Tomi Dahlberg
email: tomi.dahlberg@utu.fi

Perceived Significance of Improved Patient Data and Healthcare Services in the Formation of inter-Organizational Healthcare IT Governance

Keywords: Healthcare IT, Social welfare IT, IT Governance. 1

IT is seen as the means to develop healthcare and social welfare services for citizens and to improve the quality of medical and social welfare data. This is deemed to require better IT cooperation between organizations. My research investigates the formation of voluntary inter-organizational IT governance in healthcare and social welfare IT engaging over 100 organizations. Attention is placed especially on the perceived benefits of IT governance. Results suggest that concrete benefits are necessary for the formation of interorganizational IT governance arrangements. The anticipated benefits of patient data improvement and short-term benefits were evaluated more important than the expected long-term improvements of healthcare and social welfare reforms.

Introduction

Healthcare and social welfare professionals, national governments and international organizations consider questions such as: How to arrange and provide healthcare and social welfare services for citizens? How to improve the integration and quality of patient / customer data? How to govern and manage information technology (IT) and patient / customer data as a part of healthcare and social welfare services? Societal developments, especially the aging of population, make it necessary to consider reforms to national healthcare and social welfare systems [START_REF] Obi | Aging Society and ICT: Global Silver Innovation[END_REF]. Data mining, analysis, visualization etc. techniques offer huge potentials to improve healthcare and social welfare services [START_REF] Nahar | Issues of Data Governance Associated with Data Mining in Medical Research: Experiences from an Empirical Study[END_REF]. At the same time the fragmentation and poor quality of data and data storages as well as lack of message and data model standards hamper electronic data transfer and the deployment of these potentials [START_REF] Hovenga | National Healthcare Systems and the Need for Health Information Governance[END_REF]. IT-enabled services are seen as one key element both for reforms and for data quality improvements, at the same time as healthcare and social welfare IT faces several "make ends meet" type challenges that limit the potential of IT [START_REF] Wintley-Jensen | EU Activities on Aging[END_REF].

According to an UN 2012 estimate [START_REF]World Population Prospects: The 2012 Revision[END_REF], persons older than 60 years accounted for 11 per cent of the world's population. During the next four decades, the proportion of older population is projected to increase to 22 per cent [START_REF]World Population Prospects: The 2012 Revision[END_REF]. Within the European Union (EU), including the country of this study, the demographic changes with longer life expectancies and lower birth rates have dramatic effects. In EU, dependency ratio is estimated to drop from 1:4 to 1:2, cost of (health and social) care to increase with 4-8 % of GDP and work force to shrink with 20 million by 2025 [START_REF] Wintley-Jensen | EU Activities on Aging[END_REF]. Increasing demand for healthcare and social welfare services is deemed to require coordinated activities and better information sharing between social welfare, basic healthcare and specialized medical care services. The same is true for all groups with disabilities and special needs [START_REF] Hovenga | Impact of Data Governance on a Nation's Healthcare System Building Blocks[END_REF]. IT is seen to support reforms in two ways. Automation of routines, integration of information systems (IS), and the usage of data storages and electronic data transfer are expected to produce better services. Interoperability, standards and cooperation between organizations are needed for this. Secondly, new IT-based services are called for so that citizens are able to take more responsibility for their wellbeing and for living more healthily, are empowered to active aging with new types of work arrangements and longer participation to the activities of a society [START_REF] Wintley-Jensen | EU Activities on Aging[END_REF]. Ease of use and new health and social care models are necessary for this. Economic growth, markets and novel business models are needed to support needed innovations [START_REF] Wintley-Jensen | EU Activities on Aging[END_REF].

At the moment, fragmentation and inconsistency of healthcare and social welfare data appears to be more the norm than the exception [START_REF] Hovenga | Impact of Data Governance on a Nation's Healthcare System Building Blocks[END_REF], [START_REF] Nahar | Issues of Data Governance Associated with Data Mining in Medical Research: Experiences from an Empirical Study[END_REF]. For example, out of the 194 member states of World Health Organization (WHO) only 34 members were able to provide reliable health data in 2012 [START_REF] Hovenga | Impact of Data Governance on a Nation's Healthcare System Building Blocks[END_REF]. A major reason for this is the way, how healthcare and social welfare service providers run their patient/customer ISs and databases [START_REF] Hovenga | Impact of Data Governance on a Nation's Healthcare System Building Blocks[END_REF]. They register medical measurements, events, radiographs, prescriptions, case summaries, etc., social welfare service actions, decisions etc., and other data into their unique databases. Data sharing remains challenging, even when organizations have purchased the same IS from the same vendor. Organization-specific implementations result in differences in data models, in data coding schemes and in data handling practices, which then prevent electronic data sharing [START_REF] Nahar | Issues of Data Governance Associated with Data Mining in Medical Research: Experiences from an Empirical Study[END_REF]. Data structures and messages need to be standardized together with the related identification and authentication services and data transfer interfaces. Also data collection and processing practices need to be standardized to the extent of producing consistent data.

Organizational silos and limited coordination contribute to the existence of "making end needs" type challenges of healthcare and social welfare IT. Resources are insufficient as organizations develop similar IT solutions independently. Possibilities to recruit highly skilled specialists and to purchase rare IT assets or skills are limited due to financial, availability, size etc. constrains. The power of one organization is little in negotiations with IT service vendors as compared to pooled purchases and negotiation power. The absence of established inter-organizational (IT) cooperation and governance arrangements limits cooperation to experience exchange instead of resource sharing and joint IT service development and operations.

The usage of IT to reform national healthcare and social welfare systems, to improve data quality and interoperability, and to solve the "making ends meet" challenges of IT resourcing lead to the same conclusion. Better inter-organizational IT cooperation and governance is needed. IT governance bodies should define clear objectives for IT cooperation, direct cooperation by agreeing accountabilities for plans, activities etc., and monitor cooperation by reviewing outcomes. National governments typically emphasize reforms' long-term benefits and impacts on data quality. Local professionals probably focus more on short-term service and data interoperability benefits and IT professionals may also wish to solve IT-specific challenges.

The current IT governance research addresses IT governance mainly within one organization [START_REF] Van Grembergen | Implementing Information Technology Governance: Models, Practices and Cases[END_REF], [START_REF] Weill | IT Governance: How Top Performers Manage IT Decision Rights for Superior Results[END_REF] with a few case studies as the exceptions. These case studies describe inter-organizational IT governance between related business units or partners in domestic [START_REF] Croteau | Interorganizational Governance of Information Technology[END_REF][START_REF] Croteau | Contractual and Consensual Profiles for an Interorganizational Governance of Information Technology[END_REF] or in global company [START_REF] De Haes | Inter-Organizational Governance of Information Technology: Learning from a Global Multi-Business-Unit Environment[END_REF] contexts. My research examines the formation of voluntary inter-organizational IT governance engaging a large number of independent healthcare and social welfare organizations. Research has also examined the benefits of IT governance limitedly. Financial metrics such as cost, revenue and return on assets have been investigated [START_REF] Weill | IT Governance: How Top Performers Manage IT Decision Rights for Superior Results[END_REF]. My study draws on the resource based view (RBV), transaction cost economics (TCE) and social network theories to complement the theoretical basis. They address alliances (=inter-organizational governance) as a form of governance [START_REF] Das | A Resource-Based Theory of Strategic Alliances[END_REF], [START_REF] Wintley-Jensen | EU Activities on Aging[END_REF], [START_REF] Zaheer | It's the Connections: The Network Perspective in Interorganizational Research[END_REF], have been used in prior IS research [e.g. [START_REF] Park | A Resource-based View of Strategic Alliances and Firm Value in the Electronic Marketplace[END_REF], [START_REF] Wiengarten | Exploring the Important Role of Organizational Factors in IT Business Value: Taking a Contingency Perspective on the Resource-Based View[END_REF] and have rich metrics for the benefits of inter-organizational governance.

