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Internet hospital (or e-hospital) services have been developing at a rapid pace in China since 2014, which refer to hospital-based service platforms that integrate consultation, prescription, payment, and drug delivery, mostly featured in digital follow-up and routine consultations [,]. To date, China has witnessed the establishment of over 1700 internet hospitals with an extensive array of services []. The rapid growth of internet hospitals in China is expected to enhance the availability and accessibility of medical resources nationwide while controlling the costs associated with distant medical services []. Additionally, the strike of the COVID-19 pandemic has further expedited the advancement and acceptance of remote medical care, with internet hospitals playing a pivotal role [,]. However, despite the rapid development of internet hospitals, assessments regarding their service quality and patient satisfaction have not been well developed []. This study attempted to fill in this research gap.
Internet hospital services heavily rely on various digital platforms such as smartphone apps or miniprograms integrated into popular social media platforms (eg, WeChat or Alipay). The service quality provided by internet hospital platforms directly impacts the medical experience of patients as it encompasses (1) appointment, registration, guided triage, and referral during the previsit stage; (2) remote payment, and instant access to case and test reports during the visit stage; and (3) prescription management, drug delivery, health monitoring, and remote health education during the postvisit stage. Granted these benefits, it was undeniable that the rapid development and engagement of internet hospitals had raised several practical issues such as limited service accessibility to older people and risks of personal information leakage. Therefore, it was critical to comprehensively assess, and therefore, improve the service quality of internet hospitals [].
The Service Quality QuestionnaireThe service quality model was initially developed by Parasuraman et al [] to investigate potential causes of service quality issues and assist managers in improving service quality. The model was further refined and a measurement tool was developed accordingly, namely, the Service Quality Questionnaire (SERVQUAL) [,], which measures customers’ expectations and perceptions of the service quality provided by an entity, reflecting their attitudes toward the service provider [], highlighting the gaps between what customers believe should be provided (expectations) and what they believe they have received (perceptions). The SERVQUAL questionnaire consists of 5 dimensions (22 items) []: tangibles, which refers to the physical facilities, equipment, and appearance of personnel; reliability, which assesses the ability to deliver services accurately and dependably; responsiveness, which examines the willingness to assist customers and provide prompt service; assurance, which evaluates employees’ knowledge, courtesy, and ability to convey trust and confidence; and empathy, which assesses the level of care and individualized attention provided to customers. The SERVQUAL questionnaire has been applied to evaluate service quality in health-related contexts [-], demonstrating its suitability for assessing medical service quality. Therefore, it was adopted to evaluate the service quality of Chinese internet hospitals and to identify the possible gaps between expected and perceived service qualities.
This StudyTo briefly summarize, the purpose of this study was threefold, (1) to investigate the current status of Chinese patients’ use of internet hospitals, as well as their familiarity and willingness to use internet hospitals; (2) to evaluate Chinese patients’ expected and perceived service qualities of internet hospitals using SERVQUAL with a nationally representative sample; and (3) to explore the association between service quality of internet hospitals and overall satisfaction of associated medical platforms.
A total of 1586 participants were recruited via convenient sampling from 31 provinces in China. Inclusion criteria were (1) had used medical services in China within 1 year and (2) consented to participate in this study.
ProcedureA cross-sectional e-survey was administered on the SoJump platform (a popular Chinese digital survey platform) from June to September 2022. Recruitment for the survey was carried out through WeChat, a widely used social media platform in China. Potential participants were invited to complete the survey via WeChat moments. Investigators received digital data collection training sessions in advance for survey distribution, data collection monitoring, and quality control. Research team members conducted quality control on submitted responses based on (1) duplicate IP addresses, (2) shorter-than-expected response time window, and (3) incomplete responses. A total of 105 responses that failed at these criteria were excluded from the following analyses. Therefore, the final sample consisted of 1481 participants. Additionally, the 758 people who self-reported having used internet hospital services were further included in the analysis.
