Journal of Business Research 123 (2021) 557–567

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Journal of Business Research

journal homepage: www.elsevier.com/locate/jbusres

Digital transformation in healthcare: Analyzing the current

state-of-research
Sascha Kraus a, *, Francesco Schiavone b, c, Anna Pluzhnikova d, Anna Chiara Invernizzi e
a
Free University of Bozen-Bolzano, Piazza Università 1, 39100 Bolzano, Italy
b
Parthenope University, Via Generale Parisi 13, 80132 Napoli, Italy
c
Paris School of Business, Paris, France
d
ESCE International Business School Paris, 10 Rue Sextius Michel, 75015 Paris, France
e
University of Eastern Piedmont, Via Perrone 18, Novara 28100, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Digital transformation in healthcare is of increasing relevance for both scholars and practitioners in the field. Our
Digital transformation article attempts to assess the research question how multiple stakeholders implement digital technologies for
Stakeholder analysis management and business purposes. To answer this question, we perform a systematic literature review about
Healthcare
the state of the art of digital transformation in healthcare. Our findings show that prior research falls into five
Patient empowerment
clusters: operational efficiency by healthcare providers; patient-centered approaches; organizational factors and
Systematic literature review
managerial implications; workforce practices; and socio-economic aspects. These clusters are linked together into
a model showing how these various forms of technology implementation lead to operational efficiencies for
services providers. Various directions for future research and management implications are offered.

1. Introduction scholars and practitioners (Reis, Amorim, Melão, & Matos, 2018). A
recent systematic literature review about DT in HC (Marques & Ferreira,
Digital transformation (DT) refers to “a process that aims to improve 2020) shows how much research on this topic has increased over the last
an entity by triggering significant changes to its properties through 20 years and highlights the most common technology-related research
combinations of information, computing, communication, and connec­ themes within this domain. However, due to the strict focus on tech­
tivity technologies” (Vial, 2019, p. 118). DT affects many aspects of nology, it does not adequately highlight the various management ap­
companies, such as the acquisition of digital resources, the design of plications and business impacts of DT on the multiple stakeholders of
digital growth strategies, the change of internal organizational struc­ this industry (Nudurupati, Bhattacharya, Lascelles, & Caton, 2015). A
ture, and the definition of proper metrics and goals (Verhoef et al., multi-stakeholders perspective is critical to understanding properly
2019). This phenomenon has become a very popular topic within how, in practice, the various players of a HC ecosystem (patients,
various streams of business research (e.g. information systems, strategy, pharmaceutical companies, hospitals, public agencies, and many more)
marketing) and is revolutionizing the business sector writ large. For exploit DT technologies and means to quality of care, value creation, and
many years, healthcare (HC), which refers to all services that medical many more managerial issues. Mainstream literature about DT scarcely
professionals deliver to preserve people’s physical and mental well- analyzes the stakeholder perspective, in which it is generically reported
being, has been one of the main industries in which DT has occurred that a heterogeneous set of network stakeholders is a crucial condition
(Agarwal, Guodong, DesRoches, & Jha, 2010; Marques & Ferreira, for the organization of value creation, growth, digitalization and DT
2020). The digital revolution in HC creates new business opportunities (Verhoef et al., 2019; Vial, 2019).
and yields new business models to address issues in medical practice, Drawing on these assumptions, the research question of the present
value creation and other problems related to, among others, the ageing article is: how should the industry’s multiple stakeholders implement DT
society (Elton & O’Riordan, 2016). technologies for management and business purposes? To answer this
The rising relevance of DT in this industry became evident to both question, we perform a systematic literature review (SLR) about the

* Corresponding author.
E-mail addresses: [email protected] (S. Kraus), [email protected] (F. Schiavone), [email protected] (A. Pluzhnikova), anna.
[email protected] (A.C. Invernizzi).

https://doi.org/10.1016/j.jbusres.2020.10.030
Received 11 February 2020; Received in revised form 7 October 2020; Accepted 11 October 2020
Available online 21 October 2020
0148-2963/© 2020 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
S. Kraus et al. Journal of Business Research 123 (2021) 557–567