To summarize, with this research I investigate the formation of voluntary interorganizational IT governance between legally independent organizations. Special attention is paid to IT cooperation benefits during the formation of an IT governance arrangement. The two research questions are: What is the significance of IT cooperation benefits for the formation of inter-organizational IT governance? Secondly, how important are short-term benefits in healthcare and social welfare patient / customer data and in "making ends meet IT" as compared to long-term service improvements? Section 2 explains how the objectives of this research were achieved and the research questions answered by theoretically discussing IT and health information governance, RBV, TCE and social network theory. Section 3 describes how that was done through a case study with a related expert survey. Results from the empirical case study and the survey are shown in Section 4. Finally, in Section 5, the theoretical and empirical findings of this study are discussed and conclusions are drawn.

Theoretical Background

This study follows the social network theory definition of inter-organizational (IT) governance [START_REF] Jones | A General Theory of Network Governance: Exchange Conditions and Social Mechanisms[END_REF]: "Network governance involves a select, persistent, and structured set of autonomous firms engaged in creating products or services based on implicit and open-ended contracts to adapt to environmental contingencies and to coordinate and safeguard exchanges. These contracts are socially-not legally-binding." The case I investigated has all characteristics of the definition although "firms" are nonprofit public sector organizations. The establishment of (IT) governance is one phase in its lifecycle, also called the formation of an alliance [START_REF] Das | A Resource-Based Theory of Strategic Alliances[END_REF]. Literature is reviewed to understand, why do organizations decide to form alliances, such as formal IT governance arrangements? What benefits do participating organizations expect from that? Since IT governance research on inter-organizational governance is scarce, constructs from RBV, TCE and social network theory are reviewed to answer these questions.

IT Governance and Health Information Governance research: As explained above, prior studies have examined mainly intra-organizational IT governance. However, [START_REF] Croteau | Interorganizational Governance of Information Technology[END_REF] and [START_REF] De Haes | Inter-Organizational Governance of Information Technology: Learning from a Global Multi-Business-Unit Environment[END_REF] investigated IT governance arrangements within single-organization multiunit and [START_REF] Croteau | Contractual and Consensual Profiles for an Interorganizational Governance of Information Technology[END_REF] within value network contexts. Value networks included single buyermulti-vendor (contractual) and single service organizer -multi-partner (consensual) arrangements. The mentioned articles suggest that the formation of both intra-organizational and inter-organizational IT governance follow rather similar practices. De Haes et al. [START_REF] De Haes | Inter-Organizational Governance of Information Technology: Learning from a Global Multi-Business-Unit Environment[END_REF] explain how IT governance structures, processes and cooperation mechanisms could be extended from intra-organizational to inter-organizational settings. The generic purpose of IT governance is to "enable both business and IT to execute their responsibilities in support of business and in the creation of business value from IT investments". [START_REF] De Haes | Inter-Organizational Governance of Information Technology: Learning from a Global Multi-Business-Unit Environment[END_REF] It is noteworthy that IT governance benefits are classified into business (e.g. healthcare and social welfare services and better patient / customer data) and into IT performance benefits. Business and IT performance benefits are also built in into IT governacne best practice methods, especially COBIT.

The benefit proposition is that "IT governance effectiveness is positively associated with organizational performance" [START_REF] Mohamed | A Conceptual Framework for Information Technology Governance Effectiveness in Private Organizations[END_REF]. Mohamed et al. [START_REF] Mohamed | A Conceptual Framework for Information Technology Governance Effectiveness in Private Organizations[END_REF] note that the benefits of IT governance consist of financial, customer, learning and growth, and of internal and business process benefits (=the 4 dimensions of the balanced scorecard). Weill et al. investigated the business performance impacts of alternative IT governance arrangements with three types of measures; cost-efficient use of IT, business profitability and revenue growth [START_REF] Weill | IT Governance: How Top Performers Manage IT Decision Rights for Superior Results[END_REF]. Huang et al. [START_REF] Huang | Influencing the Effectiveness of IT Governance Practices through Steering Committees and Communication Policies[END_REF] classified the IT performance impacts of IT governance into the efficiency of IT use, the breath of current IT use and the breath of potential IT use. Bradley et al [START_REF] Bradley | An Empirical Examination of Antecedents and Consequences of IT Governance in US Hospitals[END_REF] studied IT governance outcomes in US hospitals by dividing them into social risk management, technical risk management, market responsiveness, external relationship management and operational IT effectiveness. In summary, the current IT governance literature considers rather thinly, why organizations cooperate and what are the benefits of inter-organizational IT governance.

The definitions of health information governance [START_REF] Nahar | Issues of Data Governance Associated with Data Mining in Medical Research: Experiences from an Empirical Study[END_REF], [START_REF] Hovenga | National Healthcare Systems and the Need for Health Information Governance[END_REF] differ slightly from those used in IT governance research and show how elusive the IT governance concept is. Definitions emphasize "standardizing the management, policy design and risk management associated with information". Hovenga [START_REF] Hovenga | Impact of Data Governance on a Nation's Healthcare System Building Blocks[END_REF] investigated the versatile beneficial impacts of health information governance on one nation's (Australia) healthcare system. Potential benefits include improved evaluating and comparing of health outcomes from transitioning to digital environment, and better sustainability of heath systems. Other potential benefits are: improved leadership and governance (national strategic policy framework, health process management and strategic health policy frameworks); financing of healthcare (health insurance versus funding, terminology and coding systems etc.); health workforce (planning of roles, occupational categories, workforce registration, licensing etc.); medical products, devices and technologies (device and technology types, medical device regulations, medical device nomenclature, etc.); health service delivery types and regulations (harmonization of service delivery data, accessing healthcare services, planning and managing resources and health service delivery, epidemiology issues etc.); and information and research (for leaders and governors, other key decision makers, professionals, researchers etc.)

RBV, TCE and Social Network Theory research: RBV, TCE and social network theory [START_REF] Williamson | The Economic Institutions of Capitalism[END_REF] regard single organizations (vertical governance in TCE), markets (market governance in TCE) and networks / alliances (hierarchical or relational governance in TCE) as alternative governance models. (Strategic) alliances are voluntary cooperative inter-organizational agreements that aim to produce competitive advantages for alliance partners [START_REF] Das | A Resource-Based Theory of Strategic Alliances[END_REF]. Within the context of this research, voluntary interorganizational IT governance is seen as an arrangement to agree how to govern (the management of) IT as an alliance with the motive to provide better healthcare / social welfare services for citizens through the means of IT and digital data deployment.

Barney [START_REF] Barney | Firm Resources and Sustained Competitive Advantage[END_REF] introduced the work of Penrose into IS research. RBV sees each organization unique [START_REF] Barney | Firm Resources and Sustained Competitive Advantage[END_REF], [START_REF] Wiengarten | Exploring the Important Role of Organizational Factors in IT Business Value: Taking a Contingency Perspective on the Resource-Based View[END_REF], as an equivalent to the broad set of tangible and intangible resources that it owns (semi-)permanently [START_REF] Geyskens | Make, Buy, or Ally: A Transaction Cost Theory Meta-Analysis[END_REF], [START_REF] Wiengarten | Exploring the Important Role of Organizational Factors in IT Business Value: Taking a Contingency Perspective on the Resource-Based View[END_REF]. Intangible resources include IT and information, and the usage arrangements of resources. The resources of the organization as a whole, and especially imperfectly mobile, non-imitable and nonsubstitutable resources determine the organization's value creation potential. RBV proposes that inter-organizational cooperation happens, if cooperation provides winwin value for the participants by pooling, aggregating, sharing and exchanging their valuable unique resources, and if such value cannot be better achieved in other ways.

