Ijerph 15 01972

International Journal of
Environmental Research
and Public Health
Article
Understanding the Role of Mobile Internet-Based
Health Services on Patient Satisfaction
and Word-of-Mouth
Dongxiao Gu 1,2,† , Xuejie Yang 1 , Xingguo Li 1,† , Hemant K. Jain 3,† and Changyong Liang 1, *
1 The School of Management, Hefei University of Technology, Hefei 230009, China;
[email protected] (D.G.); [email protected] (X.Y.); [email protected] (X.L.)
2 The School of Informatics, Computing and Engineering, Bloomington, IN 47405-3907, USA
3 College of Business, The University of Tennessee at Chattanooga, 615 McCallie Ave, Chattanooga, TN 37403,
USA; [email protected]
* Correspondence: [email protected]; Tel.: +86-181-2391-7616
† These authors contributed equally.

Received: 30 July 2018; Accepted: 3 September 2018; Published: 10 September 2018
Abstract: With the rapid advancement of Web 2.0 technologies, Internet medicine, and mobile
healthcare, the influence of the use of patient-oriented Mobile Internet-based Health Services
(MIHS) on patient satisfaction and the electronic word-of-mouth (WOM) of health service agencies
is becoming the focus of the academic research community. Many large hospitals, including
some Internet hospitals, have provided various online healthcare service platforms that enable
patients to expediently consult with physicians and obtain healthcare services in an online to offline
format. The purpose of this study is to analyze the main mechanisms of how the features and
users’ experiences of MIHS influenced patient satisfaction and continuous use behaviors of the
system to generate additional WOM dissemination behaviors. Based on post-adoption behavior
and Expectation Confirmation Model of Information Technology Continuance (ECM-IT), this study
conducted an empirical study through data collection from users (patients) from a large hospital
providing online healthcare services. A total of 494 pieces of data were collected and analyzed using
SmartPLS2.0(SmartPLS GmbH, Hamburg, Gernmany). The results show that: (1) patient satisfaction
with MIHS and their intentions to continue use of MIHS have significantly positive influences on
WOM; (2) patient satisfaction with MIHS is positively influenced by perceived usefulness and
confirmation of MIHS performance expectations; (3) and patient intentions to continue use of
MIHS are also affected by some technology factors, such as facilitating conditions and perceived
risk, as well as some subjective feelings, such as perceived usefulness and perceived interactivity.
The results of this study provide important implications for both research and practice of public health.
Keywords: patient satisfaction; mobile Internet-based health service; expectation confirmation model;
patient participation; Internet medicine; patient word-of-mouth
1. Introduction
Health care is one type of service, which involves intangibility, heterogeneity and deep customer
participation. With the advancement of Web 2.0 technologies, the traditional method of understanding
disease and treatment has been changed, and an increasing number of public sector big hospitals
are providing online healthcare service by using an online healthcare platform. Among these kinds
of platforms, there are also a healthcare service and communication community in which patients
can easily find preferred doctors and make appointments for diagnosis and treatment. For patients,
finding a doctor through an online healthcare platform has significantly changed from the traditional
Int. J. Environ. Res. Public Health 2018, 15, 1972; doi:10.3390/ijerph15091972 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2018, 15, 1972 2 of 23
method of finding a doctor in a brick-and-mortar hospital. In an online health community, patients

can choose whether to make an appointment to see a doctor based on other patient word-of-mouth
(WOM) of the hospital and doctors’ previous treatment results.
In practice, almost all healthcare service agencies expect patients to spread WOM online or offline,
which helps them to earn a better reputation for attracting patients, as well as promoting mutual
understanding between doctors and patients. In developing countries such as China, doctor-patient
conflict issues are becoming one of hot topics for the entire society. The reasons for the conflicts
are mainly due to distrust between doctors and patients, which are partly caused by information
asymmetry and lack of effective communication. Some scholars focus on the topic of how to reduce
information asymmetry and improve communication effectiveness between doctors and patients.
Some studies examine how patients can improve their understanding of medical services provided
by doctors and nurses in the hospitals from an information technology perspective. For example,
Sundberg et al. tested the effect of the Information and Communication Technologies (ICT) platform
on patient involvement and symptom assessment through efficient communication between doctors
and patients [1]. Furthermore, some scholars discussed how the patient’s WOM reflect the medical
service quality and doctor-patient’s trust [2,3]. Hence, from the social perspective, patient health is of
great significance for enhancing the trust between doctors and patients, and thus improving patients’
WOM to health service agencies.
Prior research has paid attention to what affects consumer WOM behavior. It focused more
on some factors, such as consumer satisfaction [4,5], emotion tendency [6], and some psychological
factors—social interaction desire, economic incentives desire, and achieves self-worth, etc. [7,8]. In the
field of medical research, some scholars have discussed the effect of WOM on patients’ or their agents’
decisions [9,10], and some studied the WOM from the view of patient interactions [11]. However, along
with the rapid development of newly emerging technology such as mobile internet, social networking
and interactive technologies, the era of internet medicine and mobile healthcare is forthcoming.
Therefore, the increasing trend in patient-oriented Mobile Internet-based Health Service (MIHS)
platforms have been widely used in practice. In MIHS, the WOM is influenced by some other new
factors, such as doctor-patient interactions that affect the patient judgments of medical service quality,
and influence their trusts. Hence, in the new platform of MIHS, it is necessary to further perfect the
research on influence factors of WOM.
From the logic of forming WOM, patient satisfaction and their intentions to continue using MIHS
are the main impacting factors. Both of them reflect the post-adoption states of patients after receiving
treatments through an electronic platform. Patient satisfaction is related to patients’ subjective feelings.
Their intentions to continue using MIHS are a subjective behavior. Prior research has proved the
positive relationships between patient satisfaction and WOM [12]. The intentions to continue usage
behaviors also reflect and strengthen the WOM [12]. Hence, WOM is influenced by patient satisfaction
and their intentions to continue using MIHS.
Generally, a patient’s WOM is based on their perceived health care service quality. The prerequisite
of WOM behavior occurrences is that patients are satisfied with the medical services of a hospital.
Hence, a hospital that wishes to promote WOM should clearly know what factors affect patient
satisfaction and how they enhance patient satisfaction. This is an important issue in examining patient
WOM, which has been addressed by some scholars. For example, Jenkinson et al. summarized the
major determinants of patient satisfaction and emphasized the effect of physical comfort, emotional
support, and information communication, etc. [13,14]. However, patient satisfaction essentially refers
to their subjective perception of MIHS. From the Expectation Confirmation Theory (ECT) perspective,
the evaluation of satisfaction in the hospital is made by patients who compare their actual experience
of receiving medical services from MIHS to the expectations of patients.
Although persistently applied in practice, the studies concerned with the role of MIHS on
patient satisfaction and WOM have received little attention from scholars. In previous studies,
researchers have primarily emphasized technology-based behavior and satisfaction rather than
post-satisfaction behavior, such as continued use of services. For example, previous studies showed
that a Hospital Information System (HIS) can promote patient satisfaction by improving doctors’ work
efficiency, reducing waiting times, and offering patients convenient services and useful information [15].
Close relationships are also proven to exist in information technology along with the use behavior and
outcomes [16,17]. Among these studies, various studies did not examine the patient post-satisfaction
behavior. Additionally, the factors affecting patient WOM behaviors are diverse and complex,
which likely include technical factors as well as social, economic, cultural and psychological factors.
Moreover, MIHS has more convenient and interactive functions compared to traditional health service
platforms. Few studies examine the role of MIHS on patient WOM. Thus, it is extremely important
to explore factors affecting patient WOM and post-adoption behaviors in the context of Internet
medicine, social networking, and interactive technology applications. To fill this gap, the current study
draws upon the theory of post-adoption behavior and Expectation Confirmation Model of Information
Technology Continuance (ECM-IT) to discuss the role of online health services on patient WOM to
health service agencies.
On the basis of our related literature review, this research could be considered as first empirical
study to examine MIHS’s role in promoting patient satisfaction, the continued use of MIHS and WOM.
This study investigates the connections of factors for patient satisfaction, continued use and WOM.
Therefore, this research work will be helpful for hospital management, offering a better understanding
about the role of online healthcare service platforms to improve patient satisfaction and hospitals’
reputation. Moreover, it can also provide guidance for researchers and practitioners who design and
develop these types of systems to support convenient and interactive online heath care services.
The rest of the paper is organized as follows: in Section 2, based on reviewing relevant theories
and research, we develop a research model and propose hypotheses. Section 3 discusses the research
methodology used to validate our proposed hypotheses. Section 4 presents the results. Finally, this
paper concludes with a discussion of findings, implications for theory, practice and opportunities for
future research in Section 5.
2. Research Model and Hypotheses Development