state of the art of DT in HC. This article contributes, first, to the general Marques and Ferreira (2020), in their review of 45 years of literature
stream of literature about DT (Verhoef et al., 2019; Vial., 2019) by about DT in HC, found seven technology-related areas of research: 1)
illustrating clearly the roles and activities of more and heterogeneous Integrated Management of Information Technology in Health; 2) Med­
(employees, customers, services providers and so on…) stakeholders ical Images; 3) Electronic Medical Records; 4) Information Technology
during this process. Second, our findings contribute to the rising body of and Portable Devices in Health; 5) Access to E-Health; 6) Telemedicine;
knowledge about DT in HC (e.g., Marques & Ferreira, 2020) by showing, and 7) Privacy of Medical Data.
via a stakeholder-based perspective, how health service providers Big data in HC is rooted in clinical research results, Electronic Health
should gain operational efficiency and strategize via digitalization. The Records (EHR), as well as consumers’ personal data retrieved from self-
findings of our SLR show prior research about DT in HC falls into five tracking devices, e.g. wearables for work-monitoring or sports (Belliger
clusters: operational efficiency by HC providers; patient-centered ap­ & Krieger, 2018). Patient data typically includes all treatment-related
proaches; organizational factors and managerial implications; work­ documentation, such as written and visual medical records, doctors’
force practices; and socio-economic aspects. These clusters are linked letters, e-prescriptions, insurance claims (Haggerty, 2017). Siemens,
together into a model showing how these various forms of technology (2016) specifies four main HC data generators: HC providers, ancillary
implementation lead to operational efficiencies by HC services pro­ service providers (e.g. pharma companies), public and private in­
viders. Various directions for future research and management impli­ stitutions, and patients. Given the fact that population is on the rise in
cations are offered. the developing parts of the world, health data analytics are driving
global changes in medical treatment models. This, among other things,
2. Background literature is driving the untapped potential of data from today’s HC models is
relevant (Reddy & Brahm, 2016). Proper use of medical big data re­
Digital disruption has become a phenomenon of the 21st century that quires accurate data gathering and analysis, including health records,
is transformational in all traditional industrial contexts (Ford, Compton, genomics, and information retrieved from different applications. Big
Millett, & Tzortzis, 2017), affecting all levels of business and society Data analytics can promote personalized individual care to predictive
(Schallmo & Williams, 2018). The introduction of digital solutions in models for big population groups.
organizations requires systematic changes of “working, roles and busi­ Big data and data analytics in HC establish a basis for electronic
ness offering” (Parviainen, Tihinen, Kääriäinen, & Teppola, 2017, p.64). health records (EHR), “[A] repository of patient data in digital form,
The performance of a company is affected by new technologies and stored and exchanged securely, and accessible by multiple users”
connectivity of all stakeholders across the value-added chain (Schallmo (Häyrinen, Saranto, & Nykänen, 2008, p. 293). By 2015, ‘Electronic
& Williams, 2018). The concept of DT incorporates digital trends at Medical Records’ (EMR) were implemented and used throughout many
different levels, including technology, processes, organizational aspects, independent entities including HC providing institutions, insurers, and
especially business model disruption and society (Klewes, Popp, & Rost- patients (Evans, 2016). EMR are “digitalized systems which functionally
Hein, 2017). provide patient history, patient demographics and registration details”
Four disruptive digital-enabled concepts currently are supporting the (Chakravorty, Jha, and Barthwal (2018, p. 9) for professionals’ use,
DT of organizations: 1) The fourth industrial revolution, or Industry 4.0 often based on telemedicine approaches. The concept of telemedicine
(I4.0), which relates to “the systematic connection of technical compo­ traces back to the 19th century (Arni & Laddha, 2017). Telemedicine is
nents and processes […], supply and […] business relationships “the delivery of [HC] services, where distance is a critical factor, by […]
including all logistical elements” (Klewes et al., 2017, p.11). It is based using [ICT] for […] treatment and prevention of disease and injuries,
on the concept of I4.0, the Internet of Things (IoT), which describes the research and evaluation, and for continuing education of [HC] pro­
interconnection of computing power and data flows of smart objects that viders, all in the interests of advancing the health of individuals and
enable the autonomous control of daily life processes (Klewes et al., their communities” (World Health Organization (2010), 2010, p. 8).
2017); 2) Artificial Intelligence (A.I.), understood as the transformation Related functional branches of telemedicine encompass tele­
of service processes into automated processes that rely on intelligent consultation, telecare, telemonitoring or telehealth, and tele diagnoses
computer systems or computer-controlled robots that do not require (Arni & Laddha, 2017; Ford et al., 2017; Tuzii, 2017).
human intervention to execute tasks associated with intelligence
(Copeland, 2019). The concept of Big Data was used to describe the 2.1. General Considerations
“volume, velocity and variety of data” (Manogaran et al., 2017, p. 264)
that becomes increasingly difficult to analyze through conventional data Drawing on these assumptions, some general considerations can be
processing tools. Currently, digital technologies enable homogenization developed about operational efficiency led by DT in HC and industry
and storing of significant amounts of data using big data analytics, or stakeholders. First, digital technologies are often expected to improve
“advanced tools and techniques to store, process, and analyze the large the quality of care and operational efficiency by facilitating clinical and
volume of data” (Manogaran et al., 2017, p. 264). administrative tasks linked to the assessment, transmission, evaluation,
The adoption of ICT has been affecting the HC sector since the mid- and precision of medical treatment. The adoption of technological in­
20th century (Ford et al., 2017). On example of this is improved research novations, such as wearables devices and health apps, has mainly had an
and care delivery. The introduction of the Internet in the mid-1990s has impact on internal processes and the positioning of patients in the HC
strongly impacted the way in which stakeholders communicate (Arni & system. These and other solutions leverage the progress in big data and
Laddha, 2017; Suggs, 2006). The paradigm shift in HC organizations has data analytics toward new possibilities of personalized care. Second, the
only incrementally changed the HC industry over the last 20 years traditional stakeholders of the HC market are represented through four
(Tuzii, 2017). ‘DT in HC’ refers to the adoption of new technologies that closely interacting focus groups (see Fig. 1): patients and consumers, HC
enables the shift towards secure, high-quality care (Haggerty, 2017). providers, policymakers, and third-party creditors (Schachinger, 2013).
Belliger and Krieger (2018, p. 311) add the aspects of “new de­ DT in HC changed the mechanisms of value creation linking together
velopments as self-tracking, big data and predictive analytics, e-health, these traditional focus groups and, uppermost, by extending with new
mobile health, participative medical research, e-patient communities, players (e.g., digital companies) the set of stakeholders within this
[…] and shared decision making in diagnosis and e-therapy”. Such industry.
connotations makes DT in HC a concept that overlaps with digital Third, DT does not change only the mechanisms between these
health, which refers to the “use of information and communications traditional industry actors but also revises the overall HC landscape.
technologies to improve human health, healthcare services, and well­ Various new market actors disrupted the value chain of the telemedicine
ness for individuals and across populations” (Kostkova, 2015). Recently, market: telecommunications companies and mobile operators,

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Fig. 1. Stakeholders of the traditional HC system. Source: Own elaboration.