Barney proposed that four properties of (IT) resources make them unique, valuable, rare, imperfectly imitable and non-substitutable [START_REF] Barney | Firm Resources and Sustained Competitive Advantage[END_REF]. Das et al. [START_REF] Das | A Resource-Based Theory of Strategic Alliances[END_REF] treat mobility, imitability and substitutability as the basic unique properties of resources. Resources have also other attributes. They can be property based (human, intellectual or physical) or knowledge based (organizational, technological or managerial). Resources can be supplementary, complementary, surplus or wasteful. Melville et al. [START_REF] Melville | Information Technology and Organizational Performance: An Integrative Model of IT Business Value[END_REF] classify IT resources into human and technical. According to Wiengarten et al. [START_REF] Wiengarten | Exploring the Important Role of Organizational Factors in IT Business Value: Taking a Contingency Perspective on the Resource-Based View[END_REF] IT resources are typically complementary to an organization's business resources. They can be complementary to other assets, capabilities, organizational processes, firm attributes, information, knowledge, etc. controlled by the organization. IT resources can thus be complementary both to non-IT resources and to other IT resources.

Wiengarten et al. [START_REF] Wiengarten | Exploring the Important Role of Organizational Factors in IT Business Value: Taking a Contingency Perspective on the Resource-Based View[END_REF] propose that IT resources provide value to an organization / alliance: "(1) When IT resources are aligned, integrated or coupled with organizational processes such as knowledge processes, or management processes, synergies and higher-order capabilities can be created. (2) Moreover, these higher-order capabilities may result in long-term performance improvement. (3) To develop these longterm performance enhancement capabilities, a firm may need to redesign its processes in terms of its employed resources (i.e. human resources and facilities)." Park et al. [START_REF] Park | A Resource-based View of Strategic Alliances and Firm Value in the Electronic Marketplace[END_REF] classify the outcomes of resource properties as: (1) conserve resources, (2) share risks, (3) obtain information, (4) access complementary resources, (5) reduce product development costs, (6) improve technological capabilities and (7) enhance reliability.

TCE introduced by Coase was developed further and operationalized by Williamson [START_REF] Williamson | The Economic Institutions of Capitalism[END_REF]. He introduced asset specificity, uncertainty and transaction frequency as the determinants by which firms (=organizations) choose to make, buy or ally while they execute transactions. Geyskens et al. [START_REF] Geyskens | Make, Buy, or Ally: A Transaction Cost Theory Meta-Analysis[END_REF] define relational governance (alliance) as: "Governance modes characterized by the parties to a transaction jointly developing policies directed toward the achievement of certain goals." The voluntary interorganizational IT governance arrangement investigated here is relational in its nature.

Geyskens et al. [START_REF] Geyskens | Make, Buy, or Ally: A Transaction Cost Theory Meta-Analysis[END_REF] provide operationalized construct definitions and metrics for asset specificity, volume uncertainty, technological uncertainty and behavioral uncertainty. The metrics of asset specificity include organization nature, (healthcare / social welfare) product and services, customer (patient) complexity, need of training to use assets etc. Volume uncertainty metrics contain expected volume fluctuation and uncertainty of volume estimates, and the stability of industry (e.g. healthcare and social welfare) volumes, ability to predict trends, etc. Technology uncertainly is captured with such metrics as technology improvement and specification changes. The metrics of behavioral uncertainty include buyer expectations, (healthcare and social welfare IT services) seller competition, price quality in relation to seller competition and the importance on non-selling activities (e.g. support to IT services). Ability to codify transactions (for example, patient/customer data) and task complexity (for example, the design of enterprise architecture) are other metrics of asset specificity. Similarly, intention to conduct R&D (for example, the development of novel IT-enabled selfdiagnostic healthcare services to citizens) is another technology uncertainty metric.

Geyskens et al. [START_REF] Geyskens | Make, Buy, or Ally: A Transaction Cost Theory Meta-Analysis[END_REF] divided the performance impacts (benefits) of TCE into cost inclusive and into cost exclusive categories. Levels and changes of revenues and costs, abnormal returns on assets (e.g. IT investments) are cost inclusive metrics. Levels and changes of activities are cost exclusive. Other metrics used so far include speed of development (e.g., time needed to execute healthcare and social welfare IT projects), and level and changes in quality (for example, in the quality of patient / customer data) [START_REF] Gereffi | The governance of global value chains[END_REF]. Wang et al. [START_REF] Wang | Interorganizational Governance Value Creation: Coordinating for Information Visibility and Flexibility in Supply Chains[END_REF] investigated the impacts of information visibility (assets specificity), inter-organizational supply chain flexibility (behavioral uncertainty) and integration (technological uncertainty) on supply chain performance. They used three measures for outcomes; fit of work practices between organizations, fit of work outcomes between individuals and fit in routines between organizations [22, appendix].

The social network theory started to investigate the social embeddedness of institutions with the so-called structural macro-level studies [START_REF] Granovetter | Economic Action and Social Structure: The Problem of Embeddedness[END_REF]. Markets are seen to consist of social rather than economic structures [START_REF] Granovetter | Economic Action and Social Structure: The Problem of Embeddedness[END_REF], and to contain strong or weak ties between people and organizations [START_REF] Zaheer | It's the Connections: The Network Perspective in Interorganizational Research[END_REF]. Social network theory proposes that an organization perceives the world through a network with a structural rather than an individual lens. Such perception gives the organization a more complete, but not necessary only view to reality. A network, such as healthcare and social welfare IT cooperation, offers opportunities and constraints to participants, which then guide actions taken.

Embeddedness of organizations is the key construct of social network theory. Embeddedness impacts actions that organizations take in their responses to markets. The longer and the tighter the relationships between organizations, the more embedded they are [START_REF] Zaheer | It's the Connections: The Network Perspective in Interorganizational Research[END_REF]. Zaheer et al. [START_REF] Zaheer | It's the Connections: The Network Perspective in Interorganizational Research[END_REF] discovered that organizations in tight networks are likely to take different actions than traditional un-networked organizations. Social capital and structural holes are other key constructs. Social capital describes the value of connections between organizations. Structural hole means the lack of a straight connection between two organizations. Social network governance uses social mechanisms -cooperation mechanisms in traditional IT governance terminology -to guide actions and to solve network problems. Jones et al. [START_REF] Jones | A General Theory of Network Governance: Exchange Conditions and Social Mechanisms[END_REF] identified four social mechanisms; restrictions to access the network, collective sanctions, use of social memory and cultural processes. Restricted access and cultural processes are used to coordinate network operations. Collective sanctions and social memory are used to safeguard network operations. Brass et al. [START_REF] Brass | Taking Stock of Networks and Organizations: a Multilevel Perspective[END_REF] classified networks on the basis of following characteristics: strategic alliance and collaboration, flow of information, affect or friendship, good and services work flow, influence or advice, and overlapping group memberships. Organizations form and join networks motivated by their needs, such as responding to market challenges (e.g. reforms) and need to development services.