Ethical ConsiderationsThis study was approved by the Shanghai Jiao Tong University School of Medicine Public Health and Nursing Research Ethics Committee (reference: SJUPN-202203). All eligible participants who consented to participate were informed about the study’s purpose and procedure and then were asked to respond to the e-survey without interference. Data collection was conducted anonymously to ensure confidentiality. For participants deemed minor according to their reported age, further consent was requested from their legal guardians. Participants did not receive any material or monetary rewards for participation.
MaterialsParticipants responded to a battery of surveys including SERVQUAL-C, satisfaction with internet hospital services, and their demographic information.
Internet Hospital Use and ExperiencePatients first reported whether they had used the internet hospital (0=no or 1=yes), together with the frequency of use: “How often do you use the internet hospital” (1=never used before to 5=more than five times per year). Reasons for and against using internet hospitals were followed via multiple-choice questions (ie, “What are your reasons for using internet hospitals?” and “What are your reasons against using internet hospitals?”). Then, participants reported their overall familiarity, willingness to use, and satisfaction with internet hospitals by answering the questions “How much do you know about internet hospitals?” (1=barely to 5=very well), “How willing are you to use internet hospitals?” (1=very unwilling to 5=very willing), and “All things considered, how satisfied were you toward Chinese internet hospitals in general?” (1=not at all satisfied to 10=extremely satisfied).
Service Quality of Internet HospitalsThe 22-item SERVQUAL questionnaire consists of five dimensions of service quality (4 to 5 items each; 1=very poor to 5=very good), namely tangibles (TG; eg, “The aesthetic degree of internet hospital platform page design”), reliability (RA; eg, “Reliability of treatment results in internet hospitals”), responsiveness (RS; eg, “The timeliness of the internet hospital doctor’s response”), assurance (AS; eg, “The extent to which the internet hospital platform meets the needs of patients”), and empathy (EP; eg, “The extent to which internet hospitals provide personalized care for patients”), each question measures both the perception and the expectation perspectives, respectively. Therefore, SERVQUAL yields three scores, specifically, the perception (P) and the expectation (E) scores, which are computed by averaging the 22 items from each perspective, respectively, and the gap score, which is further computed by subtracting the latter from the former (ie, P–E).
Sociodemographic InformationAt the end of the questionnaire, participants reported their sociodemographic information, including gender (0=man and 1=woman), age (1=19 years or younger, 2=20-29 years, 3=30-39 years, 4=40-49 years, and 5=50 years or older), location (1=eastern region, 2=central region, 3=western region, and 4=northeast region), marital status (1=unmarried and 2=married), education level (1=below high school’s degree, 2=high school’s degree, 3=bachelor’s degree, and 4=higher than bachelor’s degree), as well as personal annual income (1=¥50,000 or below, 2=¥50,001-100,000, 3=¥100,001-150,000, 4=¥150,001-200,000, and 5=¥200,001 or above). The exchange rate of US $ to RMB ¥ mentioned in this paper is 1:7.0354.
Statistical AnalysisAll personal identifiers have been removed prior to data analysis to ensure anonymization. All data were analyzed with SPSS (version 25.0; IBM Corp) and R (version 4.2.0; R Core Team). The questionnaire was calculated to reflect internet hospital patients’ evaluations. Additionally, important-performance analysis (IPA) [] was used to compare patients’ expectations and perceptions of the services provided by internet hospitals and to reveal critical management perspectives. Finally, multiple linear regressions were also conducted to examine the association between service quality, demographics, familiarity, and willingness in patient satisfaction. All continuous variables have been centralized.
presents the sociodemographic characteristics of all the participants (n=1481; 635 men and 846 women). Participants were mainly women (n=846, 57.1%), aged between 20 and 29 (n=429, 29%), and married (n=820, 55.4%). The majority of the sample received a bachelor’s degree education (n=969, 65.4%) and received less than 50,000 Chinese Yuan per year.
It was found that 51.2% (n=758) of patients had used internet hospitals. Results suggested that there were significant differences in whether patients had used the internet hospital at different levels of age (P<.001), education level (P=.006), and annual income (P<.001), while differences in gender or marital status were not statistically significant.