pharmaceutical companies, and manufacturers of medical and moni­ ‘healthcare’ both in titles only to ensure that publications covering both
toring devices and platforms (Wright & Androuchko, 1996; Baum & core areas could be identified. This first search yielded 31 articles. With
Abadie 2013). the intent to increase the breadth of the SLR, a further broader search
should produce a more significant number of articles: Hence, even if
3. Systematic literature review many were less relevant to the present topic, the combination ‘digital*’
in titles AND ‘healthcare’ in abstracts was applied. The search was
3.1. Methodology conducted according to the same search criteria as above, e.g. publica­
tion date, source type and language. This further search yielded 114
To provide an overview of the current state of academic literature, a manuscripts. After excluding 15 multiple entries, the search sample for
SLR was conducted in the first semester of 2019, with a focus on pub­ EBSCOhost consisted of 130 journal articles. Furthermore, to strengthen
lications in the field of Management, Business and other related areas the inclusiveness of the sample of articles in this field, the databases
such as Information Systems. In recent years, this research methodology Elsevier ScienceDirect and SpringerLink were also scanned according to
became very popular within the field of innovation and entrepreneur­ the same keywords as mentioned above. The above search resulted in a
ship studies (e.g. Kivimaa, Boon, Hyysalo, & Klerkx, 2019). A SLR “is a total of 340 articles. Articles that did not fall under the conceptual
review of an existing body of literature that follows a transparent and criteria set earlier were then systematically excluded. In order to provide
reproducible methodology in searching, assessing its quality and syn­ a quality threshold, we adopted the official German journal ranking
thesizing it, with a high level of objectivity” (Kraus, Breier, & Dasí- “VHB-JOURQUAL 3” and considered only those articles that were
Rodríguez, 2020, p. 4). The literature review reported in the previous released in journals ranked at a “C” level or higher ratings remained in
section comprised different peer-reviewed and non-refereed articles, the sample (Bouncken et al., 2015). We did not apply other quality
case reports, book chapters and consulting reports. Following a well- criteria (e.g., impact factor) or journal rankings (e.g. ABS). After this
established approach used for studies of different types (e.g. check, 198 articles were excluded due to low or non-ranking statuses of
Bouncken, Gast, Kraus, & Bogers, 2015; Vallaster, Kraus, Lindahl, & the journals they were published in. The revised subsample then con­
Nielsen, 2019), a SLR focused above a certain quality level of publica­ tained 142 high-quality articles.
tions in peer-reviewed academic journals with specific criteria chosen to To further the conclusions, after reading the titles, keywords, and
be conducted hereafter. A stepwise research approach has been under­ abstracts, another 115 articles of the resulting subsample were elimi­
taken to ascertain a broad perspective for an in-depth understanding of nated, based on subjective decision-making. These publications were
the context (Cook & West, 2012) and linkages between DT and HC. The determined not to be a fit for the field of research, either because they
first step was the literature search through the EBSCO host databases were not covering the overall focus of digitalization in HC or lacked a
‘Business Source Ultimate’ and ‘Business Source Complete’ (see e.g., meaningful discussion of this topic. This final step of excluding a rela­
Mas-Tur, Kraus, Brandtner, Ewert, & Kürsten, 2020). Since digitalization tively high number of ill-fitting manuscripts has condensed the sample
in HC, understood as the use of information technology for processing into 27 academic journal articles. All results have been gathered in Excel
and managing data, information, and processes, started to become data extraction sheets, including the exclusion criteria. Afterwards, the
popular in the early 2000s (Agarwal et al., 2010), the 2000–2019 time sample was scanned multiple times to develop clusters of recurrent
frame was set. Non-refereed articles, conference papers and book topics covered. A visual overview of the literature search process,
chapters have been excluded from the search. including the set of restricting criteria and further limitations, is pro­
An initial search included the keyword combinations ‘digital*’1 AND vided in Fig. 2.

3.2. Descriptive results of research

1
Asterisks at the end of words point variations of the word ‘digital’ regarding
British or American English spelling and variations in its root out, e.g. digi­ By analyzing descriptive elements of the sampled publications, the
talisation, digitalization, digitalised, digitalized, digitally. distribution of articles per year (Fig. 3) reveals that publications range

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Fig. 2. Literature search process. (Source: Own elaboration).

Fig. 3. Chronological development of the number of academic articles, 2004–2019 (n = 27). (Source: Own elaboration).

from the years 2004 to 2019. Only one study of the sample was pub­ Remaining articles mostly have their origins in Europe, especially in the
lished in 2004, followed by an interruption until 2008. From 2015, a Western and Northern area, e.g. Ireland, Germany, Italy (n = 2 for all),
steadily increasing interest in this field of research can be observed, indicating emerging trends and actions by the EU. A total of 18 journals
showing a peak in 2019 with ten manuscripts. Crucially, 67% of all the are represented,2 and the journal with the highest number of accepted
identified articles have been published since 2017, indicating the articles is ‘Health Care Management Science’ (n = 5 in 2004–2019).
generally high topicality of digital health in high-quality journals. Such findings suggest that research into DT of HC remains rooted in the
The highest number of papers (n = 7) cover articles from researchers HC industry area and that the topic remains emergent.
in North America (e.g., Agnihothri, Cui, Delasay, & Rajan, 2020; Gray, In order to get an understanding of the fields of research the cross-
El Sawy, Asper, & Thordarson, 2013). Furthermore, five articles origi­ functional topic is rooted in, the general publication subjects repre­
nate from cross-country research, especially in the cases of conceptual sented by the academic journals were also analyzed: For this purpose,
frameworks (e.g. Mishra et al., 2019, Patrício, Teixeira, & Vink, 2019). the journal publication details from the respective online databases

2
Information Systems Research (n=2); Health Care Management Science
(n=5); MIS Quarterly (n=1); MIS Quarterly Executive (n=2); European Journal
of Marketing (n=2); Health Services Management Research (n=1); Journal of
Business Research (n=2); Marketing Theory (n=1); Service Business (n=1);
Management Revue (n=1); Business Process Management Journal (n=1);
Journal of Decision Systems (n=1); Health Policy and Planning (n=1); AMS
Review (n=2); International Journal of Operations and Production Manage­
ment (n=1); Public Relations Review (n=1); Information and Management
(n=1); International Journal of Information Management (n=1).

