International Journal of Medical Informatics 97 (2017) 247–260

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International Journal of Medical Informatics

journal homepage: www.ijmijournal.com

Social capital and transaction cost on co-creating IT value towards

inter-organizational EMR exchange
Hsin Hsin Chang a,∗ , Chung-Jye Hung b , Ching Ying Huang a , Kit Hong Wong a , Yi Ju Tsai a
a
Department of Business Administration, National Cheng Kung University, Tainan, Taiwan, ROC
b
Department of Surgery, Medical College and Hospital, National Cheng Kung University, Tainan, Taiwan, ROC

a r t i c l e i n f o a b s t r a c t

Article history: This study adopts social capital theory and transaction cost theory to explore the feasibility of an inter-
Received 29 October 2015 organizational cross-hospital electronic medical records (EMR) exchange system, and the factors that
Received in revised form 26 October 2016 affect its adoption. The concept of value co-creation is also used to assess such a system, and its influence
Accepted 28 October 2016
on the performance of participating medical institutes. This research collected 330 valid paper-based
questionnaires from the medical staff of various institutes. The results showed that social interaction ties
Keywords:
and shared vision positively affected medical institutes’ willingness to adopt the EMR exchange system,
Social capital theory
while asset specificity and uncertainty increased the related transaction costs. With a greater willingness
Transaction cost theory
Co-creation
to invest in relation-specific assets and to meet the related transaction costs, this behavior lead to an
Inter-organizational EMR exchange systems increase in medical IT value, as well as better results for the related medical institutes, medical staff, and
patients. Therefore, this study suggests that such institutes encourage their medical staff to participate
in seminars or reunions in order to develop their professional and social networks, and set up clear
schedules and desire for expected effects when introducing the cross-hospital EMR exchange system.
© 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction enough information to track patients’ health conditions. As a result,

Traditionally, medical institutes used paper-based medical
records to record patients’ health conditions, which took up a lot of
space and may often be unreadable or difficult to locate and share.
However, electronic medical record (EMR) can overcome these
problems, thus increasing the usability of medical records. Accord-
ing to the report in Taiwan, “2005 Survey on the Status of Medical
Record Computerization at Medical Care Institutions Nationwide”
showed that about 50% of hospitals had already digitalized their
medical records, and 30% of them had conducted clinical documen-
tation integration and made preparations for inter-organizational
exchanges. In 2013, most hospitals in Taiwan are capable of
sharing medical images and reports, hematologic examinations,
discharge summaries, and outpatient pharmacy records. However,
such exchanges primarily occur among three hospital levels (i.e.,
medical center, metropolitan hospital, and district hospital), rather
than in clinics. Although nearly 59.8% clinics have a certain degree
of computerized EMR, few have achieved the required level of
development. This limited amount of information exchange hin-
ders the practice of holistic healthcare because general clinics lack
∗ Corresponding author.
E-mail address: easyhhc@mail.ncku.edu.tw (H.H. Chang).
improving inter-organizational EMR system has become an impor-
tant issue.
This research aims to discuss the following three questions: (1)
Could different levels of medical institutes build up their collabora-
tive relationships?, (2) What would be the trade-off between costs
and value co-creation when conducting EMR integration among
different medical organizations?, and (3) Has inter-organizational
EMR actually enhanced the performance of these medical institutes
or delivered any benefits after integration?
Rooted by social capital theory (SCT) and transaction cost
theory (TCT), this study tries to explore the possible difficul-
ties that each medical institute may face when introducing an
inter-organizational EMR system. Although past research [1] used
SCT and TCT to examine the factors affecting cross-hospital EMR
exchanges, it only focused on regional hospitals and medical cen-
ters, where respondents were only taken from IS departments.
Therefore, following the criteria of Taiwan hospital stratified man-
agement, this study included three hospital levels and clinics, and
the research group was expanded as well. Meanwhile, the idea
of investment in relation-specific assets was separated from SCT
to see whether a medical institute’s willingness to adopt inter-
organizational EMR has anything to do with the relationships it
has with other such institutes.