Drawing on ECT and Technology Adoption Model (TAM), Bhattacherjee proposed a model
relevant to the continued usage of information technology (IT) based on ECT (ECM-IT) [18,19].
ECT emphasizes the positive association between confirmation and satisfaction, and states that both
of these factors motivate people to repeat their behaviors [20]. ECM-IT focuses only on post-usage
constructs, highlights the importance of post-usage expectations and uses perceived usefulness of
post-usage to represent consumers’ post-adoption expectations, which differs from traditional ECT [19].
The main objective of this study is to examine the influence of online health service on WOM against
the backdrop of Internet medicine. To achieve this goal, the Expectation Confirmation Model of
Information Technology Continuance (ECM-IT) is utilized as the theoretical foundation. This study also
incorporates facilitating conditions, perceived risk and perceived interactivity, which are the important
factors affecting patient usage experiences with MIHS, and further influencing their intentions to
continue use of MIHS. This could provide a more integrated model as shown in Figure 1.
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 4 of 23
Facilitating Conditions
H9-11
Intention to
continued use of
Perceived Risk
MIHS
Perceived Interactivity
H1-2 Electronic
word-of-
H8 H3
Mouth(W
H6-7
OM)
Perceived Usefulness
H5
Patient
Confirmation of MIHS Satisfaction with
Performance MIHS
H4
Expectation
Figure 1.
Figure Research Model.
1. Research Model.
2.1. Post-Adoption Behavior: Continuous Intention and WOM

2.1. Post-Adoption Behavior: Continuous Intention and WOM
Information systems (IS) continuance and WOM were suggested as the primary behavioral
Information systems (IS) continuance and WOM were suggested as the primary behavioral
outcomes of the post-adoption stage [20]. IS continuance refers to an IS user’s decision to continue using
outcomes of the post-adoption stage [20]. IS continuance refers to an IS user’s decision to continue
a particular IS for a long period, which generally includes both continuance intentions and continuous
using a particular IS for a long period, which generally includes both continuance intentions and
use behavior [21]. In the IS research field, IS continuance is often used as a synonym for post-adoption
continuous use behavior [21]. In the IS research field, IS continuance is often used as a synonym for
behavior [22,23]. As another form of post-adoption behavior, WOM is defined as a channel for
post-adoption behavior [22,23]. As another form of post-adoption behavior, WOM is defined as a
broadcasting product or service information [24–28]. Consumers often assess WOM information
channel for broadcasting product or service information [24–28]. Consumers often assess WOM
as having greater value than information in corporate brochures, because it is provided by friends,
information as having greater value than information in corporate brochures, because it is provided
classmates or acquaintances rather than companies, and it is perceived to be more reliable [29,30].
by friends, classmates or acquaintances rather than companies, and it is perceived to be more reliable
Hence, WOM serves as a reliable source of information for customers [31]. It generally has a powerful
[29,30]. Hence, WOM serves as a reliable source of information for customers [31]. It generally has a
influence on consumers’ assessment process on products or services, as well as subsequent decision
powerful influence on consumers’ assessment process on products or services, as well as subsequent
behavior [28,32].
decision behavior [28,32].
WOM has an important influence on customer behavior [33]. People often share their opinions in
WOM has an important influence on customer behavior [33]. People often share their opinions
their social circles, such as with friends, classmates, relatives, etc. Prior marketing research has shown
in their social circles, such as with friends, classmates, relatives, etc. Prior marketing research has
that a customer who is loyal due to his or her commitment to the product or service provider will
shown that a customer who is loyal due to his or her commitment to the product or service provider
recommend the same product or service to other customers [34]. The relationship between WOM and
will recommend the same product or service to other customers [34]. The relationship between WOM
the repurchase intention has been validated in the research contexts of marketing, tourism or service
and the repurchase intention has been validated in the research contexts of marketing, tourism or
management. Choo and Petrick found that WOM behavior is positively related to the repurchase
service management. Choo and Petrick found that WOM behavior is positively related to the
intention. In the IS domain, few studies explored the relationship between WOM behavior and IS
repurchase intention. In the IS domain, few studies explored the relationship between WOM behavior
continued use intention [28,35]. In addition to previous studies, satisfaction is also considered as
and IS continued use intention [28,35]. In addition to previous studies, satisfaction is also considered
an important motivator of WOM behavior [36,37]. Satisfaction affects WOM behavior together with
as an important motivator of WOM behavior [36,37]. Satisfaction affects WOM behavior together
other stimuli that motivate WOM behavior, such as service quality, website quality, price perception
with other stimuli that motivate WOM behavior, such as service quality, website quality, price
of service, customer service strategies, loyalty, etc. [35,38]. Lam and Soan analyzed the survey data
perception of service, customer service strategies, loyalty, etc. [35,38]. Lam and Soan analyzed the
collected from tourists in Macao and revealed that satisfaction plays a crucial role in generating
survey data collected from tourists in Macao and revealed that satisfaction plays a crucial role in
travel related WOM. Kitapci et al. identified the effect of satisfaction with WOM communication and
generating travel related WOM. Kitapci et al. identified the effect of satisfaction with WOM
repurchase intention, and found that satisfaction has a significant effect on WOM and repurchase
communication and repurchase intention, and found that satisfaction has a significant effect on WOM
intention [12]. Hence, our study argues that satisfaction and continued intention to use MIHS should
and repurchase intention [12]. Hence, our study argues that satisfaction and continued intention to
be a prerequisite of WOM towards MIHS. The following hypothesis is proposed:
use MIHS should be a prerequisite of WOM towards MIHS. The following hypothesis is proposed:
Hypothesis 1 (H1). A patient satisfaction with MIHS has a significantly positive effect on WOM towards MIHS.
Hypothesis 1 (H1). A patient satisfaction with MIHS has a significantly positive effect on WOM towards
MIHS.
Hypothesis 2 (H2). A patient continued intention to use MIHS has a significantly positive effect on WOM
towards MIHS.
2.2. Expectation Confirmation Model of Information Technology Continuance (ECM-IT)

