance (e.g. by cutting costs and reducing
risk of errors). Hagel and Armstrong (1997) argued that
the Internet is an ideal platform for enhancing transaction
efficiencies resulting in streamlining business processes.
Patients can easily access databases that offer reliable
information about availability of practitioners, or copy out
a prescription, or read and review an existing prescription
or protocol at any time. Implications for quality of service
are that HITs are useful for understanding patients needs
in real time and these processes provide knowledge about
wishes and needs of patients. HITs provide an opportunity
to enhance quality of services in HHUs, and through the
use of direct, persistent, and interactive HITs, patients can
access knowledge at low cost, which may in turn improve
quality of service.

Limitations of the study

Although constructs were defined as precisely as possible
by drawing on relevant literature, this study highlights
the need for further research with more precise measurement constructs.
This study included one hospital in one country and
the HHU concerned was in the process of implementing
new HITs (i.e. SELENE), which represents a knowledge
base that provides users (patients, doctors, carers) with
easy remote access to information that would otherwise
require contact with hospital staff. Therefore, our data
helped us understand a process where learning influences
the successful utilisation of HITs and how such use can
result in improvement in the quality of service. Further
studies including additional hospitals are required for
results to be generalized to other settings.

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Research
This study was based on a single research methodological approach. Further research including interviews
and observational case studies would allow for triangulation of results, which would enhance capacity to
generalise from empirical statements to a theory of what
would happen in settings other than the HHU observed in
this study.
The important managerial implications presented
in this paper are that organisational learning may help
healthcare organisations to direct their efforts to provide
a better and competitive service to their patients though
utilisation of HITs. Consequently, some information
should be collected and organised before a website or
another HIT can be implemented. In addition, HITs are an
important tool to simultaneously achieve alignment and
adaptability within organisational learning processes.

Conclusion
The role of information and communication technologies (ICT) in sharing knowledge has been a source of
debate. Many investigators in the area of ICT suggest
that technology applications facilitate organisational
learning without sufficient regard for previous learning
undertaken by users (e.g. Mercader, Meroo & Sabater
2006). In addition, previous studies in HITs have tended
to focus on the organisations internal perspectives (e.g.
doctors and nurses) rather than underlying knowledge
created by patients, despite this knowledge having
important managerial implications (e.g. Menachemi, et
al. 2008). Although HITs are designed to enhance health
behaviour changes and management of illness, ultimate
success depends on whether or not the intended users
(e.g. patients) find applications useful (Ahern, Kreslake &
Phalen 2006).
The main contribution of this research is to question
existing models that relate to HITs and organisational
learning from the patients perspective. Our results
suggest that to foster utilisation of HITs, HHUs need to
provide and support explorative and exploitive processes
with patients and other external agents. The existence
of these processes is directly linked to improved quality
of care and successful implementation of appropriate
HITs. Thus organisational learning processes provide
the backdrop for identification and implementation of
modified or new HITs. When new or modified HITs are
implemented their adoption is facilitated by the existence
of organisational learning processes. In terms of the
current research into home healthcare, the patient is
a key participant in organisational learning processes
prior to implementing HITs. However, we argue that
improved quality of service and more successful implementation of HITs can be achieved in other healthcare
settings if patients are directly involved in organisational
learning process. This is an important finding because
many overloaded hospital managers may not actively
listen to patients demands, and HHU managers may
invest in development of HITs prematurely. Too great an
emphasis on technology without incorporating learning
36

(exploration and exploitation of knowledge) can result

in a failed system. HITs provide opportunity to increase
quality of service but to be effective they need to be
integrated with comprehensive learning processes. This
would allow HHUs to become a source of new ideas and
knowledge. These ideas are a first step towards providing
ways to support development of more useful, interactive, and accountable HITs to HHUs. It is hoped that
HHU managers and employees will be inspired to think
about problems and barriers that need to be solved for
successful HITs implementation.

Acknowledgement
Data used in this paper came from a research program
supported by the Spanish Ministry of Education (REF:
ECO2008-0641-C02-02) entitled Strategic scientific
knowledge management in the sanitary industry: an
application in home care units.

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Corresponding author
Juan Gabriel Cegarra-Navarro MBA, PhD
Associate Professor
Polytechnic University of Cartagena
Facultad de Ciencias de la Empresa
Cartagena (Murcia)
SPAIN
Tel: (0034) 968 32 57 88
Fax: (0034) 968 32 70 08
email: juan.cegarra@upct.es
Anthony K.P. Wensley MBA, PhD
Associate Professor
The J.L. Rotman School of Management
The University of Toronto
Mississauga (Ontario)
CANADA
Tel: (001) 905 569 4733
Fax: (001) 905 569 4734
email: anthony.wensley@utoronto.ca
Maria Teresa Snchez-Polo MS
Head of the Hospital-in-the-Home Unit
Virgen de la Arrixaca Hospital
Carretera Madrid-Cartagena, s/n.
El Palmar (Murcia)
SPAIN
Tel.: (0034) 968 36 95 00;
Fax: (0034) 968 36 97 76;
email: Sanchez_polo@hotmail.com

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Research
Appendix 1. Questionnaire items
Knowledge exploration:
To what extent do your homecare practitioners engage in activities that allow them to learn new skills or knowledge
(1= low frequency and 7= high frequency).
ER1: Co-operation and search in social networks for new possibilities with respect to services or processes
ER2: Co-operation and search in social networks for the renewal of outdated services or processes
ER3: Activities requiring quite some adaptability of homecare practitioners
ER4: Work meetings with patients and carers searching for new possibilities with respect to services or processes
Knowledge exploitation:
Indicate the degree of agreement or disagreement with respect to your homecare practitioners
(1= high disagreement and 7= high agreement).
ET1: Homecare goals are communicated to patients and their families
ET2: Policies and procedures aid practitioner work
ET3: Homecare operational procedures allow your homecare practitioners to work efficiently
ET4: Homecare files provide the necessary information to do homecare practitioners work
This section deals with your opinions about homecare services.
Please indicate whether your homecare services achieved your expectations regarding:
1. Physical facilities, equipment and appearance of personnel
Yes
2. Ability to perform the promised service dependably and accurately
Yes
3. Willingness to help and provide a prompt service
Yes
4. Knowledge and courtesy of homecare practitioners and their ability to inspire trust and confidence Yes
5. Caring and individualised attention
Yes
What technology does your homecare practitioners use to communicate with you?
1. Fax
Yes
2. E-Mail
Yes
3. Internet
Yes
4. Voice mail
Yes
5. Audio-conferencing
Yes
6. Freephone, telephone lines
Yes
7. Lotus notes
Yes
8. Electronic bulletin board
Yes
9. Video conferencing
Yes
10. Mobile communication
Yes
11. Bar code identifiers
Yes
12. Computer aided manufacturing/design/engineering
Yes
13. Inter- organizational IS
Yes

38

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No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No