http://dx.doi.org/10.1016/j.ijmedinf.2016.10.015
1386-5056/© 2016 Elsevier Ireland Ltd. All rights reserved.
248 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
Moreover, prior research mostly focused on discussing the
advantages of using EMR [2,3], or examining the views of medical
staff (i.e. nurses and physicians) with regard to using them [4–9].
However, those valuables were still at the inter-organizational
EMR level and considered only “internal value creation” rather
than “external value co-creation”. Therefore, this study adopted the
novel concept of “co-creation”. A co-creation construct was applied
in the current work to elevate the inter-organizational level to the
cross-organizational level.
Since few studies had examined the use of inter-organizational
EMR in Taiwan, or the benefits associated with it, this research
examined the efficiency and effectiveness of inter-organizational
EMR, and its effects on performance with regard to the organization,
staff, and patients. It is expected to be able to present an overall per-
spective of related issues that medical institutes can refer to when
considering the adoption of an inter-organizational EMR exchange
system. In order to fill certain gaps in literature, this study applied
SCT and TCT to discover the influences of relationships and internal
costs on adopting an inter-organizational EMR system, as well as
the benefits that can be derived doing so. In summary, this work
has the following four objectives:
(1) Construct a model using SCT and TCT to investigate whether
performance improvements can be achieved with the use of an
inter-organizational EMR system.
(2) Examine whether the use of SCT (social interaction ties, norm
of reciprocity, and shared values) could enhance medical insti-
tutes’ investments in relation-specific assets, and subsequently
increase the value co-created with the inter-organizational
EMR system.
(3) Examine whether the use of TCT (asset specificity and
uncertainty) could increase internal costs when adopting cross-
hospital EMR exchanges, and further decrease co-creating IT
value.
(4) Examine whether the value co-created when using an inter-
organizational EMR system could enhance the performance of
participation in medical institutes.
2. Literature review
2.1. Electronic medical records (EMRs)
Medical records are a transaction record produced during med-
ical services, which serve as the basis for computing medical
expenses and also as a source of auxiliary information for med-
ical staff [5,10]. In addition to EMR, these were also referred to
computer-based patient records (CPR) by IOM in 1997 [11] or elec-
tronic patient records (EPRs)[12]. According to Lorence et al. [12],
EPRs preserve information about an individuals’ lifetime health
status encompassing all forms of health information, and make it
easier to retrieve a person’s medical history, current medications,
laboratory test results, and X-ray images. In this study, the term
EMR, as well as CPR and EPR, can all be used to refer to patients’
digitalized medical records. To avoid confusion, this study adopts
the term EMR to include all forms of EMRs and refer to the medi-
cal law in Taiwan, which defines EMR as “the electronic document
that medical institutes use to create and maintain an individual’s
lifetime health status and health care.”
According to Waegemann [13], the evolution of EMRs can be
divided into five stages: (1) Automated medical records (AMRs):
electronic records, which are printed out for use. (2) Comput-
erized medical records (CMRs): store details of medical cases in
computer systems that can be printed out with a doctor’s seal
in order to preserve the traditional paper-based medical records.
(3) Provider-based patient medical records (CMRs): reliance on
medical professional-oriented information system with computer-
based medical records being used more often than paper-based
ones. (4) Electronic patient records (EPRs): permission for the cross-
national transmission and global exchange of patient-oriented
electronic medical records via the internet. (5) Electronic health
records (EHRs): integration of disease and non-traditional health
information with the aid of the patients’ participation, not only
storing medical records, but also providing a broader view of an
individual’s healthcare data. Although there are some barriers to
implementing inter-organizational EMR today, the potential bene-
fits are still attractive to many medical institutes. For example, EMR
systems can help reduce misdiagnoses, unnecessary repetition of
medical treatments or tests, and unintended drug interactions
[3,14]. It can also simplify and streamline processes in medical prac-
tices, offer healthcare practitioners (i.e. physicians, nurses, physical
therapists, and public health practitioners) up-to-date information,
reduce costly lab findings and diagnosis reports, avoid loss of med-
ical reports, and save labor with regard to retrieving, placing, and
transcribing pencil-and-paper-based medical records [15]. How-
ever, the exchange of EMR is different from the information sharing
occurring among other non-medical organizations on the basis of
money.
Inter-organizational EMR exchanges can not only create better
medical service quality for users, but also better meet the needs
for self-healthcare. As noted before, there are few studies focus-
ing on the issue of inter-organizational EMR exchanges. Most of
the works related to EMR examined the advantages of or barri-
ers to using EMR within an organization. Although Chang et al.
[1] applied social exchange theory and TCT to examine the fac-
tors affecting cross-hospital EMR exchanges, their research sample
was rather narrow on certain types of hospitals and respondents.
As a result, this study applies SCT and TCT to examine the influence
of relationship-building and cost-benefit analysis on medical insti-
tutes’ cooperative behavior with regard to the exchange of EMR.
2.2. Social capital theory (SCT)
The social capital literature focuses on three dimensions: struc-
tural, relational, and cognitive [16]. The structural dimension refers
to the overall patterns of relationships among individuals, such
as social interaction ties [17], while the relational dimension
pays attention to personal relationships that people have mutu-
ally developed over a history of interactions [18]. The cognitive
dimension is regarded as those resources enabling shared represen-
tations, interpretations, and systems of meaning among the parties
involved, and the key facets of this may be a shared language, cul-
ture, and vision [18–20].
The current study extracts a facet from each dimension based
on Chiu et al. [20], whose research subjects were members of a vir-
tual community, to measure the influence of social capital on EMR
exchange environment. This study examines social interaction ties
(structural dimension), norm of reciprocity (relational dimension)
and shared vision (cognitive dimension) as the facets, which are
explained in more detail below.
(1) Social interaction ties: In a medical context, more intensive
contacts between medical institutes may help strengthen the
degree of information sharing and the level of cooperation. To
fit the context of this research, this study adopts Chiu et al.’s [20]
definition and change the focus members from virtual commu-
nities to those in medical institutes, and thus redefines social
interaction ties as the strength of the relationships, the amount
of time spent, and the communication frequency among mem-
bers in different medical institutes.
(2) Norm of reciprocity: Wasko and Faraj [21] defined the norm
of reciprocity as a feeling of mutual indebtedness based on
 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
the behavior that individuals usually give back the bene-
fits they receive to ensure the continuation of constant and
supportive exchanges. The exchange of medical information
is a type of knowledge sharing among medical staffs, who
expected the ongoing interchanges of information to improve
their work efficiency. Generally health organizations are accus-
tomed to sharing information, but the inter-organizational EMR
allows easier flow of information. However, such an inter-
organizational EMR system creates issues regarding patient
privacy, which means that institutes need to closely monitor
what is exchanged, and by whom. Therefore, this study adopted
Chiu et al. [20] concept of “norm of reciprocity” to measure the
relational dimension, and define it as a behavior by which dif-
ferent medical institutes will anticipate constant knowledge
sharing unless the other parties stop this information flow
when participating in medical information exchanges.
(3) Shared vision: The notion of shared vision is often used to
denote shared values and mutual understanding in coopera-
tive relationships [22]. To strengthen collaboration, a collective
goal or vision is necessary [17,20]. In this study, shared vision
can be viewed as the extension of the common beliefs which
different medical institutes have toward the importance, ade-
quacy, and validity of behaviors, goals, and policies. To achieve
this goal, medical institutes have to develop an exchanging sys-
tem and sharing medical information through well-constructed
communication mechanisms.
2.3. Transaction cost theory (TCT)
Williamson [23] suggested that transaction costs should include
direct costs for relationship management and opportunistic costs
for decision making. In this study, transaction cost is defined as the
costs of running a system, including ex ante costs (i.e. drafting and
negotiating contracts) and ex post costs (i.e. monitoring and enforc-
ing agreements). Teo and Yu [24] further divided transaction costs
into searching costs, monitoring costs, and adapting costs. When
adopting a new information system, medical institutes need to col-
lect medical information, supervise internal operational efficiency,
and respond to the updated services. As a result, these three costs
may all increase during this process. This study draws on Teo and
Yu’s basic concept of transaction costs, and redefines it as follows.
(1) Searching costs: Due to differences with regard to their degree
of EMR development and organization level, each medical
institute has to search for related EMR information (i.e.,
on other institutes’ EMR adoption, government policies and
regulations, or additional supportive information) from the
external environment before undertaking inter-organizational
EMR exchanges.
(2) Monitoring costs: To clearly identify the implementation status
of inter-organizational EMR, medical institutes have to dispatch
additional staffs to supervise system operations and carry out
follow-up maintenance, if needed. The extra time and expenses
are seen as the monitoring costs in this work.
(3) Adapting costs: In Taiwan, EMR are being developed in order
to carry out inter-organizational exchanges. Since various lev-
els of medical institutes will participate in this project, each
organization has to spend time and effort communicating and
renegotiating information that is being constantly updated,
which leads to the increase of the adapting costs.
Moreover, in TCT framework, asset specificity and uncertainty
are the key factors that may affect the development of EMR and may
increase transaction costs in future exchanges of medical informa-
tion.
249
(1) Asset specificity: Asset specificity is defined as “the degree to
which an asset can be redeployed to alternative uses and by
alternative users without sacrifice of productive value” [23].
A specific asset generally has particular purposes or users,
which cannot be transferred to other transactions and retain
the same value. Different hospital levels may require particular
EMR to meet their needs [6]. A small change (e.g. informa-
tion exchange, system integration, resource sharing) that might
seem simple when considered in isolation becomes incredi-
bly complex when considered in the context of the broader
tiered network of established system integration initiatives. As
a result, operability challenges within different hospital levels
arise and the asset-specific costs will rise accordingly. Thus,
asset specificity in this study is defined as the degree to which
inter-organizational EMR can be redeployed to alternative uses
and by alternative users without sacrifice of productive value.
(2) Uncertainty: Uncertainty may be induced by bounded ratio-
nality, information asymmetry, and the danger of opportunism
[24]. The degree of uncertainty refers to the unpredictable
events which could happen during a transaction; the longer a
transaction is, the greater the uncertainty is. In TCT, uncertainty
can be divided into two types: environmental and behav-