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where the articles were retrieved from were also included. Being a topic aim to identify consumers’ perceptions of health throughout a content
of high currency and rapid technology adoption, DT of HC is a subject of analysis of digitized accounts on social media channels, e.g. Instagram.
Business, Management and Marketing research, with 15 articles classi­ They develop a four-quadrant model grounded in a commercialized
fied as Business and/or Management, three among them from journals meaning-making processes. The authors find that meanings of health on
solely publishing about Marketing topics. A focus on consumerization to social media are often reproduced around consumption objects, and
approach DT in HC becomes evident. On the one hand, main streams consequently leverage conceptualizations around specific themes,
relate to more specific technology-linked areas like Information Man­ namely food, fitness, fashion, and feelings. In this regard, other re­
agement, Management of Information Systems, or Information Tech­ searchers explore the effect of online networks on elderly Spanish con­
nology (n = 8). On the other hand, an important number of articles (n = sumers’ health-related information seeking and the impact on their
7) retrieved from journals on the threshold of management and HC interconnectedness (Sanders, Sánchez Valle, Viñaras, & Llorente, 2015).
stands out. However, DT in HC has been researched in other fields, such Their study outlines that the internet does not replace face-to-face
as Public Relations (n = 1) and Operations Management (n = 1). In this consultation, but rather serves as a complementary, dispensable ser­
sense, the relevance of cross-functional research for the management vice. Nevertheless, little research exists on the correlation of consumers’
practice becomes evident. multi-channel health information-seeking and value co-creation.
Given the relatively young research field, most of the studies rely on Therefore, Dahl, Peltier, and Milne (2019) investigate consequences of
empirical data from qualitative analyzes (n = 10), mostly single or autonomous information-seeking on consumers’ health awareness and
multiple case studies, and in some cases, interviews. Yin (2012) points flow patterns for health service systems. Their understanding of patient
out that qualitative analysis brings the advantage of gaining an in-depth empowerment discloses a transition from provider-controlled to
understanding of people’s viewpoints without being limited by certain externally-controlled digital information sources, which mainly results
answers through surveys. Further, seven methods were quantitative in from patients’ active engagement in networks.
nature, mostly in the context of factor analyzes and structural equation More specifically, the impact of m-health technologies on disease
modeling. Additionally, four conceptual papers and four Literature Re­ progression is examined by Agnihothri et al. (2020) and Yousaf et al.
views could be identified and two articles applied multimethod (2020). Agnihothri et al. (2020) measure benefits according to two in­
approaches. dicators, namely the average life expectancy, as well as the expected
total lifetime earned. The latter literature review concentrates on the
3.3. Findings: Five clusters of healthcare research about digital identification of mobile dementia applications and their assessment in
transformation terms of utility for patients suffering from dementia or Alzheimer’s
disease, as well as benefits for caregivers (Yousaf et al., 2020). Whereas
3.3.1. Cluster 1: Emphasis on patient-centered approaches Agnihothri et al. (2020) specifically develop a market chain to design
Patients are empowered by the rise of digital technologies and are disease progression with regard to various factors, both studies point out
therefore becoming active decision-makers in their medical care pro­ that the value of m-health is dependent upon factors, such as the current
cess. Gray et al. (2013) examine the value creation of DT on the HC state of health, frequency of measurement and intervention, and care­
provider-patient relationship through the cumulative value of center- givers’ support or patterns of disease progress (Yousaf et al., 2020).
edge models, namely value chains, value shops, and value networks. Yousaf’s et al. (2020) comprehensive study reveals that m-health based
This relationship is mainly characterized through self-service and technologies have a positive impact on supporting patients and physi­
feedback cycles. Findings of their qualitative empirical investigations cians with cognitive training, monitoring, socializing, respectively
prove that HC is a consumer-centric industry which is well-positioned screening. Further, Agnihothri et al. (2020) observe a linear correlation
for a fundamental center-edge transformation. In this regard, Mende between a patient’s severity of medical conditions and personal benefits
(2019) shows that HC consumers are both “co-producers of service” and of m-health.
“partial employees” who must actively become involved in managing
their own health. According to Mende (2019), research on patient-based 3.3.2. Cluster 2: Operational efficiencies of healthcare organizations
approaches remains nascent, but is of major relevance to achieve tech­ Technological innovations in HC influence operations and processes
nological innovation in HC, e.g. in order to explore consequences of the and research reveals various patterns in this regard. Several studies
imminent use of humanoid service-robots on elderly patients and service focus on the impact of HIT on operational efficiencies and value creation
companies. (e.g. Hong & Lee, 2017; Laurenza, Quintano, Schiavone, & Vrontis,
Research has shown that tensions between patients and physicians, 2018; Taiminen, Saraniemi, & Parkinson, 2018). Accordingly, Hong and
due to conflicts of interest, negatively affect patients’ wellness (Jefferies, Lee (2017) analyze the effects of HIT and supported knowledge skills on
Bishop, & Hibbert, 2019). For this reason, value co-creation and service- HC quality and customer loyalty. They found a positive correlation be­
dominant logic (SDL) have emerged as a focus of investigations: Leonard tween operational innovation and patient satisfaction, which pointed to
(2004), Patrício et al. (2019) and Jefferies et al. (2019) study how loyalty, mainly tracing back to reduced expenses and improved work­
participatory design approaches influence the performance of HIT. One flows (Hong & Lee, 2017; Rubbio, Bruccoleri, Pietrosi, & Ragonese,
general objective of HIT is the facilitation of information sharing among 2019). A further contribution to this aspect is provided by Laurenza et al.
interest groups. EHR, currently representing the highest financial (2018) who study the influence of digital technologies on business
burden in HC (Agnihothri et al., 2020; Leonard, 2004), are especially process (BP) performance in the HC industry, throughout the case of the
relevant in the context of treatment of chronic diseases. With the intent Italian pharmaceutical company MSD Italy. Results show that the
to develop a national EMR system, Patrício et al. (2019) equally identify adoption of digital technologies positively impacts quality of care by
the need of participatory decision-making approaches among interest reducing the reaction time of clinicians and, generally, HC institutions
groups and find that participatory service design enables institutional due to their improved administrative processes.
HC innovation. With a specific focus on telehealth, Jefferies et al. (2019) Furthermore, researchers investigate issues concerning innovations
analyze the integration of patients’ perceptions and feedback on issues in HC. An example that falls into the scope of this cluster is the mea­
related to technology, bureaucracy, and professionalism in HC organi­ surement of operational efficiency. On the basis of design science
zations. Based on inquiries of heart-disease patients, Jefferies et al. research, Mazor, Heart, and Even (2016) address this matter in emer­
(2019) find functional, relational, and translational attributes that gency departments of hospitals. The researchers develop a prototype of a
disrupt the borders between HC institutions and boundary workers. digital dashboard that assesses the impact on patients’ duration of stay.
A further stream discloses consumers’ use of web-enabled solutions Simulation results of their investigations show that the average length of
for health-related purposes. Cavusoglu and Demirbag-Kaplan (2017) stay can potentially be reduced by 34%, thusly improving productivity.