Specifically, patients in their 20s (n=268, 62.5%) and 30s (n=190, 72%) had a higher percentage of using internet hospitals. Moreover, the use of internet hospitals varied among patients with different levels of education and annual income. A total of 59.6% (n=65) of patients with higher than bachelor’s degrees had tried internet hospitals, compared with 40% (n=145) of those with lower than high school degrees. Only 39.9% (n=265) of the patients with an annual income of below ¥50,000 had participated in internet hospitals.
A total of 51.2% (n=758) of the patients had used internet hospitals, among which 42.9% (n=325) of the patients used internet hospitals 1-3 times per year. It was also found that there was diversity in the patients’ familiarity and willingness among those who have ever used internet hospital service before. Patients who knew internet hospitals well or excellently only accounted for 26.9% (n=398) and 17.4% (n=258), respectively. A total of 20.3% (n=301) of the patients had poor (n=230, 15.5%) or terrible (n=71, 4.8%) familiarity with internet hospitals. In terms of willingness, 68.1% (n=1009) of the patients gave positive answers, showing a willingness to use internet hospitals. A total of 29% (n=429) of the patients had neutral willingness, and only 2.9% (n=43) of the patients were unwilling to participate in internet hospitals.
Table 1. Sociodemographic characteristics and use of internet hospital service among Chinese patients from June to September 2022 (n=1481).presents patients’ reasons for (n=758) and against (n=723) using internet hospitals. Major reasons for and against using internet hospitals were time-saving (n=500, 66%) and inaccuracy in diagnosis or treatment (n=427, 59.1%), respectively. Meanwhile, cost-saving (n=45, 5.9%) and hard-to-find suitable platforms (n=235, 32.5%) were the least concerned.
shows the expectation, perception, and gap scores of the SERVQUAL questionnaire. In the evaluation of Chinese internet hospital service, reliability (mean E 4.12, SD 0.67) received the highest score while empathy (mean E 4.06, SD 0.40) received the lowest score for the expectation perspective, and when it comes to perception perspective, assurance (mean P 3.87, SD 0.74) received the highest score while empathy (mean P 3.79, SD 0.80) still received the lowest score. Across all dimensions, the perception did not meet the expectation of service quality of internet hospitals (namely, all gap scores were negative), and it was noteworthy that the largest gap was observed in the responsiveness dimension.
IPA results are presented in . Specifically, the x-axis represents the perception while the y-axis represents the expectation scores, therefore, items in Quadrant I were service features where the performance matched the importance (eg, Q7, protected privacy), while Quadrant II were their counterparts where service qualities should be boosted (eg, Q13, active feedback handling). More importantly, most of the responsiveness features fell into Quadrant II, indicating the perceived responsiveness of internet hospitals in the eyes of patients is less than expected and awaits substantial improvement. Quadrant III consisted of items with low expectations and low perceptions (eg, Q19, personalized care), predominantly the empathy items, where lower expectations led to these items being given a lower priority. Quadrant IV consisted of items with perceptions exceeding expectations, (eg, Q22, reasonable charge), reflecting the strengths and attractiveness of internet hospital service.
presents the results of three multiple linear regression models predicting patients’ overall satisfaction with Chinese internet hospitals. Model 1 included five dimensions of internet hospitals’ service quality. In Model 2, two variables regarding familiarity and willingness to use internet hospitals were further added. Finally, Model 3 further included gender, age, location, marital status, education level, and annual income using the “enter” method to examine the associations between service quality perspectives, familiarity, and willingness to use internet hospitals above and beyond these control variables.
Model 1 (adjusted R2=0.526; F5,752=168.8; P<.001) revealed that among the included SERVQUAL-C dimensions, only tangibles (P<.001), reliability (P=.06), and empathy (P<.001) were significant and positively associated with patients’ overall satisfaction while others were not (Bs<.250; Ps>.066). Among the significant predictors, empathy contributed the most to the explained variance in patient satisfaction.
Model 2 (ΔR2=0.033; ΔF7,750=29.7; P<.001) revealed that familiarity and willingness were significantly and positively associated with patients’ satisfaction, above and beyond the SERVQUAL dimensions, and the inclusion of which further resulted in nonsignificance of the reliability dimension (B=.260; P=.08). Willingness appeared a stronger predictor than familiarity in predicting patient’s satisfaction while controlling the SERVQUAL-C dimensions.