ioral. Environmental uncertainty refers to unpredicted changes
in conditions surrounding an exchange behavior [25]. In this
study, environmental uncertainty refers to the unexpected pol-
icy or system changes in conditions surrounding a medical
information exchange behavior. Behavioral uncertainty in the
TCT framework is conceptualized as the degree of difficulty in
monitoring exchange partners’ contractual performance [26].
The unanticipated and complex character of environmental
uncertainty limits decision makers’ understanding of transac-
tions exactly, thus leading to direct costs related to actions such
as information delivery and contract renegotiation. However,
distinct from general commercial transactions, the exchange of
EMR is primarily conducted by a central authority. Thus medical
institutes do not need to supervise other organizations’ oper-
ations. Besides, since these inter-organizational exchanges are
regulated, it is difficult to know the actual willingness of the
management or general medical staffs with regard to partici-
pating in such actions, which raises problems with regard to
performance evaluation. Therefore, this study defines behav-
ioral uncertainty as the degree of difficulty in monitoring the
operation of EMR within an organization.
2.4. Investment in relation-specific assets
Wang et al. [27] indicated that relation-specific investments can
be divided into three types: dedicated specificity, IT specificity, and
process specificity. Dedicated specificity refers to the equipment,
human assets, and IT hardware/software that are committed to a
particular task. To perform well in the future, most medical insti-
tutes need to upgrade their information system to achieve greater
interoperability and invest in compatible IT hardware/software and
training staffs to operate it. In this study, dedicated specificity refers
to the inter-organizational. IT specificity is regarded as the online
information exchange and partner-specific IT investment. Unlike
dedicated specificity, IT specificity emphasizes information shar-
ing. If an inter-organizational EMR system is in operation, then
the related medical institutes should actively invest in exchanging
patient’s medical records with each other via the internet. Process
specificity explains the work routines and interactions between IT
and people. As new technology is developed, most medical insti-
tutes are likely to redesign their work procedures so that medical
staffs can quickly get used to the new system. However, one pre-
condition for the success of relation-specific assets that is available
for enough time.
250 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
In Taiwan most medical institutes at various levels run
independently. Each of these has their own EMR system, the rela-
tionships among academic medical centers, metropolitan hospitals,
local community hospitals, and clinics are weak. Since inter-
organizational EMR exchanges require intensive interactions, these
weak connections may have negative effects on such alliances.
Therefore, in this study we redefine investment in relation-specific
assets as the willingness of different medical institutes to invest
in relation-specific assets (e.g., an inter-organizational EMR sys-
tem, available internet technology, and operational skills training)
in the future, and postulate that as long as the transactors, i.e., hos-
pitals and clinics, are willing to enter into long-term contracts of
cooperation and invest in relation specific assets based on the three
variables of SCT, they could then develop greater trust in each other
and further enhance each other’s performance.
2.5. Co-creating IT value
With recent advances in network and communication technolo-
gies, many organizations are transferring their focus to create value
collectively with their stakeholders through IT, thus raising inter-
est in the relationship between IT investment and organizational
performance. This has led to the concept of “value co-creation”,
based on the original term of “value creation.” When applying this
notion to information systems, Kohli and Grover [28] suggested
that researchers should focus not only on IT value, but also on
value co-creation with regard to IT. For B2B alliances, the nature
of resource alignment determines the success of value co-creation.
Grover and Kohli [29] pointed out that resource alignment illus-
trates the full value of certain resources that cannot be achieved
by a partner acting on its own. This corresponds to the idea of an
inter-organizational EMR exchange platform, which requires spe-
cific knowledge to be shared among medical institutes to build up
valuable patient information.
Kauffman et al. [30] used the concept of business network-based
value creation to represent the combination of different firms’ capa-
bilities to produce and deliver products and services that could not
be produced by one firm individually. In the medical context, it
refers to different levels of medical institutes. According to Grover
and Kohli [29], there are four layers of value creation that can
be enabled, expanded, or created by IT. They are the asset layer,
knowledge sharing layer, complementary capabilities layer, and
governance layer.
The asset layer focuses on the specific IT hardware and/or
software or network facilities which are capable of generating
new value inter-organizationally. In a medical context, if an inter-
organizational EMR exchange is available, hospitals can co-create
IT-enabled value by providing their partner medial institutes with
comprehensive examined reports with regard to particular dis-
eases. The complementary capability layer emphasizes the use
of resources among partners and co-creating value a single part-
ner cannot achieve on its own. With an inter-organizational EMR
exchange system, both hospitals and clinics are capable of utiliz-
ing their partners’ medical resources. Therefore, it is possible to
co-create value by rerouting patients to suitable medical institutes
and also preventing additional costs due to inappropriate health-
care, enabling different medical institutes to focus on what they can
do best. As for the knowledge sharing layer, it indicates that shar-
ing information and expertise can facilitate better decision-making
and strategies that enable the greater co-creation value. By using
an inter-organizational EMR exchange system, hospital doctors can
share their professional knowledge about specific diseases with
those in clinics. Finally, the governance layer represents a control
mechanism to incentivize value co-creation and decrease transac-
tion costs. This layer is said to integrate the knowledge sharing,
complementary capability, and asset layers [29]. On one hand, the
governance layer co-creates value for medical institutes because it
efficiently redirects the patient flow. It co-creates external value
for patients, since it offers them better medical treatment. In sum,
an inter-organizational EMR exchange system can be viewed as a
platform combining various resources and co-created values that
cannot be obtained by a single institute. An inter-organizational
EMR exchange system can co-create of IT value based on these
four layers, thus leading to better outcomes for both the medical
institutes and their patients.
2.6. Joint performance
The partners in a strategic relationship engage in collective
planning and adopt similar control mechanisms, making it eas-
ier for them to set up joint goals and performance measures [31].
Unlike traditional operational alliances, the performance of strate-
gic alliances is measured based on the entire system, rather than
the operating returns, costs, profit, and growth of the individual
partners [32]. Since the focal inter-organizational EMR exchange
system has not yet been comprehensively implemented in prac-
tice, this research sees joint performance as one of its potential
benefits. In Hillestad et al. [2], such joints benefits are referred to
as organizational (e.g., providing more medical services can pro-
duce more profits), group (e.g., medical staffs can reduce the time
needed to obtain and view clinical data), and personal (e.g., better
patient outcomes) benefits.
With regard to the organizational aspect, the current study uses
operational costs and efficiency to measure performance. By using
the new system, medical institutes can prevent repeated exam-
inations and the need for expensive equipment. This integrated
system can also reduce the time and effort needed to retrieve med-
ical records from different medical institutes, so referrals can be
conducted in a more effective way, thus decreasing medical errors
[10]. In addition, nursing staffs can reduce the time they need to
spend arranging medical information, thus raising work satisfac-
tion. Finally, with the aim of an inter-organizational EMR exchange
system, patients do not have to travel many places to obtain their
medical records. They also can obtain better, more complete and
continuous healthcare with the support of comprehensive medical
records. Consequently, joint performance in this study is defined as
the degree to which shared medical records can increase the effec-
tiveness and efficiency of outcomes with regard to the organization,
medical staff, and patients.
Based on the above discussion, Fig. 1 illustrates the concep-
tual framework of this study. This study adopts SCT and TCT to
explore the feasibility of an inter-organizational cross-hospital
EMR exchange system. Three dimensions of SCT used to delin-
eate the interactions among medical institutes. We assume that
once relationships have been established, each medical institute
may be more willing to invest in the inter-organizational EMR
exchange system. Here, we adopt Dyer’s [33] construct of invest-
ment in relation-specific assets to illustrate this idea. Furthermore,
this study uses TCT to examine the possible costs that medical
institutes face when replacing their old EMR systems with the
inter-organizational EMR exchange system. Two dimensions of
transaction costs (i.e., asset specificity and uncertainty) are used
to predict the potential expenses with regard to updating these
systems. The right-hand side is the baseline of the model, and here
we introduce an innovative concept of co-creation, as proposed by
Grover and Kohli [29], to examine whether the value of an inter-
organizational EMR exchange system can be further co-created if
different levels of medical institutes participate in it. Ultimately, we
hope that this model can be used to improve the overall medical
performance that can be achieved by applying this new type of IT.
 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
Social Capital
Social H1
Interacon
Ties
H2 Investments in
Norm of
Reciprocity Relaon-specific
H3 Assets
Shared
Vision
Asset
Specificity H4 Transacon Cost
- Searching costs
- Monitoring costs
- Adapng costs
Uncertainty H5
Transacon cost
Fig. 1. Research Framework.
3. Hypotheses development
3.1. Social interaction ties and investment in relation-specific
assets (H1)
Social interaction ties are considered as a channel for informa-
tion and resource flows [34], and, thus, people are able to obtain the
resources of others through their social contacts. This study posits
that as long as organizations form a social interaction tie, they will
have more opportunities to engage in informational sharing and
knowledge exchange activities. At the same time, the possibility
of mimetic behaviors is increased, which encourages joint action
in relation to committing relation-specific investments [27]. With
more intensive social contacts, medical staffs could get a bigger pic-
ture of new medical issues that are being raised in other medical
institutes.
When participating in EMR exchanges, different levels of med-
ical institutes are bound to face various adoption problems.
Institutions with limited resources may be more hesitant to invest
in the new EMR exchange system. However, if they have good com-
munication channels, they can examine how other institutes have
dealt with this issue and may then be more willing to make an
investment. Based on these arguments, we infer that once good
social interaction ties are built among different levels of medical
institutes, they are more likely to share beneficial medical informa-
tion with each other; and this then leads to a greater willingness to
make relation-specific assets investment in future EMR exchanges.
Consequently, we hypothesize that:
H1. Social interaction ties positively influence the investment in
relation-specific assets in medical environments.
3.2. Norm of reciprocity and investment in relation-specific assets
(H2)
Having a joint understanding of collaboration can assist in the
formation of direct reciprocal norms within a small community