Antecedents to collaborate vary at personal, inter-unit (internal units of an organization) and inter-organizational (between organizations) levels. Actor similarities, personalities, proximity and organizational structure, and environmental factors are personal level antecedents. Interpersonal ties, functional ties and organizational processes, and control mechanisms are inter-unit antecedents. Personal and inter-unit antecedents are valid also on inter-organizational level. Motives (new resources, uncertainty reduction, bigger legitimacy, common goals), learning about an industry or about networking, relational trust, common norms and monitoring, equity between partners and context affecting all participating organizations constitute interorganizational antecedents to collaborate [START_REF] Brass | Taking Stock of Networks and Organizations: a Multilevel Perspective[END_REF]. Networks transmit information to equalize common knowledge and share innovations, mediate issues between organizations and individuals and share resources and power among network participants.

Case and Expert Survey

The researcher acted as a consultant during the formation of the investigated IT governance arrangement. Thus, reflective observation approach in a single case context is used. Guidelines for case studies [START_REF] Yin | Case Study Research, Design and Methods 4 th Edition[END_REF] and for the building of research constructs are followed. For research, I have access to the full range of the case material. Volumewise workshop materials represent the largest proportion of empirical data. Workshop materials range from RACI charts to discussion notes; from agendas to thick prereading documents; and from draft revisions of the Law on Arranging Social Welfare and Health Care Services to the drafts and final memorandums of the project. Empirical data includes also memos, emails, presentation slides, and answers to Q/A. The case covers the formation of voluntary inter-organizational IT governance for healthcare and social welfare IT in one of Finland's five Special Catchment Areas. The arrangement engages over 100 organizations; 68 cities, towns or municipalities, 5 healthcare districts, 9 hospitals including one university central hospital, 33 healthcare centers and 5 social welfare development districts. The idea was to use this case as the pilot for the other four areas and to provide input to law reform work. No IT governance arrangement had existed earlier between the organizations. The IT governance arrangement also consolidated the IT services of specialized medical care, basic health care and social welfare services for the first time.

The project group that accomplished the task during 9 months consisted of 17 persons. They included the chief medical officer of one healthcare district, three healthcare district CIOs, the CIO of a major city, two enterprise architects, three specialist from social welfare development centers and the National Institute for Health and Welfare, one IT expert from another Special Catchment Area, two senior advisors from the Ministry of Social Affairs and Health, two senior advisors from the Association of Local and Regional Authorities plus the researcher as a consultant. The proposal of the project was accepted in February 2014 and its implementation started immediately. In March 2014, the Government of Finland decided to give the responsibility for the arrangement of healthcare and social welfare services to five "Special Catchment Areas". In June 2014, all political parties agreed the same. The proposal accepted in February is in compliance with these national level decisions.

The definition of concrete IT cooperation benefits was one task accomplished by the project. Nine concrete benefits were defined. Need to improve patient / customer data interoperability and data quality was considered the most burning challenge in the current status. Four additional specific data related benefits were defined for this reason. The 13 statements are shown in appendix 1. Also the connections between each statement and the theoretical constructs reviewed in Section 2 are shown.

A web-enabled self-administered survey was conducted to offer leading healthcare and social welfare experts an opportunity to evaluate the defined benefits and other aspects of the proposed IT governance arrangement prior its acceptance. This study uses only that part of the available data that concentrates on IT governance benefits. In addition to the IT governance benefit statements, the survey included demographic, situational and behavioral control variables also shown in Appendix 1. The survey items of IT cooperation benefits and the behavioral control variables were formulated into statements. Respondents were asked to evaluate each statement on a 7-point Likert scale from totally disagree (=1) to totally agree (=7).

An invitation to participate to the survey was emailed to 260 healthcare and social welfare experts throughout the country. After one reminder 68 responses (26 % response rate) were received. Survey respondents had the following characteristics:

 Slightly over half (37) of the 68 responses were from the geographic area of the case.  Seven respondents participated to the formation of the inter-organizational IT governance arrangement. Statistical comparisons to other respondents were not made.  Slightly over half (53) of the respondents worked in healthcare districts, 37 % in cities, towns or municipalities, and 10 % in other organizations.  66 % were executives and managers and 34 % were experts.  43 % were healthcare or social welfare managers or executives and 12 % specialists.

CIOs and IT managers accounted for 23 % and IT specialists for 22 %.  Healthcare and social welfare executives and managers had worked in those positions on average for 15.9 years, experts for 12.7 years. Healthcare and social welfare CIOs and IT managers had worked in those positions on average for 7.2 years and IT experts for 8.8 years.

The expectation drawn from the theoretical background was that expert evaluations would be high. On the other hand, no expectations were made regarding which benefits would be evaluated most important. Due to the limited number of responses multivariate statistical methods, including structured equation models, could not be used. Statistical analysis on the differences in the means of survey items was done with the two-tailed Stu dent t-test. For statistical analyses responses to behavioral control variables were classified into agree (values 5-7) and non-agree (values 1-3) classes.

Results

The need for IT cooperation by pooling, sharing and exchanging IT resources with envisioned concrete benefits was decisive for the willingness to participate to the formation of the IT governance arrangement. The project started with an effort to rely solely on IT governance knowledge. That approach proved insufficient in terms of participants' and organizations' commitment. One of the CIOs coined the problem: "Although I understand the governance matrix with RACI roles that we crafted…, that has been totally useless in my organization. Doctors do not understand from the matrix the benefits of IT cooperation. They ask me, why should we use time to consider inter-organizational IT governance when there are so many burning IT issues in our own organization." Improved quality of patient / customer data was also regarded important. At the dissemination presentations of the drafted IT governance model one medical director stated: "Actually, I only want to know, when will I get reliable, consistent and holistic patient and medical data from all the data sources we have."

As expected the evaluations of IT governance benefits were very high on the scale from 1 (low value) to 7 (high value) as Table 1 shows. More specific results are:

1. Patient / customer information benefits were considered more important than generic IT governance benefits. 2. Making ends meet benefits were considered more important than the long-term improvements of reforms to healthcare and social welfare services. The background documents used in the project discuss the necessities to improve the national healthcare and social welfare systems. Those appear to remain abstract in comparison to concrete needs to improve services and related IT. Alternatively it is possible that the solving of concrete challenges is seen to preside reforms. 3. None of the demographic, situational or behavioral control variables were related to variations in the means of IT governance benefits in statistically significant way (t-test). Thus, in this survey, IT governance benefits were evaluated similarly independent of geographic location, profession, professional status, length of experience, attitudes toward IT or attitudes toward the use of IT within respondent's organization. Table 1 shows averages by professional orientation.

Discussion and Conclusions

This research shows that IT governance knowledge alone was insufficient for the formation of inter-organizational IT governance arrangement in the investigated case.

Results suggest that need to cooperate with concrete benefits is critical to the formation of inter-organizational IT governance. This is the answer to the first research question presented in section one. Improvements to patient / customer data were perceived more important than long-term improvements to healthcare and social welfare services. The solving of making ends meet issues were also evaluated more important than long-term improvements to healthcare and social welfare services. Additional studies are necessary to verify these results, as this research is a single case study. This research opens up news venues for IT governance and health information governacne research, for which RBV, TCE and social network theories offer rich and theoretically proven basis. The mentioned research traditions address three governance arrangements, single organization, markets and alliances / networks. So far IT and health information governance research has investigated mainly single organizations. IT governance arrangements could be compared in various contexts such as IT or data outsourcing including cloud services, supplier-customer networks, value chain orchestration or virtual organizations. Health information governance is by nature largely inter-organizational. Linking of inter-organizational governance research approaches to this context is another possible research direction.

The advice to practitioners is to pay serious attention to concrete level IT governance benefits when inter-organizational IT governance arrangements are designed. In national reforms of healthcare and social welfare sectors, concrete advancements in the quality of patient / customer data have a key role. It is especially important to make the long-term improvement objectives of reforms operational and concrete in order to entice experts to take necessary development efforts. This probably requires that long-term healthcare and social welfare reform objectives, such as the empowerment to active aging, be turned into measurable short-term milestones.