ECM-IT developed by Bhattacherjee has a solid theoretical foundation and it pays attention to
the motivations for individual users’ IS continuance intentions that occur in the IS post-adoption
stage [34]. Bhattacherjee found that the satisfaction of users affects the intention for continued use
through prior use and perceived usefulness. In addition, previous empirical research supports the
fact that users’ satisfaction is one major factor of) IT continued use [39,40]. In a study by Wong et al.,
performance expectancy has been proven to not only have a significant effect on use intention [41], but
also on a user’s perceived usefulness [34]. User satisfaction is one salient factor that shapes continued
use intentions [42]. Compared to prior studies based on a variety of theoretical perspectives such as
TAM and Innovation Diffusion Theory that examines factors that cause users to initially adopt a
new technology, ECM-IT addresses the factors which affect users to continue to use an IT after they
had adopted the technology. Given lots of empirical support for the impact of continued use on IT
success, it becomes critical to find the salient factors that affect post-adoption behavior of users that is
either to continue or to discontinue use of a technology. ECM-IT is just a theoretical model developed
specifically to understand continued IT usage behavior [43]. MIHS is designed to help patients to
acquire information and provide feedback to hospitals [44].
The concept of patient satisfaction is derived from research associated with customer satisfaction.
People evaluate their satisfaction by comparing the actual product or service with the expectation of
the product or service before its purchase. The customers feel satisfaction with products or services
if the perception is better than expectation. The research indicates that the use of IT has an effect on
improving satisfaction of customers [45]. Individuals who choose to employ MIHS may have initial
expectations, such as improving the efficiency of consultation and treatment, reducing time spending
waiting in long lines, and communicating to hospitals their comments or suggestions associated with
their personally experienced hospital management and health care services. In the Internet health care
context, when a patient is satisfied with the MIHS, it is reasonable and rational to propose that he or she
intends to continue specific types of internet healthcare services. Meanwhile, if a patient has used MIHS
and his or her expectations have been confirmed, his or her impressions of the perceived usefulness
of MIHS and satisfaction will be further enhanced. Moreover, MIHS has gradually penetrated the
entire process of patients’ treatment in hospitals [46,47]. A patient can use MIHS in the processes of
registrations, payment, consultations, proof of diagnosis and relevant inspection and report sheet
checking and printing, treatment, post-operation health tracking and feedback, etc., and the platform
has greatly improved the efficiency of hospitals [48,49]. When a patient thinks that the MIHS is useful
for him or her to improve the efficiency of seeing a doctor or the accuracy of medical diagnosis, he or
she will more likely be satisfied with MIHS and will continue to use it [50]. Thus, we hypothesize:
Hypothesis 3 (H3). A patient satisfaction with MIHS has a significantly positive effect on the continued
intention to use MIHS.
Hypothesis 4 (H4). A patient confirmation of MIHS performance expectations has a significantly positive
effect on his or her satisfaction with MIHS.
Hypothesis 5 (H5). A patient confirmation of MIHS performance expectations has a significantly positive
effect on his or her perceived usefulness of MIHS.
Hypothesis 6 (H6). A patient perceived usefulness of MIHS has a significantly positive effect on his or her
satisfaction with MIHS.
Hypothesis 7 (H7). A patient perceived usefulness of MIHS has a significantly positive effect on his or her
intention to continued use of MIHS.
2.3. Perceived Interactivity, Perceived Risk and Facilitating Conditions
2.3.1. Perceived Interactivity

Interactivity is defined as “the extent to which users perceive their experiences as a simulation
of interpersonal interaction and sense they are in the presence of a social other” [51]. Interactivity is
a feature of technology, a process of message exchange, and a user’s perception after using a
product or experiencing a service process [52,53]. Interactivity is supposed to be one of the key
advantages of the Internet [54]. Previous studies investigated how interactivity affects users’ responses
towards continuous intention and revealed that perceived interactivity is one of the determinants
of continued use. Liu et al. found that interactive functions make individuals prefer to share and
comment [55]. Additionally, prior studies also concerned the relationship between interactivity and
usability. They found that perceived interactivity is one key determinant of perceived usefulness and
user satisfaction [56]. Abdullah et al. found that consumer perception of hotel website interactivity
influences the customer’s intention to revisit the website [57].
In this study, we focus more on the interactivity between an online healthcare service agency and
patients because facilitating interaction between managerial or medical staff (doctors, nurses, etc.) is
the design and implementation purpose of MIHS. For the remainder of this section, we will briefly
review the theoretical relationship between perceived interactivity and continuous intention of use in
the context of an interactive online system platform for medical services in hospitals. Interactivity is a
predominant feature of MIHS [58]. MIHS allows patients to participate or engage more in the health
care service process. Online messages, feedback, discussions and evaluation are main communication
channels among patients and medical staff and commonly used to support the medical services
of hospitals.
In order to enhance our understanding of continued IT usage behavior, our study incorporates
an additional user perception—perceived ease of use—into the original ECM-IT. Compared prior
studies based on a variety of theoretical perspectives such as TAM and Innovation Diffusion Theory
examining factors that cause users to initially adopt a new technology, ECM-IT addresses the factors
which affect users to continue to use an IT after they had adopted the technology. Given lots of
empirical support for the impact of continued use on IT success, finding the salient factors that affect
post-adoption behavior of users, which is either to continue or to discontinue use of a technology,
becomes critical. ECM-IT is just a theoretical model by developed specifically to understand continued
IT usage behavior. Mobile Internet-based services is a new breed of IT innovation which is gradually
becoming omnipresent in our daily life. Its usage encompasses a broad range of activities—both
work-related activities and fun activities. Interactivity is an essential metric when evaluating MIHS.
It includes not only interactions between hospital staff, doctors, nurses and patients, but also includes
interactions or hyper linking between messages or comments [58] and uses plugins for links to share
information. Because interactivity leads to jointly produced meaning or outcomes or reliance on
judgments of credibility [58,59], the users of MIHS benefit, which will facilitate their perception of
usefulness and motivate the intention of continuous use. While the usage of typical IT innovations in
prior IS research are well defined, simple, and of limited function, the interaction of MIHS s is far more
complex and comprehensive in supporting diversified health communication needs and medical care
expectations. Hence, we hypothesize:
Hypothesis 8 (H8). Perceived interactivity has a significantly positive effect on the perceived usefulness
of MIHS.
Hypothesis 9 (H9). Perceived interactivity has a significantly positive effect on the continued use intention
of MIHS.
2.3.2. Perceived Risk

The original concept of perceived risk proposed by Bauer [60] comes from psychology.
Bauer defined perceived risk as “felt uncertainty regarding possible negative consequences of using a
product or service” and believes that consumers’ purchase decisions are impacted by the uncertainty
of the results [61]. When the level of uncertainty becomes more substantial, perceived risk will also
increase [34]. Malhotra et al. found that risk is expected to exert a significant effect on behavioral
intention [62]. Heijden et al. defined perceived risk as consumers’ subjective perception of negative
consequences, and the probability that the unfavorable consequences may occur after the purchase of
products [63]. Green and Pearson found that perceived risk reduction can increase continued behavior
intentions [64].
Perceived risk has also been used to understand users’ post-adoption or resistance behavior
toward usage of IT [65,66]. From the perspective of the patients, there are several types of risk involved
with the use of MIHS systems. Compared to the general health service commonly used in the internal
network in a hospital, MIHS is based on the Internet, and patients can access the platform anytime
and anywhere. This means that MIHS will face more risks than traditional health services. Moreover,
MIHS saves a large amount of private information, including the patients’ conditions, their concerns
and questions, replies from the doctors, and patient opinions and comments regarding services from
hospitals and doctors. These different aspects of risk are relevant in the continued use of MIHS. Thus,
we hypothesize:
Hypothesis 10 (H10). Perceived risk has a significantly negative effect on the continued use of MIHS.
2.3.3. Facilitating Conditions