[21]. Chang et al. [1] and Hsieh [10] also supported this idea
and stated that reciprocal investments can be seen as a trust-
worthy commitment to decrease opportunistic actions. Provided
251
H6
Co-creang H8 Joint
IT Value Performance
H7 (-)
that opportunistic behavior is reduced, different levels of medical
institutes would increase their trust in each other and are willing
to invest more in sustaining their cooperation. Besides, once the
norm of reciprocity is established, each side tends to share infor-
mation voluntarily to achieve mutually beneficial outcomes. For
instance, while hospitals want to utilize information from clinics
(i.e., patients’ daily health records) to improve diagnostic accuracy,
clinics may make use of hospitals’ medical records to improve the
quality of patient-care.
Similar to the idea in H1, medical institutes’ expectations with
respect to reciprocity will push them to observe other institutes’
EMR performance and result in the mimetic motives. Small-scale
institutes that do not have enough resources to update their sys-
tems at the very beginning may prefer to follow the leading
institutes instead of being the pioneers. Based on this, we can
infer that medical institutes are more willing to invest in the EMR
exchange system once they know the details of other institutes’
investments in this regard. As a result, if medical institutes are to
employ each other’s valuable information, they need to feel cer-
tain that the other side will provide them the necessary materials
when needed, as this will then make them more willing to make
such exchanges. Therefore, we hypothesize that, with the founda-
tion of reciprocal norms among medical institutes, they are better
able to comprehend each other’s EMR development and having a
greater willingness to invest in relation-specific assets to support
further integration (e.g., updating their out-of-date EMR systems,
training medical staffs to use the new system, and redesigning the
related work processes). Consequently, the following hypothesis is
proposed:
H2. Norm of reciprocity positively influences the investment in
relation-specific assets in medical environments.
3.3. Shared vision and investments in relation-specific assets (H3)
In this study, shared vision is considered as the collective val-
ues and goals shared among different levels of medical institutes.
The core value of medical institutes in Taiwan is patient-oriented
medical care. Basically, these organizations embrace the concept of
providing medical staffs with enough accurate information about
252 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
patients’ health conditions. With this shared vision, medical insti-
tutes are expected to give patients adequate healthcare and, thus,
reduce the use of medical resources.
In exchanging EMR inter-organizationally, medical institutes
need to develop the idea of mutual assistance, such as allowing
medical staffs to learn from each other, with the overall goal of
saving lives [35]. With this shared vision, each medical institute
may be more willing to invest in relation-specific assets. Lower-
level hospitals, such as local-community hospitals, could then train
their medical staffs with the skills needed to use the new system.
Finally, when this infrastructure is completed, all of the medical
institutes can redesign their workflows to fit the needs of the inter-
organizational EMR exchange system. Hence, they can achieve the
collective goal of giving each patient comprehensive medical care.
As long as a shared vision exists among medical institutes, it is more
likely that they will invest in relation-specific assets to integrate
EMR exchanges, and so is the following hypothesis proposed.
H3. Shared vision positively influences the investment in relation-
specific assets in medical environments.
3.4. Transaction costs and asset specificity (H4)
In this study physical asset represents the EMR systems within
different medical institutes. Previous research assumes that as soon
as transactors carry out more investments in a particular asset, the
transaction costs will be raised. The reason is that organizations
need to make more efforts to ensure that the mutual communica-
tion and informational exchange that they engage in is successful
[24]. To avoid this, a more complicated governance structure should
be set up to reduce the possible costs that incurred by asset speci-
ficity [36]. Pilling et al. [37] also concluded that asset specificity
has a significantly positive impact on both ex ante and ex post
transaction costs.
This study applies the concept of “within” organizations and
posits that the current EMR system may influence the future
setup of an inter-organizational EMR exchange system in a cer-
tain way. In order to replace the current EMR system with an
inter-organizational one, medical institutes need to spend time
and effort to understand the new system, such as figuring out
how to implement the new IT structure and make it work with
other organizations, collecting information about regulations and
policies related to this system, or finding suitable system vendors.
These behaviors are all likely to induce searching costs. Moreover,
when changing to an inter-organizational EMR exchange system,
the operating process is bound to undergo an initial period of some
instability. To ensure success, the medical institute thus needs to
invest much time and effort in monitoring the new system. There-
fore, monitoring costs are raised. In addition, if the new regulations
are developed, then the organization also needs to revise its system
to comply with these regulations, producing the adopting costs.
Therefore, we conclude that changing EMR systems may lead to
various costs, especially when the original system does not support
the new one. We thus posit that an asset that is used for a partic-
ular medical purpose (e.g., inter-organizational EMR) could have
positive effects on transaction costs when medical institutes try to
modernize their EMR systems by adopting an inter-organizational
one, as stated in the following hypothesis:
H4. Asset specificity, that is, the inter-organizational EMR
exchange system, has a positive effect on transaction costs.
3.5. Transaction cost and uncertainty (H5)
A survey by the DOH found that the implementation of EMR was
affected by competitive pressure on the Taiwanese medical envi-
ronment, deficient IT support and unclear government policies. All
of these factors may lead to frequent adjustments of EMR systems
in different levels of medical institutes. As a result, such institutes
cannot foresee the actual situations of inter-organizational EMR
exchanges, and need to spend considerable time and effort on com-
municating or renegotiating new information about EMR.
Like environmental uncertainty, high levels of behavioral uncer-
tainty increase the costs of evaluating the performance of exchange
partners, as noted in TCT research [36]. As for behavioral uncer-
tainty, TCT views it as arising from the difficulties associated
with monitoring the contractual performance of exchange part-
ners [26]. In a medical environment, since the government takes
control of inter-organizational EMR exchanges, medical institutes
do not have to sign contracts with each other. Nevertheless, this
phenomenon produces difficulties for each institute concerning
perception of their medical staff’s real intentions related to using
an inter-organizational EMR system. If staffs are forced to make
changes, the related performance is hard to measure. Therefore, to
solve this behavioral uncertainty with regard to organizations, each
medical institute has to devote time and efforts to monitoring their
employees, incurring additional costs.
Since inter-organizational EMR exchange spans over different
levels of healthcare, evaluation is difficult and costly. Teo and Yu
[24] argued that uncertainty raises the need of the transacting par-
ties to safeguard their contracts to protect themselves and, thus, the
costs of writing, monitoring and enforcing contracts are expected
to rise under conditions of greater uncertainty. We thus infer that
under an uncertain medical environment, the costs of searching,
monitoring, and adapting will all rise.
H5. Environmental and behavioral uncertainties in the medical
context have positive effects on transaction costs.
3.6. Investments in relation-specific assets and co-creating IT
value (H6)
Relation-specific asset investments, such as dedicated assets,
IT assets, and process assets, are regarded as ways to maximize
long-run benefits by exploiting and developing the resources of an
organization. A good IT infrastructure and processes for knowledge
sharing can increase the ability to identify, to confirm, and to exploit
the information obtained from partners [38]. Grover and Kohli [29]
noted that the ability of an IT system to collect, store, and analyze
information and to distribute knowledge provides many chances
for the co-creation of value. Based on the concept of IT assets, both
dedicated and process assets could improve the quality of informa-
tion sharing; thus, enhance value co-creation. Dyer and Singh [39]
also suggested that relation-specific assets are capable of creating
value on condition that high volume exchanges are conducted and
that opportunism is limited.
In the medical context, as long as medical institutes are willing
to invest in relation-specific assets, they may be more likely to set
up new technological facilities and train their medical staffs to use
the inter-organizational EMR exchange system. In addition, new
software and hardware are needed for online exchanges of medi-
cal information so that compatible EMR systems can be developed.
Working processes also need to be redesigned to reflect changes in
the EMR system. However, if such actions are taken, then different
levels of medical institutes can use the inter-organizational EMR
exchange system to maximize the co-creation of value. The comple-
mentary medical information provided by other systems can also
increase the medical staffs’ understanding of disease and health-
care, leading to a more efficient diagnosis and decision-making
process. We thus posit that:
H6. Investment in relation-specific assets with regard to using
the inter-organizational EMR exchange system has a positive influ-
 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
ence on the co-creation IT value among different levels of medical
institutes
3.7. Transaction costs and co-creating IT value (H7)
Clemons et al. [40] and Malone et al. [41] claimed that infor-
mational systems can reduce transaction costs among business
associates and change process boundaries and, thus, generating
competitive advantages that are difficult to imitate [29]. This can
then raise value, since costs are lower than before. The support for
this assumption is that IT is able to facilitate informational inte-
gration and brokerage, as long as it is properly coordinated with
partner transactions. In addition, the resulting standards of IT pro-
vide the foundation for better interoperability among organizations
and allow alliances to achieve greater value at lower costs [30].
Likewise, Clemons et al. [42] argued that IT reduces transaction-
and opportunism-related risks. Consequently, a decrease in trans-
action costs implies that IT has been successfully used, and that
this idea can be extended to suggest that value co-creation has also
been increased.
Continuing from H5 and H6, we assume that most medical insti-
tutes have constructed their own systems, which may present an
obstacle with regard to future integration. If these medical insti-
tutes want to adopt an inter-organizational EMR exchange system,
they may need to spend much time and effort searching for the
latest information, monitoring the implementation of the system,
and renegotiating new conditions with both staffs and partners. As
a result, the value of the inter-organizational EMR exchange sys-
tem will be lower for these institutes. Based on this logic, we posit
that if the transaction costs are high, it is more difficult for med-
ical institutes to introduce an inter-organizational EMR exchange
system, which lowers the potential value that can be co-created by
using the related IT.
H7. The transaction costs when using inter-organizational EMR
have a negative impact on co-creation IT value among different
medical institutes.
3.8. Co-creating IT value and joint performance (H8)
Using IT to enable inter-organizational collaboration has been
shown to cause reductions in transaction, integration, and switch-
ing costs [30]. Based on the arguments outlined above, we believe
that different levels of medical institutes can reduce operating