Table 2. Reasons for and against using internet hospitals among Chinese patients from June to September 2022a.aResponses are presented in descending order in frequency.
Table 3. Expectations, perceptions, and gaps in service quality of internet hospitals according to SERVQUALa among Chinese patients from June to September 2022 (n=758).ItemMean (SD)GapsaSERVQUAL: Service Quality Questionnaire.
bE: Expected service quality estimated by SERVQUAL-C.
cP: Perceived service quality estimated by SERVQUAL-C.
dTG: Tangibles.
eRA: Reliability.
fRS: Responsiveness.
gAS: Assurance.
hEP: Empathy.
Figure 1. Importance-performance analysis of internet hospital service quality among Chinese patients from June to September 2022 (n=758). Grid lines represent mean scores of expectation and perception, respectively. Solid dots represent tangibles (namely, Q1 to Q4), triangles represent reliability (namely, Q5 to Q9), diamonds represent responsiveness (namely, Q10 to Q13), squares represent assurance (namely, Q14 to Q18), and circles represent empathy (namely, Q19 to Q22). Table 4. Predictors of patient satisfaction with internet hospital services: service quality, familiarity, willingness, and demographics among Chinese patients from June to September 2022 (n=758).aModel 1: F5,752=168.8; P<.001, R2=0.526.
bModel 2: ΔF7,750=29.7; P<.001; ΔR2=0.033.
cModel 3: ΔF23,734=6.48; P<.001; ΔR2=0.055.
Model 3 (R2=0.055; ΔF23,734=6.48; P<.001) revealed that gender, age, education level, and annual income were all significant predictors of patients’ overall satisfaction with Chinese internet hospital service while marital status was not. Specifically, patients with a bachelor’s degree were significantly less satisfied with internet hospitals compared to those with a high school (or below) degree (ie, the reference group; B=–.442; P=.01; 95% CI –0.794 to –0.090); and patients with an annual income between ¥50,001 and ¥100,000 were significantly less satisfied with internet hospitals compared to those with an annual income below ¥50,000 (US $ 7019.91; ie, the reference group; B=–.319; P=.02; 95% CI –0.575 to –0.063). Most importantly, after controlling for the patient’s demographic characteristics, the effects of the service perspectives (tangibles and empathy), as well as familiarity and willingness remained significant. Overall, the 5 SERVQUAL-C dimensional scores contributed significantly to the explanation of variances in patients’ satisfaction, while the inclusion of familiarity and willingness, as well as the sociodemographic variables, only slightly improved the explanation.
This study evaluated the service quality of internet hospitals in China via the Chinese version of SERVQUAL from the perspective of patients, and associated patients’ satisfaction. To summarize, the current service quality of Chinese internet hospitals as perceived by patients did not yet meet their expectations, especially in terms of service responsiveness. Factors associated with patient satisfaction suggested that patient familiarity with and willingness to use internet hospitals cast on their overall satisfaction.
In our research, we found that more than half of the sampled participants had used internet hospitals. However, there is a big gap in the penetration rate of internet hospitals between the young and the older people older than 60 years, which may be related to the older people are not used to the internet, and the psychological resistance caused by the fear of fraud. Our results also demonstrated that education level and annual income played an important role in determining whether patients had used internet hospitals. This finding emphasized the necessity of lowering the threshold and fee of using internet hospitals, which can be achieved by creating more user-friendly web pages, providing more smooth operation, or introducing more favorable policies [], etc.
Furthermore, there was diversity in the patients’ familiarity and willingness to use internet hospitals. The majority of participants found it hard to evaluate their familiarity with internet hospitals, yet many more expressed interest and willingness to use this service. This could be attributable to the lack of publicity and promotion of internet hospital services so patients were not yet aware of the possible convenience and applicability of Chinese internet hospitals. At the same time, the patients’ stronger willingness also pointed out that internet hospitals’ functions could serve as an important supplement to the current health care system and associated health care service to further improve both the health care service and patients’ experience. It was noteworthy that the COVID-19 pandemic had somehow fastened the development of the internet hospital service scope and quality, especially in China []. Therefore, it is expected that patients’ willingness toward internet hospitals might further enhance to the extent that they become more and more familiar with its services.