The Unified Theory of Acceptance and Use of Technology (UTAUT) [67] identified facilitating
conditions as one of determinants that affect users’ behavior. Venkatesh et al. defined facilitating
conditions as the degree to which a user believes that an organizational and technical infrastructure
exists to support the use of information technology [68]. Hsieh et al. used the Theory of Planned
Behavior (TPB) to identify several attitudinal, normative, and control beliefs that would predict
continued IT use intentions. Hsish et al. found that facilitating conditions were particularly important
among the underprivileged [69]. Venkatesh and Sykes also found that facilitating conditions and
social network conditions existed, and they fostered the success of divided initiatives in developing
countries [70]. Barnard et al. identified the powerful role that facilitated conditions have on digital
technology use [71]. Liao et al. also found that facilitating conditions can seriously affect a person’s
intention to use online services [72].
After the implementation of MIHS, many hospitals in developing countries such as China
provided various facilitating conditions for patients to support the use of MIHS, which included
making available: volunteers or support staff from the providers of software and service, self-service
terminal machines, online information desks, operational instruction materials, operational procedure
posters, WeChat access (WeChat is a new form of online connection created by Tencent, Inc., and with
over 0.7 billion users from China, Europe, North America, and Southeast Asia and other counties or
areas. It has become one of the largest and most widely used Internet portals worldwide; a hospital
can collaborate with Tencent and open a WeChat Official Account (WeChatOA) for patients to access
the online healthcare service platform via the hospital’s WeChatOA more conveniently and more
quickly than traditional healthcare services.), etc. A user would obtain service support if something
went wrong, and would then know how to proceed. All these resource and technology facilitating
conditions allowed patients to feel comfortable, and helped them be able to manipulate MIHS or have
sufficient learning opportunities to do so, and encouraged their continuous intention to use interactive
information technology. Hence, we hypothesize:
Hypothesis 11 (H11). Facilitating conditions have a significantly positive effect on the continued use intention
of MIHS.
3. Research Methodology
3.1. MIHS Implementation and Use

MIHS implementation began in 2013 in AN Hospital. Doctors and patients were tasked with
promoting use of the system. Use of the system was rapidly popularized. The main functions of MIHS
are summarized in Figure 2 in which we can find the main features of MIHS, which can benefit the
patients as follows:
(a) Patients can access MIHS via the Internet or the hospital’s WeChat public account.
Doctors’ information and their schedules are also available in the system, and patients can search,
choose, and make appointments with their preferred doctors. They can complete registration,
prepay online instead of waiting in line, and cancel appointments.
(b) The hospital can conduct post-operation health tracking and evaluation for a patient. The medical
staff can obtain feedback from patients and offer medical and health-related suggestions,
if necessary. Patients can communicate their symptoms to the doctors or nurses directly.
They can discuss their current health status, postoperative rehabilitation, relevant precautions,
etc. Additionally, the doctors can also provide online remote diagnosis services to patients with
chronic diseases.
(c) Patients can assess their own health status based on a case-based health self-assessment subsystem.
The type of assessment is based on historical cases and the whole life-cycle dynamic health data
of the patients. Generally, only health status (level), but sometimes potential health risks and
health promotion solutions can also be obtained. Patients can also consult with doctors about the
assessment results and ask for suggestions.
(d) Patients can acquire various health care and expense information. Health care information
includes electronic health records, physical examination reports, etc. Expense information
includes registration fees, detailed operation fees, drug fees, etc. Digital health care reports can
be printed out by patients via a procedure of application and verification. This allows patients
to easily track care processing and outcomes. Patients can voice concerns about their treatment,
the nursing process, and expenses.
(e) Patients can also perform medical care service satisfaction evaluations on doctors, nurses,
departments, teams, the hospital, or a specific medical service event, such as an operation.
They can leave detailed information about why and in what areas they are satisfied. The hospitals
can conduct a satisfaction analysis based on the collected assessment data, which will be helpful
for the promotion of its health care service.
• Your basic information

Basic information • Your electronic health care records
• Your electronic medical records
for health care (a) • Departments and doctors lists
•…
• Health tracking and evaluation after operations

• Nursing suggestions
• Health promotion suggestions
Consistent health • Remote diagnosis
care service (b) • Information feedback from patients
• Medical care service satisfaction evaluation
•…
Patients-Oriented Online Health Service
• The schedule of available doctors

• Cyber telephone reservation & registration
• Websites/WeChat reservation &registration
Online reservation • A reminder for possible no-shows
• Online communication with customer service to
(a) cancel an appointment
• Consultation on registration
• …
…
…
• Your doctors(name, position, affiliation,

department)
Internet consulting • Consulting with your doctor online
• ’ s reply to your questions
Your doctor
& evaluation • Re-examination appointment
subSystem (e) • Nursing consultation
• Patients satisfaction evaluation
•…
Patients billing • Medical billing information by time

and expenses query • Search expenses information by operations
• Query cost of a breakdown
module (d)
• Questions and queries about charges
•…
Online health self- • Symptoms and physical examination information

assessment registration
subsystem (c) • Case-based health self-assessment
• Discuss self-assessment results with your doctor
•…
• Prepaid
Cyber patient- • Bank transfer to your healthcare card
oriented payment • Payment & Receipts
service (a) • Questions or suggestions on payment
•…
Figure
Figure 2. The
2. The main
main features
features of MIHS.
of MIHS.
3.2. Measures
3.2. Measures
Measures for all concerned variables were taken from previous studies and adapted to the context
Measures for all concerned variables were taken from previous studies and adapted to the
of healthcare. Eight variables were measured in this study: Confirmation of MIHS performance
context of healthcare. Eight variables were measured in this study: Confirmation of MIHS
expectations, Perceived Usefulness (PU), Perceived Interactivity (PI), Facilitating Condition (FC),
performance expectations, Perceived Usefulness (PU), Perceived Interactivity (PI), Facilitating
Perceived Risk (PR), Patient satisfaction with MIHS, Intention to continually use MIHS, and Electronic
Condition (FC), Perceived Risk (PR), Patient satisfaction with MIHS, Intention to continually use
Word of Mouth (WOM). The questionnaires were formed by using Likert scales ranging from 1
MIHS, and Electronic Word of Mouth (WOM). The questionnaires were formed by using Likert scales
(strongly disagree) to 7 (strongly agree), which requires respondents to select a number from the scale.
ranging from 1 (strongly disagree) to 7 (strongly agree), which requires respondents to select a
In Table 1, the measurement items and their sources are listed.
number from the scale. In Table 1, the measurement items and their sources are listed.
To measure the confirmation of MIHS performance expectations, we used a four-item scale
To measure the confirmation of MIHS performance expectations, we used a four-item scale
adapted from previous studies [73]. Facilitating Condition (FC) was measured by a three-item scale
adapted from previous studies [73]. Facilitating Condition (FC) was measured by a three-item scale
adapted from previous studies [74,75]. Intention to continued use of MIHS was measured by a
adapted from previous studies [74,75]. Intention to continued use of MIHS was measured by a two-item
scale adapted from previous studies [74,76]. Perceived Interactivity (PI) was measured by a three-
item scale adapted from previous studies [77]. Perceived Risk (PR) was measured by a three-item
two-item scale adapted from previous studies [74,76]. Perceived Interactivity (PI) was measured by a
three-item scale adapted from previous studies [77]. Perceived Risk (PR) was measured by a three-item
scale adapted from previous studies [78]. Perceived Usefulness (PU) was measured by a five-item scale
adapted from previous studies [79,80]. Patient Satisfaction with MIHS was measured by a two-item
scale and adapted from previous studies [80]. The seven-item scale for Electronic Word of Mouth
(WOM) behavior was also adapted from previous studies [4,81–84]. The users of MIHS are patients
and doctors, which are different from the classic users of a transactional application who use a system
for their daily operations. To ensure that all measurement instruments are reliable and valid for our
current study in the context of healthcare, we consulted with the relevant medical specialists and
experts in the field of management information systems and conducted the necessary adjustments and
adapted the scales to the special targeted respondents in the context of healthcare.
Based on these measures, we developed the survey questionnaire. After compiling the English
version of the questionnaire, the items were translated into Chinese by a bilingual faculty member
and then verified, refined, and back-translated for translation accuracy by a professor of healthcare
information management. The content validity of all scales was established through both a literature
review and a content validity expert panel comprising six faculty members and three doctoral students
who are experienced in the research methods of quantitative and quantitative analysis.
Table 1. Measures of constructs.
Construct Item ID Items Reference