costs and strengthen their relationship by adopting an inter-
organizational EMR exchange system. Further, when those medical
institutes are strongly connected by a cross-boundary system, the
IT value could be maximized. Ultimately, the co-created value of
IT will lead to performance improvement among the participating
institutes.
The cost-beneficial characteristics of an inter-organizational
EMR exchange system can help each medical institute to reduce
operating costs, and achieve better financial performance. With
shared access to the results obtained from a diverse range of med-
ical equipment, small-scale medical institutes (i.e., clinics) do not
need to purchase expensive machines, but can instead just get the
related reports from large-scale medical institutes (i.e., metropoli-
tan hospitals), also saving time and labor costs with regard to
repeated checkups.
For medical-service providers, the co-created IT value of com-
plementary information can be used to make better diagnosis
decisions. For instance, if clinics can provide continuous reports
about patients’ health conditions, then hospital doctors can get
a clearer understanding of their current status, and thus provide
more appropriate medical care and reduce errors without spend-
ing time and effort retrieving medical data. In addition, since their
253
workload can be reduced, the job satisfaction of medical staffs may
also be increased.
With the value that is co-created by using an inter-
organizational EMR exchange system, patients should be able to
obtain better medical treatment. Taking the referral process with an
inter-organizational EMR exchange system, medical institutes can
immediately transfer patients’ medical records. As a result, patients
can save time with regard to waiting or traveling time between
different medical institutes.
Based on the above discussion, we can assume that as long as
the IT values are co-created (e.g., by supporting medical services,
strengthening complementary medical information, increasing
decision making efficiency, and decreasing costs), medical insti-
tutes should be able to achieve better joint performance.
H8. An increase in IT value co-creation has positive effects on joint
performance.
4. Methods
This study develops reliable and valid measurements for these
constructs in order to assess their impacts on the implementation
of an inter-organizational EMR exchange system in different levels
of medical institutes. We use a multi-stage approach to develop the
relevant questionnaire items. Prior studies of EMRs rarely focused
on medical applications; most of the items were modified to fit
the context of the current work. All of these questions are used
to measure the medical institutes’ relationships with each other,
EMR implemented conditions, the willingness to use an inter-
organizational EMR exchange system, and the joint performance
between each medical institute.
A prior test of the questionnaire was carried out to make sure the
measurement scales and questions were clear, and some modifica-
tions were then made before the final questionnaire was given to
the respondents. The Cronbach’s alpha values in this study ranged
from 0.736 to 0.969, while the item-to-total correlations ranged
from 0.550 to 0.991. Therefore, there are 46 items for construct
measurements and 11 demographic questions in the formal ques-
tionnaire.
Several revisions were made so that the questionnaire was more
suitable for the medical context of this study. First, the items gath-
ering the basic information of the medical institutes were moved to
the last part of the questionnaire, along with those on the respon-
dents’ characteristics. In addition, the definitions of each construct
were also given so that the respondents could better understand the
focus of each item. Finally, the wording of some items was changed
to make them more comprehensible to the respondents.
An interview with five senior doctors was conducted to further
check the validity of the questionnaire. Based on the sugges-
tions received from these interviewees, the question sequence was
changed to achieve a better sense of flow. Items related to the inter-
nal EMR of each medical institute were moved to the first part of
the questionnaire, while those related to the inter-organizational
EMR system exchange were put in the later part of the survey. In
this way it is expected that the respondents were not confused with
regard to the adoption of internal and external EMR.
5. Results
By using a paper-based survey, the formal questionnaires were
sent to four levels of medical institutes in Taiwan. The respondents
were restricted to people who came into contact with medi-
cal records in their work, including doctors/physicians, nurses,
administrative staff, information technicians, and other employees.
Respondents were asked to rate each item on a seven-point Likert
254 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
scale ranging from 1 (strongly disagree) to 7 (strongly agree). A total
of 330 valid samples were gathered for further analysis.
As shown in Table 1, most of medical institutes that the respon-
dents working for were public (44%), belonged to the EMR stage of
provider-based medical records (32%), and ranked as the academic
medical centers (40%). Approximately 37% of them had imple-
mented EMR for less than three years. Even though most of the
respondents (56%) were not sure about whether the institute they
are working is participating in the EMR related program of Min-
istry of Health and Welfare (MOHW), however, they were aware
of the importance of implementing EMR. In term of respondent’s
demographics, there were about 77% female respondents and 36%
of them were aged 25–29 years old. Most of respondents had under-
graduate education (76%) and served as nurses (58%). Besides, 13%
of administrative staff respondents (e.g., the staffs of medical record
department) were included in the formal analysis, because they
also involved in the EMR practice in daily work. Their opinions were
important for improving the effectiveness of EMR program, and for
the institute to boost the program across the department and the
hospital. As for their seniority, 22% of respondents had worked for
the institute less than one year, 42% had worked for 1–4 years, and
36% for more than 4 years (including 12% more than 10 years).
According to the reports of Taiwanese National Health Research
Institutes [43], the ratio between medical doctors and nurses is
0.344. The average age of nurses is 33.77 years old and more than
half (52.35%) are aged between 25 and 34. Nurses with an under-
graduate education occupy 92.9%. Compared to Western countries,
the demission rate of nurses in Taiwan is high (average 19.94%) and
more than half of them with an accumulated experience of nursing
work are less than six years. The turnover rate within the first year
is ranged from 8.13%-27.8% [44]. Obviously, our sample distribution
reflects the actual demography of health workers in Taiwan.
5.1. Measurement model analysis and discriminant validity
analysis
Table 2 summarizes the descriptive statistics for the ques-
tionnaire items, including mean values (4.404–5.679), standard
deviations (0.991–1.542), item-to-total correlations (0.540–0.870),
average variance extracted (AVE) (0.522–0.933), factor loading
(0.620–0.931), Cronbach’s ␣ (0.701–0.937), and composite relia-
bility (0.573–0.975). All items conformed to the standard, meaning
that all correlations between items and their constructs were good.
Statistically, the convergent validity, internal consistency, and reli-
ability of each variable were acceptable. The model fit indices, the
Chi-square/df in the measurement model (=2.311) is significant
(<3), proving that the observations are consistent with the theo-
retical model. The values of other fit indices, such as GFI, AFGI, CFI,
and RMR, all meet the related criteria set by Hair et al. [45].
As shown in Table 3, all of the square roots of AVE were greater
than the correlation values they corresponded to. Therefore, the
discriminant validity of this measurement model was satisfied.
5.2. Hypotheses testing
The overall results of the standardized path coefficients, path
significances for each construct, and model fit indices were pre-
sented in Fig. 2. The chi-square/df = 2.585 met with the criterion
(<3). The other indices for this hypothesized model were good-
ness of fit = 0.791, adjusted goodness of fit = 0.755, and comparative
fit = 0.889. Although these three indexes were lower than the stan-
dards, they were close to the minimum values of 0.80, and so are
considered accepTable Similarly, because the root mean square
error of approximation (RMSEA) was only slightly higher than the
standard of 0.08, we again consider that the model has acceptable
fit. Fig. 2 also demonstrates that most of hypothesized relation-
ships are supported, with the exceptions that the influence of norm
of reciprocity on relation-specific asset investment is insignificant
(ˇ = 0.003, p > 0.05) and the influence of transaction costs on co-
creating IT value (ˇ= 0.324, p < 0.05) is significant but positive rather
than negative. Therefore, H2 and H7 are not supported.
6. Conclusion and recommendations
6.1. Discussion
This study applies the idea of social capital to explore whether
the strength of the relationships among medical staffs has any influ-
ence on medical institutes’ investment in the inter-organizational
EMR exchange system. As shown in Table 4, H1 was supported,
meaning that the informational stream will become more flu-
ent with stronger interactions among medical staffs in different
medical institutes, giving those organizations enough resources to
observe the operations of others [46]. Therefore, as long as medi-
cal staffs in different institutes are able to learn more information
about the positive aspects of inter-organizational EMR exchanges,
it is more likely that they will make the related investment in this
mutually beneficial system.
In this study, the norm of reciprocity refers to a constant behav-
ior of knowledge-sharing which does not end until the other party
stops the flow of information. Both Wasko and Faraj [21] and Chang
et al. [1] viewed this dimension as one of the most important
factors for cooperative relationships. However, H2 showed that,
in a medical context, this dimension had no significant effect on
relation-specific asset investment. The possible reasons for this
might be related to the research context. In previous studies [20,47],
the research objects were from various backgrounds and may not
have had a basic sense of reciprocity toward each other. For exam-
ple, members in a virtual community would not have the feeling
of reciprocity until they joined the group. However, for medical
staffs, the concept of reciprocity is an inherent part of their profes-
sion, which exists even before they start to cooperate. Therefore,
the norm of reciprocity might not be a major factor that affects
the willingness to make relation-specific asset investments in this
context.
Shared vision in this work is regarded as the common values
and goals that different levels of medical institutes have. Support
for H3 in the results echoes the findings of previous research, which
considered that a shared vision is a way to connect members of
different groups and improve their cooperative relationships [48].
Because different levels of medical institutes have different goals
(i.e., medical centers are supposed to focus on academic research
and clinics concerning basic treatment), it is important for them to
have a shared vision to facilitate cooperation. Likewise, when think-
ing about adopting an inter-organizational EMR exchange system,
it is better for medical staffs in different organizations to come up
with a common view of this cooperation, such as learning from oth-
ers. With this kind of shared vision, each medical staff is expected
to increase their willingness to make relation-specific asset invest-
ments.
The significant support found for H4 confirms not only that asset
specificity can effectively influence transaction costs but also that
this relationship is an important one in a medical context. That
is to say, when a medical institute is attempting to introduce a
new inter-organizational EMR exchange system, the original EMR
system will become an obstacle. More specifically, three types of
transaction costs can be increased by asset specificity. Take search-
ing costs as an example. Medical institutes with a certain-level of
EMR need to spend time and effort in figuring out the differences
between their original EMR and the inter-organizational one. In
addition, medical institutes also have to spend considerable time
 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260 255