6 . 4 Generic

 64 IT Governance Benefits: Improved Healthcare and Social Welfare Services (Resulting from Reforms) --Inter-Organizational Well-Organized Cooperation in Healthcare and Social Welfare IT Is Needed in Order to … Generic IT Governance Benefits: Bnefits from Better Usage of Resources ( Making Ends Meet) -Inter-Organizational Well-Organized Cooperation in Healthcare and Social Welfare IT Is Needed in Order to … IT Governance Benefits from Improved Patient Data -The development of patient / customer information systems and data storages requires …

Table 1 .

 1 Results of the expert survey

	Survey Item	Mean	Median	Proportion of strongly agree	Mean, Biz experts	Mean, IT experts
	Increase the interoperability of patient/customer information systems and data storages	6.3	6.5	86.8%	6.3	6.3
	Ensure ability to participate to the national level development of healthcare and social welfare services	5.8	6.0	72.1%	5.8	5.7
	Ensure the availability of equal healthcare and social welfare services everywhere in the country	5.7	6.0	67.6%	5.8	5.5
	Avoid the development of overlapping and difficult to integrate IT services	6.4	7.0	86.8%	6.4	6.4
	Create enterprise architectures	6.1	6.0	79.4%	6.2	6.0
	(Co-)source IT-services cost-efficiently and effectively	6.0	6.0	75.0%	6.2	5.7
	Implement national level healthcare and social welfare IT services efficiently and effectively in the area	6.0	6.0	75.0%	6.2	5.9
	Use IT resources and assets efficiently and effectively	5.7	6.0	70.6%	5.7	5.8
	Ensure access to specialized capabilities and competencies everywhere in the area	5.8	6.0	69.1%	5.9	5.7
	Tighter cooperation on national level	6.4	7.0	89.7%	6.4	6.3
	Tighter cooperation on regional level (this Special Catchment Area)	6.3	6.5	85.3%	6.4	6.1
	The creation of jointly agreed data models and sticking to them	6.3	7.0	85.3%	6.4	6.3
	Tighter cooperation between healthcare and social welfare	6.3	7.0	79.4%	6.3

Appendix 1.

Operational definitions of IT governance benefits used also as survey items with their references to theoretical constructs reviewed as the theoretical basis of the research


Nasreen Azad
email: nasreen.azad@abo.fi

Matti Mäntymäki
email: matti.mantymaki@utu.finajmul.islam@utu.fi

S Samiul Islam

A K M Najmul Islam

S M Samiul Islam

TAM and e-learning Adoption: A Philosophical Scrutiny of TAM, Its Limitations, and Prescriptions for e-learning Adoption Research

Keywords: e-learning, IS continuance model, technology acceptance model, theory of reasoned action

des établissements d'enseignement et de recherche français ou étrangers, des laboratoires publics ou privés.

Introduction

The Technology Acceptance Model (TAM) [START_REF] Davis | Perceived usefulness, perceived ease of use, and user acceptance of information technology[END_REF] was originally developed from Ajzen & Fisbein's (1980) [START_REF] Ajzen | Understanding attitudes and predicting social behavior[END_REF] Theory of Reasoned Actions (TRA). TAM can be viewed as an adaptation of the TRA to the IS discipline. It has been regarded as one of the most influential theories in the IS discipline. It has been widely applied for explaining IT users' intention regarding IT use [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF]. TAM researchers have developed a number of extensions to TAM. In addition, they have also contributed in developing the Unified Theory of Acceptance and Use of Technology (UTAUT) [START_REF] Venkatesh | User acceptance of information technology: toward a unified view[END_REF] and IS continuance model [START_REF] Bhattacherjee | Understanding information systems continuance: An expectation-confirmation model[END_REF][START_REF] Mäntymäki | Social virtual world continuance among teens: Uncovering the moderating role of perceived aggregate network exposure[END_REF] based on the TAM. TAM has been validated across time, population, and contexts [START_REF] Venkatesh | Dead or alive? The development, trajectory and future of technology adoption research[END_REF]. It is a wellestablished theory in IS research as well as used in other domain [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF]. [START_REF] Venkatesh | Dead or alive? The development, trajectory and future of technology adoption research[END_REF] [START_REF] Venkatesh | Dead or alive? The development, trajectory and future of technology adoption research[END_REF] argued that TAM has become nearly a law-like model and it often serves as a basis for studies in other areas. TAM and its constructs have been used in areas outside the technology adoption such as information adoption [START_REF] Sussman | Information influence in organizations: An integrated approach to knowledge adoption[END_REF], marketing [START_REF] Dabholkar | An attitudinal model of technology-based selfservice: Moderating effects of consumer traits and situational factors[END_REF],

and advertising [START_REF] Rodgers | Post-adoption attitudes to advertising on the internet[END_REF]. In addition, TAM has been used as a basis for comparing SEM techniques-PLS vs. LISRELL [START_REF] Chin | On the use, usefulness and ease of use of structural equation modeling in MIS research[END_REF].

TAM and its variants have also been used extensively in e-learning adoption research. For example, [START_REF] Sumak | A meta-analysis of e-learning technology acceptance: The role of user types and e-learning technology types[END_REF] [START_REF] Sumak | A meta-analysis of e-learning technology acceptance: The role of user types and e-learning technology types[END_REF] conducted a meta-analysis with the articles of e-learning adoption and found that 86% studies used TAM, 4% studies used UTAUT, 2% studies used Theory of Planned Behavior (TPB) [START_REF] Ajzen | The theory of planned behavior[END_REF], and 6% studies used other theoretical frameworks to explain users' e-learning systems adoption.

Despite its widespread use, TAM researchers have not carefully scrutinized the philosophical and epistemological foundations of the model [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF]. In addition, the researchers have often ignored addressing the limitations of TAM in their adaptation of TAM to their research context. As such it has created two confusions among the scientists in the recent years. The first confusion is related to what extent TAM meets the criteria for scientific theories established for causal, positivistic explanations. The second confusion is related to how the researchers may address the TAM limitations in their research. [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF] [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF] strongly argued that TAM might not be falsifiable. He continued to argue that TAM research is not progressive as the TAM researchers do not question the fundamental foundation of TAM but provide alternative hypotheses when they face anomalies. We believe these arguments are valid due to the fact that very few previous studies have addressed these issues [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF][START_REF] Silva | Post-positivist review of technology acceptance model[END_REF]. This research gap motivates this paper. We address these issues in this paper by taking e-learning adoption research as an example. Consequently, we address the following two important TAM related issues in this paper.

 First we present the philosophical holes of TAM research and discuss our reflections with these holes. We discuss possible prescriptions to these philosophical holes for e-learning adoption researchers.  Second, we present the limitations of TAM research and discuss possible prescriptions that could be applied by e-learning adoption researchers to address those limitations.

Addressing philosophical holes

There are two major philosophical critiques regarding TAM and its variants in the prior literature [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF]. These critiques are identified based on the perspective of two prominent post-positivist philosophers of science: Karl Popper and Irme Lakatos. The first critique asks: Is TAM falsifiable? The second critique asks: Is TAM research progressive? In the next we discuss these questions and present our reflections in answering these questions based on the prior literature.

Is TAM falsifiable?