My experience with using MIHS was better than what I
CPE01
expected.
The service level provided by MIHS was better than
Confirmation of CPE02
what I expected.
MIHS performance Hong et al., 2006 [73]
expectations The service level provided by MIHS are really same as
CPE03
what I expected.
Overall, most of my expectations from using MIHS
CPE04
were confirmed.
FC01 I have the resources necessary to use the MIHS system.
FC02 I have the knowledge necessary to use the MIHS system.
Facilitating Ajzen 1991 [74]; Taylor
Conditions Given the resources, opportunities and knowledge it and Todd 1995 [75]
FC03 takes to use the MIHS system, it would be easy for me to
use the system.
I intend to continue using MIHS frequently during the
ICU01
next three months.
Intention to
Ajzen 1991 [74]; Ajzen
continued use I intend to continue using MIHS for online registration,
and Madden 1986 [76]
of MIHS ICU02 bills checking, consultation, evaluations, and etc. during
the next three months.
MIHS allows me to interact with it to receive various
PI01
health service or communicate with others.
Perceived MIHS has interactive features, which help me Song and Zahedi,
interactivity PI02
accomplish my task. 2005 [77]
I can interact with the MIHS system in order to get
PI03
specific information or provide feedback/evaluation.
I think it is risky to provide my personal information in
PR01
the MIHS system.
I think it is risky to input my bank card information for McKnight, et al.,
Perceived risk PR02
registration, bill paying or prepaid. 2002 [78]
Entering personal information over the MIHS system
PR03
is unsafe
Table 1. Cont.
Construct Item ID Items Reference

The MIHS system is useful for searching and obtain
PU01
the information I need.
The MIHS system enhances my effectiveness in
PU02
obtaining healthcare service.
Yoon, 2009 [79];
Perceived The MIHS system enables me to get healthcare
PU03 Bhattacherjee & Premkumar,
usefulness service faster. 2004 [80]
PU04 Using MIHS system will improve my performance.
Using MIHS system will increase my productivity
PU05
during health service process.
Patient Satisfaction PS01 I am pleased with my use of MIHS system. Bhattacherjee & Premkumar,
with MIHS PS02 I am satisfied with my use of MIHS system. 2004 [80]
WOM01 I am willingness to recommend MIHS to others.

Exactly I will tell the other person that MIHS is
WOM02
very good.
I am willing to tell other people about the good
WOM03
aspects of MIHS. Harrison-Walker, 2001 [81];
Electronic
Anderson, 1998 [4]; Andrei,
word-of-mouth Told my friends and relatives about my good
WOM04 2013 [82]; Kim, et al.,
(WOM) experience of using MIHS.
2001 [83]; Singh, 1990 [84]
I will mention this good service of MIHS to others
WOM05
quite frequently.
WOM06 I will tell more people about the service of MIHS.
WOM07 I am proud to tell others that I use MIHS service.
MIHS: patient-oriented Mobile Internet-based Health Services.
3.3. Sample and Data Collection

To validate the above research model, an empirical study was conducted at AN Hospital, a 3-A
hospital and one of the largest hospitals in East China. The 3-A stratum represents some of the best
hospitals in mainland China. This hospital has implemented patient-accessible MIHS, which allows it
to provide mobile Internet-based healthcare services. Since we have a stable collaborative relationship
with this hospital, our survey had full support from the hospital administrators. This allowed the data
collection to be completed smoothly. A multistage iterative process was used for the data collection.
First, we adapted the original measures from the literature (described in next section) into hospital
context and then we translated the instrument into Chinese using professional translation staff. Second,
we conducted a pilot study to improve ambiguous expressions, awkward wordings, or distortions of
the original meanings using 100 respondents. Based on the data and respondents’ suggestions in the
pilot study, we modified the questionnaire. The modified questionnaire was then used to collect data
from patients at the hospital. The data collection lasted approximately two years, from July 2015 to
June 2017.
Small gifts were given to the respondents for completing and returning the questionnaire. The gift
with a value of approximately RMB 52.00 ($8.00). The questionnaires were randomly distributed to
patients in the hospital. Patients who were not able to read or write were not selected to participate
in the study. A total of 600 questionnaires were distributed and 528 questionnaires were returned;
the response rate is 88%. After removing invalid questionnaires (incomplete, used same answers,
obvious contradictions, etc.), we obtained 494 valid questionnaires with an effective response rate of
93.56%. Table 2 presents the demographic features of the respondents of this study.
Table 2. Sample Demographics.
Category Number (%)

Gender
Male 253 (51.21%)
Female 241 (48.79%)
Age
<18 years old 4 (0.81%)
18–28 years old 103 (20.85%)
28–48 years old 169 (34.21%)
48–60 years old 103 (20.85%)
>60 years old 115 (23.28%)
Educational background
Elementary school 62 (12.55%)
Middle school 123 (24.90%)
High school 135 (27.33%)
College 162 (32.79%)
Graduate school 12 (02.43%)
Types of interaction, use duration with MIHS (multi-choices)
Consultations about registration, card opening, prepay 456 (92.31%)
Consultation about bills (avg. use duration of this function: 23.4 months) 471 (95.34%)
Satisfaction Evaluations (avg. use duration of this function: 20.7 months) 429 (86.84%)
Consulting individual diseases with medical staff (avg. use duration of this function: 19.9 months) 415 (84.01%)
Others such as appointment cancelling, nursing consultation, etc. (avg. use duration of this function:
436 (87.85%)
21.3 months)
Treatment duration days
Outpatient 32 (06.48%)
Inpatient <5 days 96 (19.43%)
Inpatient 6–10 days 156 (31.58%)
Inpatient 11–20 days 133 (26.92%)
Inpatient >20 days 77 (15.59%)
4. Results
4.1. Measurement Model