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Regarding performance measurement, Kohl, Schoenfelder, Fügener, and analysis results in two factors to be considered: first, the different levels
Brunner (2019) introduce Data Envelopment Analysis (DEA) as a of current expertise with HIT in the HC entity, and second, diverse
preferred tool to examine the efficiency of hospitals. They study the change management approaches. Positive effects of EMR systems can be
utility of DEA throughout a SLR of 262 publications. Notwithstanding a expected if the implementation is supported by clinical staff and man­
high number (n = 99) of papers found on approaches to estimate agers adopt a “’bottom-up approach’ marked by a participatory process
operational performance, it becomes apparent that research insights starting from initial selection onwards” (Cucciniello et al., 2016, p.141).
have often been ignored in practice. Conversely, if managers impose the implementation and medical staff is
Another important contribution in this field is made by Taiminen not sufficiently involved in the co-development, it negatively impacts
et al. (2018), who investigate physicians’ perspectives on value creation the DT of HC entities. Finally, a valuable contribution with regards to
through digital self-services. Although results of their survey (n = 412) business model transformation is made by Laurenza et al. (2018). The
show that physicians agree on a positive effect on service quality, the authors observe that IT plays a central role for BP improvement and the
authors state that the HC industry is too immature for a full integration shift towards value-oriented HC by supporting both administrative tasks
of digital self-services, which is consistent with previous research as­ and cooperation with other stakeholders.
sumptions. Ozdemir, Barron, and Bandyopadhyay (2011) likewise
consider physicians’ perspectives, but in relation to countermeasures 3.3.4. Cluster 4: Impact on workforce practices
against issues in EMR adoption and data sharing. Due to physicians’ Just two studies can be identified that build on the transformation of
general reluctance to adopt EMR at that time, especially because of employees within HC organizations (Eden, Burton-Jones, Casey, &
distrust in providers, the authors consider an enhancement of PHRs by Draheim, 2019; Huber & Gärtner, 2018). In order to relate DT and
legal requirements and point out the positive effects of data sharing on workforce transformation, hospitals must first “engage in flexing,
added value for HC providers. Physicians’ support of such platforms deepening and revitalizing” (Eden et al., p.16): ‘Flexing’ refers to the
appears fundamental, especially if the goal is to enhance the manage­ way employees and hospitals respond to external restraints and leverage
ment of chronic diseases. HIT to gain flexibility; ‘deepening’ relates to employees’ behavior and
Sultan (2015) conceptual paper contributes to the topic from a reconsideration of their roles as health professionals; the influence of
technological point of view: he reflects on the potential of wearable constant disruptions on tasks and skills is described as ‘revitalizing’.
technologies for health monitoring and health data access and concludes These three practices are interdependent and influence the strategic
that their contribution is positive to HC quality, especially regarding orientation of a firm. With regard to the bottom-up approach, Eden et al.
health data reporting. Sultan (2015) uses the example of increased ef­ (2019) determine the adoption of two behavioral capacities, collabo­
ficiencies for measuring heart rate and blood pressure with the aid of rative visioning and evidence-based improvisation. A development of
wrist-or eye-based devices, i.e. Apple’s iWatch. Finally, a specific focus competences is called for around the management of tensions between
on operational failures and the role of DT on HC organizations’ resil­ revitalization efforts across all hierarchical levels. Leaders should try to
ience is provided by Rubbio et al. (2019). Throughout a multiple-cases achieve quick wins to keep staff motivated.
study with two Italian hospitals, and importantly the authors find that Huber and Gärtner (2018) attempt to identify the effects of Health
resilience-oriented practices lack expertise in improving patient safety. Information Systems (HIS) on an operating room module in a medium-
Concerning operational failures, they distinguish between workflow sized hospital in Germany. They analyze the differences between au­
dysfunctions that occur from lacking availabilities of equipment, and tonomy and control in normal and hectic situations of surgeons’ work,
operational failures due to incorrect usage or task execution. and the impact of transparent management on accountability. Con­
cerning ‘normal’ situations, HIS seem to facilitate daily work practices,
3.3.3. Cluster 3: Organizational factors and managerial implications due to the encoding of standards and complex guidelines. Regarding
Three studies could be identified that investigate the role of orga­ “‘hot situations’ in which unexpected events occurred and routine
nizational factors and managerial implications (Agarwal et al., 2010; behavior had to be suspended” (Huber & Gärtner, 2018, p.150), the HIS
Cucciniello, Lapsley, & Nasi, 2016; Hikmet, Bhattacherjee, Menachemi, was found to be too time-consuming due to a lack of clear guidelines. HC
Kayhan, & Brooks, 2008). Hikmet et al. (2008) focus on the strategic, professionals, therefore, engage with the technologies to keep their
administrative, and clinical HIT adoption3 at hospitals by testing professional autonomy. Digital technology increases personal exercising
different organizational variables. Overall, the results from their field power and accelerates work processes. Moreover, the simple access to
survey with 98 hospitals in Florida show hospital size and tax status, as medical results by team members of different hierarchies leads to
well as system affiliation being key influencing factors for the motiva­ improved co-evaluation and understanding of dynamic situations.
tion of adopting HIT. The authors, therefore, especially recommend Finally, digital technologies are considered to impact the reallocation of
standardizing administrative HIT systems. In contrast, Agarwal et al. working practices and shift of power, especially between physicians,
(2010) find significant research gaps in the significance of organiza­ radiologists, and nurses.
tional factors. Their review of existing studies on HIT results in two
research streams: a focus on levels and barriers to the adoption of HIT 3.3.5. Cluster 5: Socio-economic aspects
and, the impact on quality of care, operational efficiency, and financial Four remaining articles of the sample discuss social matters and
performance. Future research opportunities could come from HIT design mitigating financing solutions. A focus on HC market investment and the
implementation and meaningful use for organizations, measurement of relation to technological hype is provided by Geiger and Gross (2017).
HIT return, and extension of the traditional application areas. Concerning the development of the European digital health market over
A specific focus on the interdependence of implementing EMR sys­ the past 15 years, direct market investments are highly linked to socio-
tems and organizational conditions is provided by Cucciniello et al. economic and technological promises, as well as policy initiatives. Based
(2016). The latter attributes a high potential of EMR systems to secure on their SLR, Mishra et al. (2019) construct a conceptual framework to
operational processes and enhance data sharing, and thereby relate to understand opportunities and challenges of digitalization for prospects
previous suggestions of factors in their comparative study. Thus, their of Community Health Workers (CHWs4) in social services. Opportunities
relate to an easy peer-to-peer communication and decision-support,