In a particular model, all factors are represented at the same level of aggregationwhereas the actual world is a complex interweaving of different structures at many levels. Such complex world cannot be fully captured with a theory like TAM. Indeed TAM has been confirmed thousand times in the prior IS literature. [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] in this regard states that there are no reasons to believe that a theory is scientific only because data-no matter how much of it there is-confirm it. He further states that the reason we find regularities in nature because of a mental habit that makes us jump to conclusions. He advises the scientists to keep their guard up and be suspicious of continuous confirmations. [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] suggested the scientists to design experiments that aim to falsify the theory to the maximum effects. If they are successful in falsifying all or parts of their theories, they should go back to the drawing board and reformulate a new one. The alternative to this approach is to set up a theory and look for evidences for confirming the theory. According to [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF] [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF], many studies utilizing the TAM targeted confirming the theory instead of falsifying it. It can be hazardous because the world is sufficiently complex and some confirming evidences can be found, no matter how unlikely the theory may be. Following [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF], it can be argued that researchers also need to keep their eyes open and find types of computer adoption behavior that cannot be explained by TAM. However, as discussed in the following it is very difficult to find a computer adoption that cannot be explained by TAM in prior research.

Can a theory account for all type of human behavior?

As discussed before TAM was developed from the TRA. According to [START_REF] Ajzen | Understanding attitudes and predicting social behavior[END_REF] [START_REF] Ajzen | Understanding attitudes and predicting social behavior[END_REF], TRA is very general, and designed for studying virtually any human behavior. If we accept that TRA can account for all types of human behavior, then it is not a scientific theory. [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] calls such theory as pseudoscience. The difference between a scientific theory and pseudo-science is that a scientific theory is falsifiable-meaning that the theory cannot explain all types of human behavior. [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] notes the following. "Every good scientific theory is a prohibition: it forbids certain things to happen. The more a theory forbids, the better it is…."

To evaluate whether TRA is scientific theory, a review of the previous psychological literature is necessary. [START_REF] Ogden | Some problems with social cognition models: A pragmatic and conceptual analysis[END_REF] [START_REF] Ogden | Some problems with social cognition models: A pragmatic and conceptual analysis[END_REF] has performed such review among psychological literature. His review revealed that indeed TRA has been found weak in predicting certain behavior. However, he discovered that in such situation instead of rejecting the theory the researchers provided several explanations such as the model should be accepted but the variables were not operationalized properly, the model should be accepted but the sample characteristics may explain the results, etc.

We observed similar things in e-learning adoption research as well when the researchers employed TAM and its variants. For example, [START_REF] Limayem | Understanding information systems continuance: The case of Internet-based learning technologies[END_REF] [START_REF] Straub | Measuring system usage implications for IS theory testing[END_REF] used the IS continuance model (a TAM derived model) and habit to investigate e-learning system users' continued use behavior. They found that their combined model explained only 23% variance of continued use. Instead of rejecting their theory, they described the following.

"We therefore believe that other significant factors (such as socio-cultural and political impacts) may affect students' decisions to continue using the IBLT. In Hong Kong, as in other Chinese communities, social factors have significant impact on usage behavior" Based the above findings, we argue that the TRA and TAM are falsifiable although the way these have been used in many studies might make an illusion that no data can be collected to falsify the theory. In other word we may argue that this philosophical hole is less related to the TRA or TAM framework and more related to how it has been applied in different studies. The illusion becomes even stronger when we discuss the analytic nature of the relationships among beliefs, attitude, intentions and behavior in the next.

Logical-connection argument

TAM and its variants follow the tradition of beliefs-attitude-intention-behavior relation. According to Rosenberg (1995) [START_REF] Rosenberg | Philosophy of social science[END_REF], actions are composed of desires and beliefs and that both provide actions with their meaning. He illustrates this with an example of a person named Smith carrying an umbrella. The action of Smith carrying an umbrella-as a meaningful action-can be explained by Smith's belief that it is going to rain and desire of not getting wet. Thus, the intention of carrying an umbrella can be stated in terms of Smith's beliefs and desires. It implies that there cannot be actions without intentions. [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF] [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF] referring to Rosenberg's example stated that Smith might carry an umbrella for different reasons than his belief in imminent rain and his desire to not get wet. He can carry an umbrella because it is part of his attire or because he wants to use it as a weapon. Following this, it is clear that carrying an umbrella will always linked to intentions, and identifying them will not predict the action-instead, they render an action its meaning. Hence, beliefs, intentions, and self-reported behavior measured in a cross-sectional survey are linked by definition. This is called the logical connection argument [4,[START_REF] Melden | Free Action[END_REF].

According to the logical connection argument, intentions cannot predict behavior as these are not linked contingently but analytically. The difference between these two types of connections is that a contingent entity depends on natural process to occur, while an analytic one does not depend on natural process [START_REF]The Oxford companion to philosophy[END_REF]. An analytic truth is true by definition [START_REF] Ogden | Some problems with social cognition models: A pragmatic and conceptual analysis[END_REF]. A chemical reaction can be regarded as contingent entity as it requires the conjunction of different natural factors. On the other hand stating that a rectangle has four sides is an analytical truth. Empirical science based on experiments and observation can deal only with contingent entities.

Ogden (2003) [START_REF] Ogden | Some problems with social cognition models: A pragmatic and conceptual analysis[END_REF] observed that the relationships in TRA are often analytical in nature. His review revealed that researchers often measure different constructs with similar statements. For example, he observes that researchers attempted to correlate perceived behavioral control with behavioral intentions, while both were measured using similar questions. Hence, finding a high correlation between these two constructs is not surprising. This makes the theory analytical. A good theory should avoid analytical truth, otherwise it will be tautological [START_REF] Ogden | Some problems with social cognition models: A pragmatic and conceptual analysis[END_REF]. In such a case belief, attitude, and intention cannot be linked causally. [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF] [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF] states the problem of this in the following way.

"The problem is that intentions, stated in terms of desires and beliefs, constitute only a re-description of the action they are thought to be predicting."

It implies that when beliefs, attitude, and intentions are linked analytically, the causal relationships between these cannot be tested empirically and cannot be subjected to falsification. Hence, in such situation the causal links of TAM cannot be regarded as scientific according to Popper's [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] classification.

According to our critical evaluation, TAM's relationships have not been analytical in prior literature. For example, [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF] [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF] reported examples of many studies where TAM relationships were inconsistent. We argue that if the relationships are truly analytical, then such inconsistency should not be visible. But we accept that adoption researchers are required to be more careful in their research design, especially while operationalizing the constructs of their models to avoid analytical nature. For example, the original TAM was developed to predict users' organizational IS use and cautious should be taken when operationalizing the constructs to the elearning context. We present two suggestions for the e-learning adoption researchers in relation to construct operationalization.

First, researchers should avoid similar statements in measuring different constructs. In addition, they should present the questions in a random fashion. Second, researchers should consider using objective measures of both beliefs and behavior to test the theories like TAM. Neuroscience approaches [START_REF] Dimoka | NeuroIS: Hype or Hope?[END_REF] can be used to collect objective data. Both suggestions can avoid analytical nature of the constructs to some extent.

2.2

Is TAM research progressive?

The original TAM had only two beliefs: perceived usefulness and perceived ease of use to predict IS use. When TAM is applied to explain adoption of a mobile service, it can be thought that the users adopt mobile services due to its usefulness and ease of use. But let's think about the adoption of an Enterprise Resource Planning (ERP) system in an organization. Although the system might be difficult to use and disruptive to employees' work, they use it. The TAM researchers argued that such adoption could be explained by subjective norm-that is the influence of authorities. The original TAM model did not include subjective norm, but latter whenever researchers found that TAM may not be able to explain a particular adoption, they add more variables to it. This approach can be explained by the concept of research programme proposed by [START_REF] Lakatos | Falsification and the methodology of scientific research programmes[END_REF] [START_REF] Lakatos | Falsification and the methodology of scientific research programmes[END_REF]. A research programme is an organic unity, which contains both rigid and flexible components-essential, structural components as well as nonessential components. The essential structural components are the hard-core and positive heuristic of the research programme. The hard core consists of a set of theoretical assumptions to which a community of scientists is committed. The committed scientists will defend the credibility of the hard core against any threats posed by others. Yet the research programme does contain or generate components, which could be given up or replaced without abandoning the hard core. Non-essential, replaceable components of the research programme are called protective belt of the research programme. The protective belt can be viewed as the auxiliary hypotheses in defense of the hard core.