Validation assessed the reliability of the measures, while hypothesis testing analyzed the
hypotheses we proposed. Structural equation modeling with partial least squares (PLS) was used
to perform a simultaneous evaluation of both the measurement quality (measurement model) and
construct interrelationship (structural model). By using ordinary least squares as the estimation
technique, PLS performed an iterative set of factor analyses, and applied a bootstrap approach to
estimate the significance (t-values) of the paths [85,86]. Prior studies indicated that PLS-SEM overcame
problematic model identification issues and that it is a powerful method for analyzing complex models
using smaller samples [87]. Thus, in this study, we used SmartPLS2.0 to evaluate the measurement
properties and test the hypotheses.
A latent variable is equal to λ* observed variable in which λ is a factor loading. The value of λ
changes from zero to one and shows the correlation between observed variables and latent variables.
Factor loadings in Table 3 present the means and loadings of each measured item and the descriptive
statistics of each item. The loadings of all the items are above the threshold of 0.7, indicating that the
observed variables have high convergent validity. The values in Table 3 also show a high correlation
between observed variables and latent variables.
The acceptability of the measurement model was assessed by the reliability of the individual items,
the internal consistency between the items, and the model’s convergent and discriminant validity.
Table 4 shows the composite reliability, Average Variance Extracted (AVE), and square root of the AVE,
as well as the correlations between the constructs. Scale reliability is an important measure of scale
adequacy. When scale reliability is high, variables measuring a single factor share a high degree of
common variance. The Cronbach’s alphas of the seven constructs are all above the recommended
criterion of 0.70 [88] which shows that the measures are internally consistent. The composite reliability
values of all the constructs are exceeding the cut-off value of 0.70 [89], which indicated adequate
internal consistency [90]. The AVE for each construct is higher than 0.50, suggesting that the observed
items explained more variance than the error terms [91]. In addition, the square root of the AVE
for each construct was higher than the correlations between the construct and all other constructs,
suggesting excellent discriminant validity. Thus, all scales of the measurement model demonstrate
adequate internal consistency for further analysis of the construct model.
Table 3. Descriptive statistics of the measure.
Item Statistics
Construct
Construct Items Mean Std. Deviation Loading 1
CPE01 5.60 1.23 0.7951
Confirmation of MIHS CPE02 5.44 1.24 0.8270
performance expectations CPE03 5.61 1.23 0.8508
CPE04 5.78 1.19 0.8730
FC01 5.46 1.49 0.7480
Facilitating conditions FC02 5.65 1.38 0.8544
FC03 5.69 1.38 0.8572
ICU01 5.69 1.20 0.8950
Intention to continued use of MIHS
ICU02 5.62 1.29 0.8848
PI01 5.77 1.20 0.8293
Perceived interactivity PI02 5.86 1.19 0.8662
PI03 5.65 1.28 0.8163
PR01 3.41 1.93 0.8708
Perceived risk PR02 4.12 2.04 0.8440
PR03 3.86 1.91 0.7674
PU01 6.07 1.10 0.8150
PU02 6.02 1.10 0.7965
Perceived usefulness PU03 6.02 1.05 0.8435
PU04 5.93 1.16 0.8177
PU05 5.83 1.18 0.7494
PS01 5.75 1.45 0.8950
Patient satisfaction with MIHS
PS02 5.63 1.46 0.8848
WOM01 5.99 1.18 0.7999
WOM02 6.17 1.06 0.7809
WOM03 6.04 1.09 0.8258
Electronic word-of-mouth(WOM) WOM04 5.71 1.23 0.7823
WOM05 5.88 1.17 0.8102
WOM06 6.06 1.07 0.8084
WOM07 5.74 1.20 0.7869
1 The loading is reported by SmartPLS 2.0. It shows a high correlation level between observed variables and
structural variables.
Table 4. Measurement model results.
Composite Cronbach’s
AVE 1 CPE FC ICU PI PR PU PS WOM
Reliability Alpha
CPE 0.8812 0.7981 0.7121 0.8439
FC 0.8705 0.7769 0.6916 0.7992 0.8316
ICU 0.8839 0.7374 0.7919 0.6429 0.6063 0.8899
PI 0.8756 0.788 0.7013 0.677 0.6183 0.7159 0.8374
PR 0.8676 0.7812 0.6865 −0.2154 −0.2115 −0.2218 −0.2235 0.8286
PU 0.8995 0.851 0.6912 0.6546 0.5965 0.6918 0.7817 −0.1018 0.8314
PS 0.9003 0.7786 0.8187 0.8016 0.7924 0.6238 0.6539 −0.1842 0.6277 0.9048
WOM 0.9294 0.9134 0.6221 0.7336 0.6848 0.6561 0.7174 −0.1365 0.7887 0.7199 0.7887
1AVE stands for Average Variance Extract. The bold numbers listed diagonally are the square root of the variance
shared between the constructs and their measures. The off-diagonal elements are the correlations among the
constructs. For discriminate validity, the diagonal elements should be larger than the off-diagonal elements.
WOM06. As a result, all of the construct correlation values are below 0.75. The highest construct VIF
Int. J. Environ.to
is lowered Res. PublicConstruct
2.521. Health 2018, reliability
15, 1972
validity are still established. The results show that14all
and of 23
of
the path coefficients are significant at 5% level. Using multiple commonly accepted approaches, we
haveCommon
4.2. shown that our results
Methods Varianceare not threaten by multicollinearity.
To test for
4.4. Structural Common Methods Variance (CMV), we conducted Harman’s single factor test.
Model
According to Podsakoff et al., if a detrimental level of common method bias exists, “(a) a single
To determine the statistical significance of the path coefficients, we ran the bootstrapping
factor will emerge from the exploratory factor analysis (unrotated) or (b) one general factor will
method setting the number of samples at 2000 and the number of cases at 494. The parameter
account for the majority of the covariance among the measures” ([92], p. 889). In the exploratory factor
estimated in the structural model exhibited the direct effects of one construct on the other; a
analysis of this study, more than one factor emerged to explain the variance, and one general factor
significant coefficient at a certain level of α reveals a significant relationship between the latent
did not account for most of the covariance among the measures. Thus, the common method bias in
constructs (Figure 3, Table 5).
this study is low.
H1, which hypothesized a positive relationship between patient satisfaction with MIHS and
electronic Word of Mouth (WOM) behavior, was supported (path coefficients = 0.508, p < 0.01).
4.3. Multicollinearity
Additionally, H2, which hypothesized a positive relationship between the intention to continue use
To ensure that there is no risk of multicollinearity, we tested the data and found that none of the
of MIHS and WOM behavior, was also supported (path coefficients = 0.339, p < 0.01). Satisfaction with
bivariate correlations was above 0.90 [93]. Additionally, the tolerance values, which are averaged to be2
MIHS and the intention to continue use of MIHS explain 58.8% of the variance in WOM behavior. R
greater than 0.30, are acceptable. The highest VIF among the constructs was 3.537. This is comparable
represents the degree of interpretation of the dependent variable by the independent variable.
to many prior studies and is well below the commonly accepted threshold: 10 [94]. This suggests
50%~60% is a suitable number. Patient satisfaction with MIHS has a positive and significant effect on
that multicollinearity is not severe in our research model. To further demonstrate that our results are
Intention to continued use of MIHS (H3) with path coefficients of 0.124 (p < 0.05). As predicted by H4
robust to multicollinearity, we removed the following measurement items (that caused high construct
and H5, confirmation of MIHS performance expectations significantly influenced patient satisfaction
correlation) and estimated the model again: CPE01, CPE04, FC01, PU03, PI02, WOM06. As a result,
with MIHS and perceived usefulness with path coefficients of 0.684 (p < 0.01) and 0.232 (p < 0.01),
all of the construct correlation values are below 0.75. The highest construct VIF is lowered to 2.521.
respectively. As predicted by H6 and H7, confirmation of MIHS performance expectations and
Construct reliability and validity are still established. The results show that all of the path coefficients
perceived usefulness significantly influenced the intention to continue use of MIHS with path
are significant at 5% level. Using multiple commonly accepted approaches, we have shown that our
coefficients of 0.18 (p < 0.01) and 0.279 (p < 0.01), respectively. Perceived interactivity had a positive
results are not threaten
and significant effect onby multicollinearity.
perceived usefulness (H8) with path coefficients of 0.625 (p < 0.01). Perceived
interactivity, perceived
4.4. Structural Model risk and facilitating conditions significantly influenced the intention to
continue use of MIHS with path coefficients of 0.322 (p < 0.01), -0.072 (p < 0.05) and 0.127 (p < 0.05),
To determine
respectively. the statistical
The path coefficientsignificance of the path
of H10 is negative coefficients,
because we ran thethat
we hypothesized bootstrapping method
perceived risk had
setting the impact
a negative numberon of the
samples at 2000
continued and
use the number
intention, that of
is, cases at 494.the
the higher The parameter
perceived estimated
risk, the less in the
likely
structural model exhibited the direct effects of one construct on the other; a significant
the patient would continue to use MIHS. All these indicators showed that the model fit the data well. coefficient at a
certain level of α reveals a significant relationship between
We will discuss these findings in detail in the next section. the latent constructs (Figure 3, Table 5).
0.127*
Facilitating Conditions
-0.072* Intention to
continued use of
Perceived Risk MIHS
R2=0.594
0.322**
Perceived Interactivity Electronic
0.339**
0.279** Word-of-
0.625** 0.124* Mouth(W
OM)
Perceived Usefulness
R2=0.588
R2=0.640
0.232**
0.180**
Patient 0.508**
Satisfaction with
Confirmation of MIHS MIHS
Performance R2=0.661
0.684**
Expectation
Figure 3.3.Model
Figure Modelresults. Path
results. coefficients
Path coefficients t value
withwith in parentheses;
t value * represents
in parentheses; p < 0.05; **
* represents p represents
< 0.05; **
prepresents
< 0.01. p < 0.01.
Table 5. Structural parameter estimates.
Hypothesized Path t-Value Results