Our results also indicated that patients’ expectations as regards the quality of the provided services are not met. All of the five quality dimensions have a negative gap between patients’ expectations and perceptions. These results are similar to other studies using the SERVQUAL model in China [] and other countries such as Greece [-]. The greatest gap lies in responsiveness (–0.308) and reliability (–0.276). However, the difference between the two dimensions of expectations and perceptions does not necessarily indicate a low quality of service, but rather that the patient’s requirements are not met, thus leading to patient dissatisfaction. IPA results showed that prompt response, clear feedback pathway, and active feedback handling demonstrate high expectations but low perception levels, which covered three of the four items of responsiveness. Gaps revealed in IPA corroborated patients’ reported reasons for and against using internet hospitals. Specifically, timely responses, as well as diagnosis and treatment accuracy, were the most concerning reasons. Improvement in these perspectives would significantly enhance patients’ willingness toward internet hospitals. Another item that warranted research attention was reliable diagnosis, it was undeniable that the convenience of digital interaction inevitably introduced higher risks of misdiagnosis. Therefore, developers should pay more attention to the importance of user-friendly interfaces and feedback from internet hospital users to promote efficient and effective responses. Furthermore, more policies and regulations ought to be adopted to regulate information security and digital health care processes to minimize the perceived information risk and medical risks.
Results revealed that patient-perceived tangibility, reliability, and empathy positively predicted satisfaction, with increased empathy being particularly effective in improving satisfaction. This may be due to the fact that patients originally have low expectations of empathy, and once a high-quality empathic service is perceived, the sense of surprise that comes with it can substantially increase satisfaction. At the same time, responsiveness, which had a low patient perception score, was unexpectedly not a significant predictor of satisfaction, which may be the result of a large gap between perceived and expected aspects of responsiveness, and the fact that if responsiveness is not currently sufficient for normal service delivery, patients will also see improved responsiveness as a basic requirement that should have been achieved and will not be able to establish a link with satisfaction.
In addition, patients’ familiarity and willingness to use the internet hospital were similarly significantly and positively associated with satisfaction, and the association of these dimensions on satisfaction was not affected by the introduction of demographic variables. Therefore, strengthening the publicity and promotion of internet hospitals among the patient population so that more people can learn to use internet hospitals more conveniently and quickly, as well as increasing the willingness of patients to use internet hospitals when they have a need for medical care, can better improve satisfaction and establish a more amicable and stable digital consultation platform.
ConclusionsUsing the SERVQUAL questionnaire, this study shed light on gaps between the expected and the perceived service quality of Chinese internet hospitals from patients’ perspectives. In the future, internet hospitals should focus more on how to improve reliable diagnosis, prompt response, and active and clear feedback pathways. In this way, internet hospitals could improve patients’ satisfaction and provide superior telemedicine services, and consequently, patient’s willingness to use internet hospitals in need.
We thank all the participants and staff of this study. No generative artificial intelligence was used in the writing of this manuscript.
The datasets analyzed during this study are available from the corresponding author upon reasonable request.
TH designed the study, conducted all statistical analyses, and wrote the manuscript. QW organized project implementation and wrote the manuscript. TH and QW contributed equally and share the first authorship. RW assisted with the results section. YC assisted with the discussion section. HZ provided data for tables. JC provided data for the figure. ZZ designed and supervised the study. SL provided methodology and data verification and supervised the completion of manuscript revisions. ZZ (zhangzhiruo@sjtu.edu.cn) and SL contributed equally and share correspondence. All authors have read and agreed to the published version of the manuscript.
None declared.
Edited by A Mavragani; submitted 05.12.23; peer-reviewed by M Mota Morales, X Ma, L-J Jang; comments to author 23.05.24; revised version received 12.06.24; accepted 26.09.24; published 08.11.24.
©Tao Han, Qinpeng Wei, Ruike Wang, Yijin Cai, Hongyi Zhu, Jiani Chen, Zhiruo Zhang, Sisi Li. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 08.11.2024.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research (ISSN 1438-8871), is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.
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