For TAM derived research programme the hard core is the basic TAM model with beliefs-attitude-intention relation. The protective belt is the additions of different researchers committed to the TAM derived research. New constructs have been added and auxiliary hypotheses have been offered to explain unexpected results without questioning the hard core. For example, several TAM studies [START_REF] Gefen | The relative importance of perceived ease of use in IS adoption: A study of e-commerce adoption[END_REF][START_REF] Ma | The technology acceptance model: A meta-analysis of empirical findings[END_REF] have noticed that perceived ease of use has not been consistently linked to adoption. These studies explained the anomalies by suggesting that the role of perceived ease of use depends on the task, which is an auxiliary hypothesis according to [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF] [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF]. [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF] [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF] in their review found that about 24% prior studies did not find a significant relationship between perceived ease of use and behavioral intention. However, many of these studies did not challenge the TAM, instead provided auxiliary explanations. Silva (2003) [START_REF] Silva | Post-positivist review of technology acceptance model[END_REF] noted the following in relation to this. "In the light of Lakatos methodology of scientific research programmes, I argue that the complementary constructs and additional theoretical explanations were added by TAM researchers to protect the hard core. The additions can be considered auxiliary hypotheses that have been incorporated in the protective belt. In this sense, it is also worth mentioning that in my reading of TAM literature, I could not find papers that challenged the hard core."

Following [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF] [START_REF] Popper | Conjectures and refutations: The growth of scientific knowledge[END_REF], such auxiliary hypotheses can be regarded as ad hoc and eventually a bad thing while following [START_REF] Lakatos | Falsification and the methodology of scientific research programmes[END_REF] [START_REF] Lakatos | Falsification and the methodology of scientific research programmes[END_REF], it can be argued that adjusting and developing protective belt is not necessarily a bad thing for a research programme. We argue that instead of asking whether a theory is falsifiable, the more important question is to ask whether the research programme is progressive or degenerative. A research programme is progressive if it is able to discover novel facts, develops new experimental techniques, and performs precise predictions. A research programme is degenerative if it is not able to produce novel facts by changing the protective belt. In such cases, the added hypotheses of the protective belt can be considered as ad hoc and not acceptable according to [START_REF] Lakatos | Falsification and the methodology of scientific research programmes[END_REF] [START_REF] Lakatos | The methodology of scientific research programmes: Philosophical papers[END_REF].

According to our critical evaluation, the TAM derived research program has been progressive. For example, TAM researchers have added several new constructs to the original TAM such as age, gender, prior experience, management support, and voluntariness to explore the boundary conditions for TAM [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF][START_REF] Silva | Post-positivist review of technology acceptance model[END_REF]. Researchers have discovered that the psychological motivation behind initial use and subsequent use is different and thus have put more importance on post-adoption behavior than adoption behavior [START_REF] Bhattacherjee | Understanding information systems continuance: An expectation-confirmation model[END_REF][START_REF] Jasperson | A comprehensive conceptualization of post-adoptive behaviors associated with information technology enabled work systems[END_REF][START_REF] Karahanna | Information technology adoption across time[END_REF]. In this regard, the IS continuance model has been developed from the Expectation-Confirmation Theory (ECT) [START_REF] Oliver | A cognitive model of the antecedents and consequences of satisfaction decisions[END_REF] to study post-adoption behavior. In addition, leading IS researchers also pointed that there are still many unexplored research areas regarding IS adoption and use, such as testing the effect of IT artifact's design characteristics on perceived ease of use, perceived usefulness and use [START_REF] Benbasat | Quo vadis, TAM?[END_REF][START_REF] Benbasat | HCI research: Future challenges and directions[END_REF], investigating actual usage and its relation with objective performance measures [START_REF] Benbasat | Quo vadis, TAM?[END_REF][START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF] and exploring organizational and societal adoption and use of IS [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF] to name only a few.

TAM limitations and possible prescriptions

There are a number of other limitations of TAM derived studies as described by leading IS researchers [START_REF] Bagozzi | The legacy of the technology acceptance model and a proposal for a paradigm shift[END_REF][START_REF] Benbasat | Quo vadis, TAM?[END_REF][START_REF] Goodhue | Comment on Benbasat and Barki's "Quo vadis TAM" article[END_REF]. TAM researchers must need to address these limitations for progressing TAM research. In the following we discuss these limitations and provide possible prescriptions in order to overcome these limitations in an e-learning adoption study.

TAM lacks design and implementation constructs

Benbasat & Barki (2007) [START_REF] Benbasat | Quo vadis, TAM?[END_REF] argued that TAM lacks investigating and understanding both design-and implementation-based antecedents of IT adoption and acceptance. The beliefs: perceived usefulness and perceived ease of use are regarded as black boxes with little research effort into investigating what makes a system useful or easy to use. As such TAM studies often lack actionable guidance for practitioners. Indeed, TAM 2 and TAM 3 investigated the possible determinants of perceived usefulness and perceived ease of use. However, it was assumed that these two beliefs would always mediate the effects of other beliefs on behavioral intention or actual behavior. Following these assumption researchers rarely the direct effect of other variables on behavioral intention or actual behavior. Benbasat (2010) [START_REF] Benbasat | HCI research: Future challenges and directions[END_REF] argued that to provide more practical implications for designers and managers, researchers must need to investigate the potential effects of design and implementation characteristics related variables of an IT artifact on the construct of interest such as attitude, behavioral intention and actual behavior.

In fact prior research has found that there are variables other than perceived ease of use and perceived usefulness, which may have significant impact on behavioral intention [START_REF] Islam | The determinants of the post-adoption satisfaction of educators with an e-learning system[END_REF]. Utilizing only two beliefs have made TAM parsimonious. However, parsimony is an Achilles' heel for TAM. In practice, although TAM predicts behavioral intention using only two beliefs, but there could be more beliefs in a particular context.

The problem related to lack of variables is even more severe for the context of elearning. TAM does not contain any specific variable related to e-learning. When researchers use TAM model to investigate e-learning system users' adoption behavior they definitely need to use variables related to e-learning. However, very few prior studies have done so [START_REF] Islam | The role of perceived system quality as the educators' motivation to continue e-learning system use[END_REF][START_REF] Islam | Continuance of professional social networking sites: A decomposed expectation-confirmation approach[END_REF][START_REF] Islam | Investigating e-learning system usage outcomes in the university context[END_REF]. Most of the studies used TAM in such a format that does not contain any e-learning context specific variables.

We believe that e-learning adoption researchers should consider potential design and implementation variables related to e-learning for employing TAM and its variants in their research. The researchers should keep in mind that e-learning systems are distinct from general IS at least to some extent. For example, [START_REF] Shee | Multi-criteria evaluation of the web-based e-learning system: A methodology based on learner satisfaction and its applications[END_REF] [START_REF] Shee | Multi-criteria evaluation of the web-based e-learning system: A methodology based on learner satisfaction and its applications[END_REF] argued that an e-learning system is a highly user-oriented system that focuses on the content and how it is presented. An e-learning system offers educators and learners "possibilities", rather than "ready to use" resources. In this regard, while general IS elicits performance from individual users, e-learning is based on the cooperation between educators and students. There are many factors that may cause users' dissatisfaction and rejection of e-learning system use such as lack of cues, lack of face-to-face contact, non-verbal communication, isolation, problems with hardware/software, and network connectivity [START_REF] Buckley | Evaluation of classroom-based, web-enhanced, and web-based distance learning nutrition courses for undergraduate nursing[END_REF]. Additionally, educators' roles and teaching models also affect students' learning outcome [START_REF] Coppola | Becoming a virtual professor: Pedagogical roles and asynchronous learning networks[END_REF].