H1: Patient satisfaction with MIHS → WOM 13.244 ** Supported
H2: Intention to continued use of MIHS → WOM 8.194 ** Supported
H3: Patient satisfaction with MIHS → Intention to continue use of MIHS 2.041 * Supported
H4: Confirmation of MIHS performance expectation → Patient satisfaction with MIHS 20.086 ** Supported
H5: Confirmation of MIHS performance expectation → Perceived usefulness 5.021 ** Supported
H6: Perceived usefulness → Patient satisfaction with MIHS 4.606 ** Supported
H7: Perceived usefulness → Intention to continued use of MIHS 4.861 ** Supported
H8: Perceived interactivity → Perceived usefulness 13.77 ** Supported
H9: Perceived interactivity → Intention to continued use of MIHS 4.799 ** Supported
H10: Perceived risk → Intention to continued use of MIHS 2.484 * Supported
H11: Facilitation conditions → Intention to continued use of MIHS 2.166 * Supported
* represents p < 0.05; ** represents p < 0.01.
H1, which hypothesized a positive relationship between patient satisfaction with MIHS and
electronic Word of Mouth (WOM) behavior, was supported (path coefficients = 0.508, p < 0.01).
Additionally, H2, which hypothesized a positive relationship between the intention to continue use of
MIHS and WOM behavior, was also supported (path coefficients = 0.339, p < 0.01). Satisfaction with
MIHS and the intention to continue use of MIHS explain 58.8% of the variance in WOM behavior.
R2 represents the degree of interpretation of the dependent variable by the independent variable.
50%~60% is a suitable number. Patient satisfaction with MIHS has a positive and significant effect
on Intention to continued use of MIHS (H3) with path coefficients of 0.124 (p < 0.05). As predicted
by H4 and H5, confirmation of MIHS performance expectations significantly influenced patient
satisfaction with MIHS and perceived usefulness with path coefficients of 0.684 (p < 0.01) and
0.232 (p < 0.01), respectively. As predicted by H6 and H7, confirmation of MIHS performance
expectations and perceived usefulness significantly influenced the intention to continue use of MIHS
with path coefficients of 0.18 (p < 0.01) and 0.279 (p < 0.01), respectively. Perceived interactivity had a
positive and significant effect on perceived usefulness (H8) with path coefficients of 0.625 (p < 0.01).
Perceived interactivity, perceived risk and facilitating conditions significantly influenced the intention
to continue use of MIHS with path coefficients of 0.322 (p < 0.01), -0.072 (p < 0.05) and 0.127 (p < 0.05),
respectively. The path coefficient of H10 is negative because we hypothesized that perceived risk had a
negative impact on the continued use intention, that is, the higher the perceived risk, the less likely
the patient would continue to use MIHS. All these indicators showed that the model fit the data well.
We will discuss these findings in detail in the next section.
5. Discussion, Implications and Limitations
5.1. Discussion
In this study, we focused on the impact factors that influence patient electronic word-of-mouth
(WOM) based on post-adoption behavior and ECM-IT. The empirical results supported all research
hypotheses and proved the significant impact of the use of MIHS on patient WOM behaviors.
The supported H1 and H2 indicated that patient satisfaction and the continuous use of MIHS had
a significant positive influence on improving the patient WOM, and the supported H3 shows that
satisfaction with MIHS could promote the intention to continue using MIHS. The empirical results
of H6 and H7 indicated that the perceived usefulness of MIHS had a positive influence on patient
satisfaction and continuous use of MIHS. Both the perceived interactivity and confirmation of MIHS
performance expectations positively and significantly affected the perceived usefulness.
From the IT perspective, we mainly studied MIHS. MIHS is an emerging generation of healthcare
system platforms that provide interactions between hospital staff and patients, and allow patients
to access various pieces of healthcare information through smartphones. The main characteristics of
MIHS are accessible to both doctors and patients, and allows for convenient interactions with one
another. The use of this novel MIHS is powerful for doctor-patient interactivity experience.
In our study, the perceived interactivity enhanced the perceived usefulness. This is understandable
because the interactivity of MIHS helps patients ascertain their healthcare situation instantly and
obtain suggestions by consulting with their doctors at any time. Perceived interactivity and perceived
usefulness helped users make decisions on their continued use of MIHS. Perceived usefulness also
promoted patient satisfaction experience. The patients with higher satisfaction levels were more likely
to continuously use MIHS, which was consistent with a previous study [16]. The patient expectation
confirmation on MIHS performance was also an important factor when evaluating the patient perceived
usefulness of and satisfaction with the system. Facilitating conditions, such as increasingly convenient
WiFi and 3G networks, as well as increasingly widespread use of smartphones and WeChat, further
enhanced continued use of MIHS. The reduction of perceived risk also improved users’ intention to
continued use of MIHS, further motivating their WOM behavior.
There are five pathways to “use intention” (H9 vs. H8 + H7). The pathways are a little complicated
but is normal in this kind of SEM-based behavioral and empirical study. Based on the results of data
analysis, there are two main pathways (path coefficients are over 0.25). For a specific individual, it is
possible for him to have high perceived interactivity but low perceived usefulness. But for our study,
our conclusion is based on SEM-based statistical analysis. This phenomenon with high perceived
interactivity but low perceived usefulness will not cause influence on our conclusion.
5.2. Implications
5.2.1. Implications for Research

The main purpose of our research was to explain the mechanisms of how the features of MIHS and
users’ experiences affect patient satisfaction and their intention to continue their use of the platform,
eventually spreading WOM. This research may have some implications for academic studies. First, our
study extended the post-adoption behavior and ECM-IT to the context of mobile Internet medicine.
MIHS, the object of our study, is a new type of mobile health service that can be used for knowledge
discovery based on electronic medical records and health examination reports; doctors and nurses
can use this system for timely communication and information feedback. As a new type of interactive
internet medicine and mobile health service using data mining technologies, it greatly improves the
efficiency and communication convenience of clinic services, which is completely different from the
traditional and relatively closed HIS system. We examined the benefits of using MIHS in improving
patient satisfaction, continued use, and eventually WOM. As users of MIHS, the patients were different
from employees who used information systems in the business field. Thus, our focus was different
from the IS post-adoption in the traditional organizational context that has been examined by other
researchers, making this study a unique contribution.
Second, based on ECM-IT, our study developed a new model by adding perceived interactivity
as mediated instruments. Prior studies investigated perceived usefulness and perceived ease of use
in influencing users’ IT behavior [16,17]. IS users’ continuous use behaviors depend on not only
the features of technology itself but also the users’ experiences, including perceived interactivity
and confirmation of IS performance expectations [2,3]. Scholars who engaged in studies associated
with post-adoption behavior seldom addressed users’ experiences during the technology use process.
Especially in the scope of internet medicine and mobile healthcare services, the continuous use
behaviors of online healthcare service toolkits are more closely related to perceived interactivity and
technology performance expectation confirmation [95].
In addition, another contribution of this study is to provide a new perspective for other scholars
to theoretically investigate the influencing mechanism of healthcare information technology on user
experiences, managerial effectiveness, and organizational reputation. We explored the positive impact
of patient satisfaction and continued use intention of MIHS on WOM, which could further influence the
trust and relationships between doctors and patients [96]. In fact, the purposes of IT use are to improve
efficiency and performance. In the context of online healthcare, the continued use of MIHS could
improve the communication efficiency between doctors and patients, encourage trust [97], and improve
the WOM of patients. Our research could help promote this type of study in theory to further focus on
the purpose and effectiveness of IT implementation in depth in the internet medicine era.
5.2.2. Implications for Practice