3
For instance, clinical HIT comprise Pharmacy Information Systems, Tran­
4
scription, Laboratory Information Systems; administrative HIT enclose Patient The WHO defines CHWs as people who are members of a community, “and
Billing, Patient Registration, E-mailing; strategic HIT cover Outcome and pertinently trained to deal with the health problems of individuals and the
quality management, BI systems and Cost accounting (Hikmet et al. 2008, p.4). community” (WHO, in: Mishra et al., 2019, p.2).

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while weaknesses of digital health literacy need to be solved. enable patient empowerment, hence redefine customer-centeredness in
Two articles attempt to study the link between HC financialization HC (e.g. Gray et al., 2013; Belliger & Krieger, 2018; Mende, 2019;
and digital division from two different geographical viewpoints (Burtch Patrício et al., 2019). Concerning contextual patterns, the SLR reiterates
& Chan, 2019; Seddon & Currie, 2017). In the EU, health financializa­ two main streams initially introduced in the course of the transition from
tion has been widely regulated by law and the demand for financial primary to secondary HC markets (Schallmo & Williams, 2018), namely
measurement is rising amongst political leaders (Seddon & Currie, connectivity of all stakeholders throughout the value-added chain and
2017). The authors uncover three country groupings that result from the empowerment of patients. Moreover, the SLR has clearly shown a
their multivariate statistical analysis of cross-country health data and connection between the parameters ‘digitalization’ and ‘HC’: Thus, in­
ICT infrastructure: frontrunners, followers, and laggard countries (Sed­ vestigations on internal business efficiency resulted in multiple affir­
don & Currie, 2017). Referring to recent questions raised about the mations (Laurenza et al., 2018; Hong & Lee, 2017; Mazor et al. 2016;
fairness of distributed financial resources from medical crowdfunding Rubbio et al., 2019) and likewise confirmed changes in business roles. In
platforms in the US, Burtch and Chan (2019) empirically study the contrast, the perspective of external business development was not
correlation between online medical crowdfunding platforms and per­ found to be covered in the sample, a research gap can thus be identified
sonal bankruptcy. The authors report medical crowdfunding could be a with regards to partnerships for HC organizations.
complementary solution to reduce bankruptcy, if governmental au­ Regarding the connection of the primary and secondary markets,
thorities take measures that enable disadvantaged populations to pur­ theoretically introduced by Belliger and Krieger (2018), implications for
posefully engage with digital platforms. key stakeholders and advanced opportunities for the traditional HC
Taken together, the various streams identified can be interlinked to market were comprehensively discussed in the SLR sample articles (Gray
generate a model showing how the various stakeholders analyzed by et al., 2013; Jefferies et al., 2019; Mazor et al., 2016; Ozdemir et al.,
prior research exploit DT for management purposes, and ultimately, 2011). The strategic positioning of hospitals and clinicians emerged as a
contribute more or less directly to the achievement of operational effi­ research focus (Hikmet et al., 2008; Mazor et al., 2016; Rubbio et al.,
ciency by HC service provides (Fig. 4). 2019), but implications and opportunities for third-party creditors and
the transformation of the health insurance system remain unexplored.
4. Discussion and implications According to the suggested ascertainment of disruptive concepts in
secondary markets (Belliger & Krieger, 2018; Commission, 2018),
4.1. Discussion scholars investigate a wide range of emerged digital health concepts,
such as PHD use and data-driven HIT solutions, m-health, e-health,
Looking at the resulting sample, over the past three years the telemedicine and telehealth, and thereby affirm that I4.0 and digitali­
increasing number of articles published emphasizes the high level of zation clearly disrupt the traditional HC system (e.g. Patrício et al.,
relevance that has drawn attention from more researchers. Research into 2019; Leonard, 2004; Jefferies et al., 2019; Agnihothri et al., 2020;
HC technology appears to be important to solve major issues linked to Yousaf et al., 2020). Nevertheless, the disruptive tendency of further
data analytics in HC and operational process improvement through EMR digital transformative technologies, such as A.I. and robotics (Imison,
systems. Moreover, the convergence of HC and IT has been found to Castle-Clarke, Watson, & Edwards, 2016; Solbach, Kremer, Grünewald,

Fig. 4. Synthesis of key SLR findings (Source: Own elaboration).