Table 1
Information of medical institutes and Respondents (N = 330).

Basic Information of Medical Institutes

Category Number (%)

EMR stage Automated Medical Record 94 28.5

Computerized Medical Record 92 27.9
Provider-based Medical Record 104 31.6
Electronic Patient Record 36 10.9
Electronic Health Record 4 1.2
Rank Clinics 50 15.2
Regional Hospitals 36 10.9
Metropolitan Hospitals 112 33.9
Academic Medical Centers 132 40.0
Type Public 145 43.9
Private 80 24.3
Medical foundation 83 25.2
Medical Corporation 19 5.7
Other 3 0.9
Location North 125 37.9
Midst 45 13.6
South 155 47.0
East 5 1.5
EMR Implementing Year Under 3 years 121 36.7
4–6 years 120 36.4
7–9 years 50 15.2
10–12 years 26 7.9
13–15 years 3 0.9
Above 15 years 10 3.0
Participating in MOHW’s EMR related program Yes 119 36.1
No 25 7.6
Not Sure 186 56.4

Respondent Characteristics

Category Number (%)

Gender Male 75 22.7

Female 255 77.3
Age Under 25 75 22.7
25–29 120 36.4
30–39 87 26.4
40–49 33 10.0
Over 50 15 4.5
Education Degree Senior High 5 1.5
Junior College 50 15.2
Undergraduate 250 75.8
Post-graduated 25 7.5
Professional Title Doctors 47 14.2
Nurses 191 57.9
Administrative staffs 43 13.0
IT- technicians 5 1.5
Others 44 13.3
Seniority Under 1 year 73 22.1
1–2 years 56 17.0
2.1–3 years 49 14.8
3.1–4 years 35 10.6
4.1–5 years 18 5.5
5.1–6 years 12 3.6
6.1–7 years 12 3.6
7.1–8 years 15 4.5
8.1–9 years 8 2.4
9.1–10 years 14 4.2
Above 10 years 38 11.5

and effort in supervising the new system’s operations. Medical
institutes which already have individual electronic medical sys-
tems in each department may find that their medical staffs are
unfamiliar with the particular format of EMR used by the new
system and, thus, data processing errors may be made when the
system is first used; this will lead to an increase in monitoring costs.
Finally, medical institutes that have individual electronic medi-
cal systems will inevitably face costs with regard to adopting and
adapting to the new system. Because inter-organizational EMR is
still new to the industry, and relatively unstable, medical institutes
that adopt it may spend considerable time and effort on obtaining
new information and implementing.
The significant support for H5 showed the relationship between
uncertainty and transaction costs is also positive in a medical con-
text. In Taiwan, inter-organizational EMR exchanges are relatively
new, and the relevant regulations and policies are being devel-
oped. In other words, the exchanges that take place within this
system remain unstable, making them more costly in terms of time
and effort. In addition, each medical institute also confronts inter-
nal uncertainty. This behavioral uncertainty is due to the unclear
adoption intentions within organizations. Since EMR exchanges
256 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260

Table 2
Summary of Descriptive Analysis.

Construct No. of Item Mean S.D. Item-to-total Factor loading ␣ CR AVE

Social Interaction Ties 4 5.072–4.555 1.422–1.542 0.580–0.781 0.620–0.899 0.825 0.741 0.561
Norm of Reciprocity 2 5.083–5.132 1.235–1.274 0.764–0.764 0.856–0.893 0.866 0.832 0.764
Shared Vision 3 5.306–5.543 0.991–1.148 0.637–0.797 0.695–0.911 0.856 0.814 0.682
Asset Specificity 5 4.404–4.906 1.277–1.510 0.699–0.787 0.746–0.844 0.897 0.848 0.637
Uncertainty – – – – – 0.532 0.521
Environmental uncertainty 2 5.121–5.196 1.076–1.184 0.540–0.540 0.725–0.745 0.701 0.573 0.549
Behavioral uncertainty 3 4.434–4.728 1.306–1.447 0.587–0.757 0.642–0.890 0.823 0.759 0.626
Investment in Relation-specific Assets – – – – – 0.968 0.917
Dedicated specificity 3 4.815–4.966 1.188–1.276 0.792–0.852 0.860–0.913 0.909 0.886 0.771
IT specificity 2 4.917–5.008 1.234–1.237 0.812–0.812 0.880–0.920 0.896 0.874 0.810
Process specificity 2 4.672–5.000 1.161–1.321 0.729–0.729 0.823–0.886 0.843 0.799 0.731
Transaction Cost – – – – – 0.975 0.933
Searching cost 3 4.691–4.923 1.175–1.301 0.798–0.821 0.834–0.904 0.903 0.875 0.755
Monitoring cost 2 4.913–4.996 1.150–1.229 0.820–0.820 0.899–0.911 0.901 0.882 0.820
Adapting cost 3 4.842–4.970 1.164–1.240 0.802–0.854 0.830–0.923 0.918 0.898 0.788
Co-creating IT value 4 5.340–5.492 1.052–1.239 0.812–0.866 0.840–0.910 0.935 0.910 0.783
Joint Performance 8 5.121–5.679 1.104–1.390 0.699–0.830 0.724–0.883 0.937 0.908 0.653

Table 3
Results of Discriminant Validity Analysis.