This research could also benefit hospitals and other healthcare providers. This research could
encourage hospital decision-makers to pay attention to how MIHS plays a role beyond its deployment
and focus more on the impact of the users’ expectations, perceived risk, perceived usefulness and
perceived interactivity on MIHS use. WOM is an important source of trust between doctors and patients
and plays a significant role in improving the relationship between them. MIHS is an innovative health
service in terms of patient satisfaction. According to its positive effect on WOM in our empirical tests,
hospital decision-makers should pay more attention to the continuous and effective operation of MIHS.
Some key factors are discussed in our studies, including technology features and user experience,
which would influence the satisfaction and continuous operation of MIHS.
First, from the perspective of technology features, the hospitals should strengthen the facilitating
conditions and safety management of MIHS. As multiple terminals and the interactivity of information
management system are involved, risks such as information leakage and attack will affect users.
Therefore, efficient safety management could reduce the risks in the system and improve patient’s
trust and perceived reliability. Moreover, the operation of MIHS also must be simplified to improve
perceived ease of use and improve their satisfaction.
Second, from the perspective of user experience, our studies have shown that both perceived
usefulness and perceived ease of use have a positive influence on the continuous use of MIHS and the
improvement of patient satisfaction. These results are similar to the results of Ong, Lai and Wang’s
research in the context of e-learning systems [98]. To improve continuous use, the basic function of
MIHS should be enriched to improve perceived usefulness. In addition, hospital managers should
enhance the interactivity functions of MIHS, which are key factors influencing the patient perceived
usefulness and intention for continuous use. This includes ensuring system stability and continuous
openness, guaranteeing sufficient interactive time between medical staff and patients, and so on.
5.3. Limitations
This paper analyzed the main mechanisms of how the features and users’ experiences of MIHS
influenced patient satisfaction and continuous use behaviors of the system to generate additional
WOM dissemination behaviors. This study could link the improving trust of doctors and patients to
the use of MIHS. However, there are some limitations that can be addressed by further studies.
Firstly, we used continued use intention rather than actual use behavior. In the research area of
information systems use, most researchers only studied behavioral intention rather than behaviors [99],
because it is not easy to obtain the real use data by survey methodology. We did not follow up and
track the actual use of MIHS, considering its difficulty and complications. It is a challenging issue
to explore other means of obtaining data. It is a further challenge to include other research methods
to obtain data indicating specific individual use of modules from MIHS data bases, as permitted
by policies associated with the use, disclosure, and privacy protection of individual healthcare data.
Future studies could consider how to establish dynamic tracking mechanism of patients continued
use behaviors.
Secondly, this paper did not analyze individual differences, so the impact mechanisms of MIHS
on patient satisfaction in different populations are not clear. In fact, the attribute variables have shown
a significant influence in the medical service area [100,101]. Future studies should further explore the
moderating effects of these attribute variables.
The third one is that our study did not consider excluding patients who could not read or write
although the number of such participants is small.
6. Conclusions and Future Directions

Based on post-adoption behavior and ECM-IT [102], this research constructs a comprehensive
model to explain the mechanisms of how the features of MIHS and users’ experiences affect the output
of MIHS use, such as patient satisfaction, intentions of continued use and WOM. Patient satisfaction,
intentions of continued use and WOM are the key factors influencing the relationship between hospitals,
doctors and patients. Based on the data from patients at AN Hospital, one of the largest hospitals in
East China, we tested the model.
The relationship between doctors and patients has become increasingly important and sensitive,
which could influence patient satisfaction of medical services. Some hospitals have attempted to
introduce the MIHS to improve their service quality. However, there are two questions that need to be
answered. First, how is the MIHS used to improve patient satisfaction and how does it stimulate its
continuous use. Second, what is the effect of MIHS use on three outputs: patient satisfaction, continued
use of MIHS, and WOM.
In this study, we established a research model on the impact of using MIHS on patient WOM
from the perspective of both technological features and users’ experience, and we empirically tested
the model with data collected from AN Hospital. All the research hypotheses were supported.
According to the above analysis and discussion, we found that the facilitating conditions of MIHS
technology had a positive impact on the patients’ intention to continue using MIHS, and the
relationship between perceived risk and continual use of MIHS is negative. In addition, perceived
interactivity and conformity with the patients’ MIHS performance expectations also influenced
patient perceived usefulness, thus improving patient satisfaction and stimulating their continuous
use behaviors. The above analysis could answer the first question about the mechanism of MIHS
impact. We further discussed the second question about the effects of using MIHS. The results showed
a significantly positive influence of using MIHS on patient WOM behaviors. That could promote trust
between hospitals or doctors and patients, and improve their relationships. Our research has a role in
the expansion of ECT theory and a guiding role in the practice of mobile Internet-based healthcare
service. Meanwhile, there are some possible directions for the future as follows.
The first one is that the depth difference of MIHS use could exist. Most of the participants used a
majority of the functions of interactivity such as consultation on registration, satisfaction evaluation,
health situation consultation with medical staff, bills consultations, communication with other users
and etc. In our study, we consider different types of interaction with MIHS but failed to successfully
communicate with the hospital and get the data of interaction in detailed granularity. This is an
interesting issue deserving further research in the future.
Secondly, in our study, we did not investigate the pre-variables (such as cost-of-care, health
outcomes, etc.) of patient expectations, usefulness, and perceived risk. The issue associated with these
factors and corresponding influential mechanism is really very interesting and deserves further study
in the future.
Last but not least, researchers can extend our research to the perspective of the role of IT use on
patient satisfaction and WOM of medical service. In our study, the research objective is MIHS, not
medical service of the hospital in which cost-of-care and health outcomes can affect patient expectations,
usefulness, and perceived risk. This issue associated with the role of MIHS use and medical care
output will be more interesting and challenging.”
Author Contributions: D.G. conceived the research, X.Y. wrote the draft; X.Y. collected the data and conducted
data analysis; C.L., H.K.J. and X.L. provided some guiding suggestions and revised the paper.
Acknowledgments: This research is partially supported in the collection, analysis and interpretation of data by
the National Natural Science Foundation of China under Grant Nos. 71331002, 71771075, 71771077, 71573071,
and 71601061.
Conflicts of Interest: The authors declare no conflict of interest.
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method of finding a doctor in a brick-and-mortar hospital. In an online health community, patients

2. Research Model and Hypotheses Development

2.1. Post-Adoption Behavior: Continuous Intention and WOM

2.2. Expectation Confirmation Model of Information Technology Continuance (ECM-IT)

2.3. Perceived Interactivity, Perceived Risk and Facilitating Conditions

2.3.1. Perceived Interactivity

2.3.2. Perceived Risk

2.3.3. Facilitating Conditions

3.1. MIHS Implementation and Use

• Your basic information

• Health tracking and evaluation after operations

• The schedule of available doctors

• Your doctors(name, position, affiliation,

Patients billing • Medical billing information by time

Online health self- • Symptoms and physical examination information

Table 1. Measures of constructs.

Construct Item ID Items Reference

Construct Item ID Items Reference

WOM01 I am willingness to recommend MIHS to others.

3.3. Sample and Data Collection

Table 2. Sample Demographics.

Category Number (%)

4.1. Measurement Model

Table 3. Descriptive statistics of the measure.

Table 4. Measurement model results.

Table 5. Structural parameter estimates.

Hypothesized Path t-Value Results

5. Discussion, Implications and Limitations

5.2.1. Implications for Research

5.2.2. Implications for Practice

6. Conclusions and Future Directions

Conflicts of Interest: The authors declare no conflict of interest.

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