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& Ickerott, 2019), remain a nascent field of research. on empirical mixed and quantitative research should be conducted.
Concerning the role of new market players, e.g. mobility and tele­ Moreover, especially in early phases of HIT adoption and testing of new
communications firms, it became evident that this field has gained high solutions, quantitative research is crucial to measure impacts for
interest in the practice (Deloitte, 2015; Commission, 2018; Solbach humans and financial returns. Whereas larger quantitative samples are
et al., 2019). A general observation is that digitalization in HC is needed to increase the generalizability of potential advantages and
currently a trending topic in non-peer-reviewed papers, such as weaknesses, the adoption of qualitative methods, e.g. in-depth in­
consulting companies’ publications, on market studies and forecast re­ terviews, and multiple cases studies, would explore the operational and
ports. In addition to the focuses on HIT, connectivity, and changes in the organizational effects for various HC institutions.
shifting balance of power, the literature has polyphonically addressed Further, a transformation of the patient experience towards e-visits
problems that relate to the digital divide. These have been described to or sensor pills has been suggested (Monti & Coleman, 2016; Tuzii,
especially affect disadvantaged populations that appear to be the ones 2017). Future research here may consider methods to enhance partici­
most in need of care (Tuzii, 2017; Coile & Russel, 2000; Deloitte, 2015; patory HIT design approaches, by integrating measurable user experi­
EY, 2019). Although scholars examine potential causes, e.g. country ence and insights from digital marketing analytics. One specific
groupings in usage of ICT or rather an unfair distribution of resources potential topic would be participatory design approaches of service ro­
from medical crowdfunding (Burtch & Chan, 2019; Seddon & Currie, bots for elder care for purposes of social interaction and cognitive dis­
2017), potential solutions to mitigate this complex issue cannot yet be abilities. Accordingly, referring to forecasts for budget shifting patterns
found. towards preventive medicine within the next eleven years (Solbach
Based on the outcome of the analysis three potential answers could et al., 2019) and to the concept of ‘4P medicine’, research is needed to
be found as to why the HC industry is lagging behind other sectors in its identify comparable and measurable determinants that allow the
DT. Firstly, researchers refer to concerns around data security that lead deployment of personalized and predictive care.
to patients’ rejection, as well as regulatory barriers for data use (Belliger With regard to operational efficiencies through the use of digital
& Krieger, 2018; Haggerty, 2017; Imison et al., 2016; Leonard, 2004). technologies, one specific topic for future research would be the po­
Second, although PHD is considered to enhance personalized and pre­ tential dangers and costs of emergent innovative drivers, in particular A.
dictive medicine, the design and implementation of PHD-based HIT are I. for automation of cognitive processes and dialogue systems for remote
linked to complex processes that require specific expertise in data ana­ services, or rather robotic applications in medicine, such as neurosur­
lytics (Groves, Kayyali, Knott, & Van Kuiken, 2013; Haggerty, 2017; gical assistance, medical transportation, or sanitational purposes. In the
Manogaran et al., 2017; Solbach et al., 2019). Third, HC professionals future, scholars should likewise address trustworthiness issues of A.I.
partly hinder further patient empowerment (Agnihothri et al., 2020; solutions that are of utmost importance in HC. Further, the analyzed HIT
Commission, 2018; Melchiorre et al., 2018; Taiminen et al., 2018), in the sample were found to affect administrative processes and pro­
mainly because of data trustworthiness concerns and a general mistrust ductivity in hospitals (Laurenza et al., 2018; Mazor et al., 2016; Rubbio
in TEC. Despite rapid progress in ICT and big data, stakeholders’ et al., 2019). Although operational efficiencies constitute the backbone
reluctance to adopt innovative technologies will slow down the process of quality of care, the impact of medical innovations on physicians’
of a DT in the sector. decision making and knowledge management principally seems to be
Consumer-centered HC (Cluster 1) is enforced through participatory neglected. Such medical innovations include complex molecular nano­
approaches for HIT design, such as EHR, telehealth and mobile appli­ technologies, middleware, digital imaging, and sensors. Predictive
cations. Current studies clearly indicate an affinity towards operational medicine requires strong expertise in in-depth analytics of PHD and data
efficiencies of care-related processes (Cluster 2) that are due to higher from EHR; big-tech companies are leveraging their core business in this
resilience, improved workflows and BP management as well as decision- field of HC innovation. Since the sample review resulted in a research
support and monitoring tools. However, considering disruptive changes, gap on external business development, a stronger focus is required on
results in augmented quality of care clearly depend on transformations collaboration and coopetition strategies for HC providers with second­
of organizational structures, in particular managers’ and clinicians’ ary market players.
value-based approaches (Cluster 3). A further important factor entails Regarding organizational aspects, the SLR illustrated that most
the adaption of new practices for workforce (Cluster 4), e.g. nursing or existing scholar papers dealt with technological innovations, although
paramedical staff. Thus, DT requires collaborative visioning and DT covers a wider scope. Further investigations into the management of
evidence-based information exchange, which is why hospitals must successful business model transformation and strategic courses that
engage in flexing, deepening, and revitalizing. Socio-economic aspects, allow disruptive changes may be particularly valuable. As observed
e.g. investments in accordance with phases of the innovation hype cycle, throughout the SLR, the adoption of digital technologies comes along
or rather the digital divide, are finally found to primarily affect HC with a redefinition of the meaning of health, thus demanding a closer
consumers (Cluster 5). examination of new core value drivers (Cavusoglu & Demirbag-Kaplan,
2017; Dahl et al., 2019). Our SLR also observed that effects of DT on
4.2. Recommendations for future research organizational aspects of HC providing institutions, other than hospitals,
are not addressed at enough depth, thus there is a clear need to inves­
The review of existing studies led to the identification of several tigate opportunities for the pharmaceutical industry with regard to the
research gaps about HC stakeholders and DT. These are derived from a expansion of market e-commerce. Equally worthwhile would be a study
surplus of qualitative research, a focus on hospitals as predominantly of how business model transformation of pharmacies impacts customer
analyzed HC institutions, lacking research on business model trans­ acquisition, switching costs, and customer loyalty.
formation and external business development, unacknowledged ques­ Fourth, in order to upskill HC professionals and identify how nursing
tions around the digital divide, as well as financing options. staff has to be trained, i.e. to make use of system integration, robots and
Recommendations for future research should build on more different A.I., research is needed to explore how knowledge transfer from other
approaches. Foremost, there are important topics that would require a advanced sectors in I4.0 and IoT, such as the automotive industry, might
more impactful evidence groundwork based on tested relevant theories lead to best workforce practices pursued in HC. Authors from the sample
and hypotheses: for instance, this refers to the enhancement of EHR have examined digital training programmes for CHWs (Mishra et al.,
services as part of a SaaS business model (Ozdemir et al., 2011), or 2019) and clinical nurses’ skills related to the introduction of HIS, but
rather the adoption of ‘flexing, deepening and revitalizing’ work prac­ with respect to market forecasts in robotics and connectivity, further
tices to achieve successful human resource transformation (Eden et al., research on disruptions for geriatric nurses and community-based care
2019). Therefore, to get a more integrative view, deeper research based seems crucial. Specifically, there could be qualitative investigations on