Variable SIT NR SV AS UC IRA TC CIV JP

SIT 0.749a
NR 0.698*** 0.874a
SV 0.615*** 0.683*** 0.826a
AS 0.642*** 0.464*** 0.424*** 0.798a
UC 0.068 0.100 0.066 0.013 0.722a
IRA 0.584*** 0.419*** 0.351*** 0.680*** 0.031 0.958a
TC 0.569*** 0.383*** 0.426*** 0.685*** 0.062 0.646 0.966a
CIV 0.408*** 0.603*** 0.471*** 0.357*** 0.063 0.341*** 0.395*** 0.885a
JP 0.349*** 0.618*** 0.404*** 0.338*** 0.065 0.332*** 0.349*** 0.679*** 0.808a

Notes: SIT = Social Interaction Ties; NR = Norm of Reciprocity; SV = Shared Vision; AS = Asset Specificity; UC = Uncertainty. IRA = Investment in Relation-specific Assets;
TC = Transaction Cost; CIV = Co-creating IT Value; JP = Joint Performance.
a
Square root of AVE value.
***
p < 0.001.

Fig. 2. Result of the SEM.

are mainly driven by the government, it is difficult to assess the
decision makers’ true intentions in each organization. One of the
concerns is that some top managers may adopt this new system
only because their institutes can receive a subsidy if they do so. In
addition, medical staffs may adopt this system in a passive way and,
thus, make the performance of the EMR exchange hard to assess.
As a result, medical institutes may need to spend much time and
effort on switching to the new EMR system. In short, since the inter-
organizational EMR exchange system has not been adopted by all
institutes, there is such considerable environmental and behavioral
uncertainty associated with it; both of which can raise the related
transaction costs.
A new concept of value co-creation was applied in this study
to examine whether interactions among medical institutes could
enhance their investments in relation-specific assets and, thus,
increase the value co-created by the inter-organizational EMR sys-
 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
Table 4
Results of SEM Paths Analysis.
Hypothesis Predictions
H1 Social Interaction Ties → Investments in Relation-specific Assets
H2 Norm of Reciprocity → Investments in Relation-specific Assets
H3 Shared Vision → Investments in Relation-specific Assets
H4 Asset Specificity → Transaction Cost
H5 Uncertainty → Transaction Cost
H6 Investments in Relation-specific Assets → Co-creating IV value
H7 Transaction Cost → Co-creating IV value
H8 Co-creating IV value → Joint Performance
*
p < 0.05.
***
p < 0.001.
tem while H6 was proposed to assess this relationship. The result is
significant, meaning that when there is a higher level of investment
in relation-specific assets (i.e., in the inter-organizational EMR sys-
tem), the inter-organizational EMR exchange system is then able to
co-create more value. Since the inter-organizational EMR exchange
system serves as an informational platform, which can only suc-
ceed by integrating medical records from different levels of medical
institutes, a more complete network of relationship can provide it
with a better foundation. As long as medical institutes are willing
to invest in this system and the related personnel training, more
IT value is likely to be created. For example, medical staffs who
are familiar with this new system can upload and transmit digital-
ized medical records more efficiently, providing a better foundation
for their technical services both inside and outside their organi-
zations. Moreover, if medical institutes can invest more on their
exchange behavior, it is more likely that they can achieve IT value
co-creation. In practice, if medical institutes make more investment
in improving the working processes of medical staff with regard to
the inter-organizational EMR system, then the co-created IT value
is likely to increase, while the quality and quantity of knowledge
sharing can also both rise and, thus, facilitating better diagnoses and
decision-making. In short, if medical institutes make more dedi-
cated specific investments (e.g., in particular equipment), IT specific
investments (e.g., in online informational exchanges) and process-
specific investments (e.g., in working routines), then more value
will be co-created.
One of our research objectives is to examine whether asset
specificity and uncertainty can increase internal transaction costs,
and thus reduce co-created value. H7 does not have any directly
related support in the literature. In this research, we assume that
once a medical institute has put more time and effort into preparing
for the implementation of an inter-organizational EMR exchange
system, the co-created value will be limited by any increase in inter-
nal costs, and thus there is a negative relationship between these.
Unfortunately, the results showed that transaction costs have posi-
tive effects on co-created IT value. One of the possible explanations
for this phenomenon might be related to the transaction costs’ char-
acteristic concerning time, which will be discussed in more details
below.
As noted in relation to H4 and H5, if medical institutes have
to look for information related to the inter-organizational EMR
exchange system in order to deal with the issue of asset speci-
ficity and uncertainty, then this will raise searching costs. Thus,
according to the original H7, these elevated costs would reduce
the co-created value. However, as time goes by and the system
becomes more mature, these costs may be transformed into a kind
of capital that can further increase co-created IT value. For exam-
ple, if the medical institutes spend more time and effort in finding
information, they will then obtain a deeper understanding of inter-
organizational EMR. They can thus engage in more effective data
processing and have better technical services.
257
Standard Coefficients C.R. (t-value) Results
0.330*** 3.972 Supported
0.003 0.309 Not Supported
0.204* 2.26 Supported
0.563*** 8.577 Supported
0.231*** 3.495 Supported
0.142* 2.229 Supported
0.324*** 5.034 Not Supported
0.820*** 12.82 Supported
The other explanation for the lack of support for H7 could be due
to the monitoring costs. From H4 and H5, this study showed that
due to asset specificity (i.e., the inter-organizational EMR system)
and uncertainty, medical staffs may initially have problems using
the new system; thus, medical institutes will face additional costs
related to monitoring their employees. Nonetheless, once medical
staffs become familiar with the inter-organizational EMR system,
such supervision will become a “guarantee” of IT value co-creation.
Take the knowledge-sharing level of co-creating IT value as an
example. Under certain degrees of supervision, medical institutes
acquire a security channel that ensures high-quality information
flows, leading to a higher degree of value co-creation. In addi-
tion, following H4 and H5, when medical institutes intend to adopt
the inter-organizational EMR system, they will encounter a chang-
ing adoption of the environment, which means they often need to
update the information they use. Therefore, costs are raised. Never-
theless, such phenomenon will support greater IT value co-creation
over time.
Thus, there are both negative and positive relationships
between transaction costs and the co-creation of IT value, and these
relationships change over time. When the inter-organizational EMR
system was first adopted, the transaction costs may have nega-
tive impacts on IT value co-creation but positive impacts shortly
afterwards. As a result, H7 was not supported. The original English
definition of transaction costs emphasized that considerable time
and efforts must be spent by the medical institutes when adopting
the new EMR system. However, in the Chinese version of the ques-
tionnaire, transaction costs were defined following the idea that
such efforts were voluntary. This difference may have caused some
misunderstandings with regard to H7 for most of the respondents,
then leading it to be rejected.
Joint performance here refers to the degree of effectiveness
and efficiency of collective medical records, as assessed from the
perspectives of the organizations, medical staff, and patients. H8
proposes that the inter-organizational EMR exchange system, if
successfully implemented, can benefit all these parties. The results
support H8 and indicate that various performance improvements
can be obtained as long as the values of the inter-organizational
EMR system are successfully co-created, as explained in more
details below.
In organizational-level performance, the values co-created by
inter-organizational EMR exchanges can decrease operational costs
and increase financial efficiency. With regard to the asset layer, the
participating institutes can retrieve patients’ records from their
partners by using the new system. For small-scale medical insti-
tutes, such as clinics, they can cut unnecessary costs related to
repeated examinations and purchases of equipment. On the other
hand, large-scale medical institutes, such as academic medical cen-
ters, can obtain medical data from clinics for better diagnoses.
Group-level performance refers to medical staff. With the
implementation of the inter-organizational EMR system, diag-
noses and related decision-making can be accelerated. This is
258 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
aided by the knowledge sharing layer, one of the characteristics
of IT value co-creation. In this exchange platform, doctors can
upload their diagnoses and transmit the data both intra- and inter-
organizationally. Therefore, the organization can save additional
labor costs with regard to delivering paper-based medical records,
giving medical staff more time to conduct diagnoses or treatment.
As for patients, with the aid of the inter-organizational EMR
exchange system, they can get more complete and continuous
medical treatment based on the co-created IT value. Take the com-
plementary capability layer as an example of this. Because the
detailed records of the patients are digitalized and shared on-line,
medical institutes can quickly retrieve medical records throughout
the system. As a result, patients do not have to go back and forth
between different medical institutes in order to get access to their
medical records. In short, by adopting the inter-organizational EMR
system various types of IT value could be co-created for medical
institutes. In addition, these values can have positive influences on
all three levels (i.e. organizational, group, and personal) and, thus,
enhancing the joint performance of medical institutes.
6.2. Theoretical implications
This work combined SCT and TCT to observe the barriers medical
institutes might confront when introducing an inter-organizational
EMR exchange system. In previous studies [18,20,24,39,49], these
two theories are usually discussed independently, resulting in an
incomplete view of cooperation. In our research context, neither