Following these, we believe that e-learning adoption researchers using TAM should investigate the effect of such factors on perceived usefulness, perceived ease of use, attitude, behavioral intention, and actual behavior. Such research will bring valuable implications for both practitioners and researchers.

3.2

Limited understanding of behavior TAM and its variant theories uncritically accept the association between intention and actual behavior. Based on this, majority of prior research has investigated behavioral intention as the final dependent variable. The idea is that if behavioral intention is high, it will automatically improve use behavior. It is assumed that use behavior is driven by conscious intentions that result from a rational decision-making process involving beliefs, expectations, reflection on past experience, etc. and emotion such as satisfaction, frustrations, etc.

However, behavioral intention may not predict behavior. For example, De Guinea & Markus (2009) [START_REF] De Guinea | Why break the habit of a lifetime? Rethinking the role of intention, habit, and emotion in continuing information technology use[END_REF] argued that emotion may also drive IS use directly. It is because: a) that the connection between emotion and behavior can occur without a person being consciously aware of the connection, and b) that the effect of emotion may not create a particular behavioral intention, but rather to derail a previously formed behavioral intention about IS use. It suggests that sudden intense emotions, such as frustration associated with a system crash or the pleasure aroused while using an IS, may be more important in its influence on behavior than intention which is driven by stable attitudes and expectations. In addition, it is often argued that frequently performed behavior becomes automatic or habitual, and it ultimately reduces the impact of intention on use [START_REF] Kim | Two competing perspectives on automatic use: A theoretical and empirical comparison[END_REF][START_REF] Straub | Measuring system usage implications for IS theory testing[END_REF].

The above argument raises one important issue -that is intention may not predict behavior as emotions and beliefs might have stronger influence on behavior. Hence, it becomes perhaps more important to investigate usage behavior rather than intention. However, very few prior studies have investigated usage behavior and its relation with intention [START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF][START_REF] Freeze | IS success model in elearning context based on students' perceptions[END_REF][START_REF] Islam | Investigating e-learning system usage outcomes in the university context[END_REF].

Indeed some studies measured behavior. However, most of these studies measured self-reported usage behavior instead of actual usage behavior. Self-reported usage is assumed to be a reasonable predictor of actual system usage in adoption studies [START_REF] Agarwal | Are individual differences germane to the acceptance of new information technologies[END_REF][START_REF] Jackson | Toward an understanding of the behavioral intention to use an information system[END_REF]. However, several studies have cautioned in the use of self-reported usage instead of actual usage [START_REF] Lederer | The technology acceptance model and the world wide web[END_REF][START_REF] Lee | The technology acceptance model: Past, present, and future[END_REF][START_REF] Rawstorne | Issues in predicting and explaining usage behaviors with the technology acceptance model and the theory of planned behavior: When Usage is Mandatory[END_REF][START_REF] Straub | Measuring system usage implications for IS theory testing[END_REF][START_REF] Szajna | Empirical evaluation of the revised technology acceptance model[END_REF]. For example, [START_REF] Straub | Measuring system usage implications for IS theory testing[END_REF] [START_REF] Straub | Measuring system usage implications for IS theory testing[END_REF] found that research based on self-reported usage shows distinctly different results from that of actual usage. In addition, self-reported usage was also found to be the major reason for common method bias [START_REF] Igbaria | Personal computing acceptance factors in small firms: A structural equation model[END_REF].

In addition, the self-reported usage itself has largely been viewed as a 'black box', and hence understanding the situation specific usage behaviors is limited [START_REF] Islam | The role of perceived system quality as the educators' motivation to continue e-learning system use[END_REF][START_REF] Teo | Understanding the intention to use technology by preservice teachers: An empirical test of competing theoretical models[END_REF]. For example, e-learning services can be used in many situations such as at school, home, and even while moving. Thus, we suggest researchers open the usage 'black box' into situation specific actual behaviors in their future research.

3.3

Missing adoption/usage outcomes TAM assumes that more use is better. In other word more utilization of a technology increases performance. Following this prior studies have put highest importance in explaining users' behavior with the target system. These studies investigated possible antecedents and determinants of system use behavior. As such these studies often ignored the outcome of system use. Many studies argued that more use might not necessarily improve individuals' or organizational performance. For example Islam (2013) [START_REF] Islam | Investigating e-learning system usage outcomes in the university context[END_REF] found that heavy usage of an e-learning system might not necessarily help students in their study to achieve better academic performance. However, only a few prior e-learning adoption studies verified the relation between use and learning outcomes. Indeed, few studies have gone beyond use to explore the factors associated with learning. [START_REF] Mcgill | A task-technology fit view of learning management system impact[END_REF] [START_REF] Mcgill | A task-technology fit view of learning management system impact[END_REF] found that e-learning system utilization influences perceived impact on learning. [START_REF] Lee | The relationship of e-Learner's self-regulatory efficacy and perception of e-Learning environment quality[END_REF] [START_REF] Lee | The relationship of e-Learner's self-regulatory efficacy and perception of e-Learning environment quality[END_REF] revealed that a number of e-learning environment quality related variables affect satisfaction with elearning. In turn, satisfaction was found to influence academic achievement. [START_REF] Liaw | Investigating students' perceived satisfaction, behavioral intention, and effectiveness of e-learning: A case study of the Blackboard system[END_REF] [START_REF] Liaw | Investigating students' perceived satisfaction, behavioral intention, and effectiveness of e-learning: A case study of the Blackboard system[END_REF] found high correlation between intention to use e-learning and e-learning effectiveness. These studies provide some empirical support about the possible relationships between e-learning system use and e-learning outcomes. However, these studies have been conducted with a variety of outcome variables that use different explanatory variables and this has led to models that offer only weak theoretical support. Thus, these studies fall short in explaining the relationship between the antecedents of adoption and use of e-learning systems and their use outcomes, and the relationship between e-learning system use and use outcomes.

We suggest researchers develop complete nomological network taking into account e-learning system usage antecedents, usage, and performance outcomes in the future. Performance outcome variables could be related to both teaching and learning. Examples of teaching performance related variables are planning, managing, instructing, assessing, and collaborating. Example of learning performance related variables are perceived learning, and grade.

Conclusion

This paper conducted a scrutiny of TAM and its variants in relation to e-learning adoption research. We presented two types of critique of TAM: philosophical holes and limitations regarding missing variables. Based on our critical evaluation, TAM has served the IS researchers as a theoretical model that speaks to the unique nature of information systems. From philosophical perspective, first we asked the question: Is TAM falsifiable? We observed from prior literature that TAM is falsifiable, although the way the results have been reported in the prior literature might make an illusion that TAM is not falsifiable. Second, we asked the question: Is TAM research progressive? Again, from the prior literature, we observed that TAM research is progressive in a variety of contexts including e-learning. Overall, we found that philosophically there is no problem in applying TAM and its variants in studying elearning adoption. However, we think that TAM contains deceptively straight-forward constructs and measures. Thus, we believe that TAM should be revisited to ensure design, usage, and outcome constructs have been measured in the best possible way by e-learning adoption researchers. The researchers should develop sophisticated conceptualizations of e-learning outcomes as well as what system usage means in a specific research contexts.