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doctors’ or nurses’ needs assessment and curricula updates which would 5. Conclusions
provide a sufficient scale for linking traditional clinical practice and
medicine in the digital age. The aims of this article were to provide an integrative view of the
Fifth, the ROI of technological progress is difficult to evaluate due to state of the art of digitalization in HC literature, find the key manage­
high Research and Development expenses and a complex connection of ment and business applications of DT technologies by HC stakeholders
different variables. In any case, the HC industry must become trans­ and identify a potential future research agenda. With the aim to identify
parent about costs and profits for patients, providers, and insurers. For potential benefits of previously introduced digital technologies for HC
instance, attempts to evaluate the efficiency of DEA models (Kohl et al., providing organizations and other stakeholders, the analysis produced
2019) remain theoretical, therefore a further inquiry into hospital five broad clusters; (1) patient-centeredness in HC management with an
managers’ knowledge seems necessary. Also, deeper research is needed emphasis on the two sub-streams of patient empowerment and the
to investigate investment strategies for how to manage costs linked to impact of multi-channel behavior on consumers’ health and well-being;
digitalization. Eventually, based on progression of health outcomes and (2) impact of the adoption of innovative HIT on operational efficiencies
customer experience, possibilities of measuring the performance of HIS and resilience of hospitals; (3) organizational key attributes and mana­
and e-health technologies should be examined. To advance the field of gerial implications; (4) consequences on workforce practices; (5) socio-
pharmacogenomics, scholars should likewise consider more fully the economic factors.
relevance of business opportunities for pharmaceutical firms. In conclusion, this article shows that the comprehension of DT in HC
Finally, a last recommendation refers to the exploration of how DT in for the most part encompasses the digitization of information and
HC affects the management of intellectual capital (e.g., Huang, Leone, adoption of HIT in traditional HC structures. To build a more holistic
Caporuscio, & Kraus, 2020). For instance, researchers could analyze view of the DT in HC, there is a great need to conduct research on
how healthcare listed companies can exploit the typical means of DT for business model transformation and implications for the management of
the voluntary external disclosure of their intellectual assets and how different interest groups. Finally, the combination of patient empower­
such digital-based disclosure could improve their operations efficiency ment, a purposeful use of digital technologies, as well as data-driven and
(Giacosa, Ferraris, & Bresciani, 2017). predictive care will allow the shift toward digital HC models, redefining
experience and improving outcomes for patients, providers and insurers.
4.3. Limitations
Acknowledgement
This work has three limitations that need to be acknowledged. First,
there are potentially many more factors that influence DT in HC than This work was supported by the Open Access Publishing Fund pro­
investigated and theoretically introduced beforehand. The choice of vided by the Free University of Bozen-Bolzano.
keywords is not extensive enough to cover all associated fields with DT.
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Mas-Tur, A., Kraus, S., Brandtner, M., Ewert, R., & Kürsten, W. (2020). Advances in
management research: a bibliometric overview of the Review of Managerial Science.
Sascha Kraus is Full Professor of Management at the Free University of Bozen-Bolzano in
Review of Managerial Science, 14(5), 933–958.
South Tyrol, Italy. He holds a doctorate in Social and Economic Sciences from Klagenfurt
Mazor, I., Heart, T., & Even, A. (2016). Simulating the impact of an online digital
University, Austria, a Ph.D. in Industrial Engineering and Management from Helsinki
dashboard in emergency departments on patients length of stay. Journal of Decision
University of Technology and a Habilitation (Venia Docendi) from Lappeenranta Uni­
Systems, 25(sup1), 343–353.
versity of Technology, both in Finland. Before, he held Full Professor positions at Utrecht
Melchiorre, M. G., Papa, R., Rijken, M., Van Ginneken, E., Hujala, A., & Barbabella, F.
University, The Netherlands, the University of Liechtenstein, École Supérieure du Com­
(2018). EHealth in integrated care programs for people with multimorbidity in
merce Extérieur Paris, France, and at Durham University, United Kingdom. He also held
Europe: Insights from the ICARE4EU project. Health Policy, 122(1), 53–63.
Visiting Professor positions at Copenhagen Business School, Denmark and at the University

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of St. Gallen, Switzerland, and was Participating Professor at the European Entrepre­ Anna Pluzhnikova is a Master’s graduate of the École Supérieure du Commerce Extérieur,
neurship Colloquium on Participant-Centered Learning (EECPCL) at Harvard University. a Grande École in Paris, France. She holds a Bachelor’s degree in Business Administration
from the Berlin School of Economics and Law in Berlin, Germany. Currently, she works as a
Consultant at PricewaterhouseCoopers in Luxemburg.
Francesco Schiavone is Associate Professor in management at Parthenope University of
Naples, Italy since 2016. He received the Ph.D. degree in network economics and
knowledge management from the Ca’ Foscari University of Venice (Italy) in 2006. He is Anna Chiara Invernizzi is Assistant Professor of Business Administration at Università
also an Adjunct Professor at Emlyon and Paris School of Business (France). In April 2017 degli Studi del Piemonte Orientale “Amedeo Avogadro”, where she holds the course in
Prof. Schiavone has been habilitated as Full Professor in management by MIUR (Italian Business Administration. Her main research interests concern small businesses, accounting
Ministry of Education and Research). Currently, his main research areas are technology firms and regional business development. She is the author of several books and has
management, strategic innovation, and healthcare management and innovation. published in national and international journals like the International Small Business
Journal or the International Journal of Hospitality Management.

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