SCT nor TCT can be omitted, because different medical institutes
will be needed in the innovative inter-organizational system to
provide information; significant changes with regard to internal
expenses in needed in the system as well. As a result, this research
combined these two theories to examine clearer about the inter-
organizational relationships and costs with regard to adopting this
new system. By doing so, this research can consider both inter-
nal and external factors that might influence the adoption of the
inter-organizational EMR exchange system.
The results of this study indicated that SCT, including the tie
of social interaction and shared vision, could effectively increase
medical institutes’ investments in relation-specific assets and sub-
sequently enhance the co-created value of the inter-organizational
EMR exchange system. In other words, the results showed that
the relationships among different levels of medical institutes could
have positive effects on co-creating value, such as by providing
supportive IT services or complementary information.
As for the TCT, the beginning of this research was assumed that
transaction costs, including the concepts of asset specificity and
uncertainty, could raise internal costs; then leading to a reduc-
tion in co-created value. Nevertheless, the results revealed that
transaction costs had a positive relationship with value co-creation,
although time is a factor here. On the one hand, transaction costs
could have negative effects on co-created value, especially at the
start of the implementation process. However, more such costs
indicate that an organization is investing more time and effort in
adopting the new system, and this may eventually lead to better
outcomes.
Finally, this study extended the concept of IT value co-creation.
By linking IT value co-creation and joint performance, the con-
cept of value co-creation was clarified. As noted before, value
co-creation in previous studies is a recent concept developed from
value creation. In order to present the ultimate benefits co-created
by the inter-organizational EMR exchange system, this research
added the structure of joint performance. Most importantly, this
research also provided a questionnaire of value co-creation that
can be used by future studies. The results indicated that the var-
ious forms of value co-created by the inter-organizational EMR
exchange system can enhance the practices of medical insti-
tutes, increase the working efficiency of medical staff, and provide
patients with better medical care.
To sum up, this study examined cooperation with regard to both
external relationships and internals costs. Moreover, both SCT and
TCT were related to the co-creation of IT value and joint perfor-
mance in order to explore the potential benefits of adopting an
inter-organizational EMR exchange system.
6.3. Managerial implication
This research explored how the collective benefits of using an
inter-organizational EMR exchange system could be obtained by
strengthening relationships and mitigating the influence of internal
costs on the adoption of the new system. This section explains the
managerial implications of the results.
First of all, because the results rated to the SCT confirmed the
positive relationship between social capital and investments in
relation-specific assets, medical institutes should work to estab-
lish stronger links with other levels of medical organizations. For
instance, directors in large-scale medical centers should encour-
age their medical staff to participate in seminars or academic
reunions so that they can learn more from others at other institutes.
As for physicians in small-scale clinics, they should join profes-
sional associations to keep in touch with other medical staff. As for
administrative personnel, such as those in medical records units
or informational management divisions, they should also establish
relationships with staff in other medical institutes so that they can
learn about new development in their areas of expertise.
Secondly, both asset specificity and uncertainty were found
to have positive relationships with transaction costs. However,
because all of the research objects in this study were medical insti-
tutes that had already adopted certain forms of EMR, it is inevitable
that they will face some costs when switching to the new sys-
tem. That’s why our practical suggestions focus on the aspect of
uncertainty as follows.
Among the items related to behavioral uncertainty, most of
the respondents stated that top managers’ true intentions are
difficult to ascertain (mean = 4.742). In order to reduce this uncer-
tainty, managers in medical institutes should spend more time
explaining their attitudes toward EMR adoption. For each phase
of EMR adoption, such efforts should involve at least the follow-
ing three elements: (1) motive: explanation of the purpose of
adopting/upgrading the EMR system; (2) target: establishment of
short-term, medium-term, and long-term targets for medical staff
to achieve; and (3) anticipated effects: the list of possible outcomes
so that medical staff could know what they are striving for.
This research was conducted to explore the influences of SCT
and TCT on adopting a cross-hospital EMR exchange system and
the effects of co-created value on each medical institute joint per-
formance. Due to the forecasting characteristics of this study, we
only offer suggestions for the first part of our framework, which is in
the period before adopting the inter-organizational EMR exchange
system.
6.4. Limitations and directions for future research
There are a number of several limitations in this study.
Firstly, although the research scope included four-leveled medi-
cal institutes (i.e., medical centers, metropolitan hospitals, regional
hospitals and clinics), however, the proportion of clinics (15.0%) and
regional hospitals (12.7%) together accounted for less than a quarter
of the whole sample; moreover, they were 22% of the respondents
who seniority has less than one year was included in the formal
analysis. These respondents’ attributes may present a bias against
the results. Future research should involve more types of medical
institutes, such as district public health centers, a list of institute
 H.H. Chang et al. / International Journal of Medical Informatics 97 (2017) 247–260
names should also be obtained from the DOH to ensure greater
accuracy with regard to the responses, as well as to control over
the respondents’ seniority in the model to avoid bias against the
hypothesis testing results.
Secondly, due to the anticipated characteristic of this study,
the overall performance of the inter-organizational EMR exchange
system may not have been presented in our results. It should
be considered in the future research concerning extending the
research period in order to observe the effects before and after
adopting the inter-organizational EMR system, as the results would
then be more complete and closer to reality.
The third limitation is that the results for the full model fit in this
study are slightly lower than the related standards, and that one
reason for this situation may be the long questionnaire. Since most
medical staffs were busy at work, they did not have much time to
complete the questionnaire. Future researchers should thus design
a shorter questionnaire, if possible. In addition, although the issues
of confidentiality and patient privacy are regarded as important
factors in the adoption of EMR [3], this study did not take them
into consideration. In conclusion, researchers who are interested in
this subject could extend the range of research objects or include
other antecedents of SCT and TCT in the future analysis. They may
also include the ideas of informational confidentiality and patients’
privacy in the further discussions.
Finally, this study did not consider the adoption of some tech-
nical solutions that the EMR exchange system could use. Future
research, for example, may discuss the influences of utilizing
Health-level 7 (HL7) messages on users of the EMR exchange sys-
tem.
Summary points
Purpose
The purposes of this work are to: (1) examine whether the use of
SCT (social interaction ties, norm of reciprocity, and shared values)
could enhance medical institutes’ investments in relation-specific
assets, and subsequently increase the value co-created with the
inter-organizational EMR system, (2) examine whether the use of
TCT (asset specificity and uncertainty) could increase internal costs
when adopting cross-hospital EMR exchanges, and further decrease
co-creating IT value, and (3) examine whether the value co-created
when using an inter-organizational EMR system could enhance the
performance of participation in medical institutes.
Design/methodology/approach
This study applied social capital theory (SCT) and transaction
cost theory (TCT) to discover the influences of relationships and
internal costs on adopting an inter-organizational EMR system, as
well as the benefits that can be derived doing so. This research col-
lected 330 valid paper-based questionnaires from the medical staff
of various institutes. The results of the structural equation model
supported the research model.
Findings
The results indicated that social interaction ties and shared
vision positively affected medical institutes’ willingness to adopt
the EMR exchange system, while asset specificity and uncertainty
increased the related transaction costs. With a greater willingness
to invest in relation-specific assets and to meet the related trans-
action costs, this behavior lead to an increase in medical IT value,
as well as better results for the related medical institutes, medical
staff, and patients.
Practical implications
This study suggests that such institutes encourage their medi-
cal staff to participate in seminars or reunions in order to develop
their professional and social networks, and set up clear schedules
259
and desire for expected effects when introducing the cross-hospital
EMR exchange system.
Originality/value
This study combined social capital theory (SCT) with transac-
tion cost theory (TCT) to explain the influences of relationships and
internal costs on adopting an inter-organizational EMR system.
Conflict of interest
There are no known conflicts of interest.
Authorship contributions
Hsin Hsin Chang, Chung-Jye Hung, Ching Ying Huang, Kit Hong
Wong, Yi Ju Tsai have made substantial contributions to all of the
following: (1) The conception and design of the study, or acquisition
of data, or analysis and interpretation of data, (2) Drafting the article
or revising it critically for important intellectual content, (3) Final
approval of the version to be submitted.
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