Andreea Molnar

Vishanth Weerakkody

Ramzi El-Haddadeh

Zahir. Habin Lee

Zahir Irani
email: irani@brunel.ac.uk

{andreea Molnar

A Framework of Reference for Evaluating User Experience when using High Definition Video to Video to Facilitate Public Services

Keywords: public services, video to video, user experience, evaluation framework

This paper proposes the use of high definition video to video as a means to facilitate the adoption of public services. High definition video can be delivered over the public Internet infrastructure by using a Right of Way platform that guarantees no interference from unwanted traffic. In this paper, we discuss the benefits of using high definition video to video communication in the public sector to facilitate services such as health, education and city experience/administration.

 and inclusion of the perception on information privacy.

Introduction

Despite the fact that it was introduced over a decade ago as a mainstream mechanism for the delivery of public services, electronic government has failed to fulfil initial expectations [START_REF] Chadwick | Web 2.0: New Challenges for the Study of E-Democracy in an Era of Informational Exuberance[END_REF][START_REF] Ferro | Making Sense of Gov 2.0 Strategies: No Citizens, No Party[END_REF]. To alleviate this problem, several projects have used other channels of service delivery such as mobile applications [START_REF] Abdelghaffar | The Adoption of Mobile Government Services in Developing Countries: The Case of Egypt[END_REF] or digital TV [START_REF] Da Silva | The Importance of digital TV for countries in development: A case study of Brazil[END_REF]. Although successful, these initiatives are still in pilot stages and their impact has yet to be proven on a broad scale. Furthermore, the problems encountered during the adoption and diffusion of public services are not uniform. Simple customer facing services such as payments for services, fines or renewals of applications through the use of e-government have been successfully adopted, while more complex services are struggling with being accepted. Indeed, the research literature suggests that average citizens often prefer to have face-to-face contact when dealing with complex public services. This is particularly true for complex services such as health, education, and social or domestic services such as social security, housing, or employment [START_REF] Andreassen | European citizens' use of E-health services: a study of seven countries[END_REF][START_REF] Santana | Online communication between doctors and patients in Europe: status and perspectives[END_REF]. Among the problems that online services face is that they are distant and impersonal [START_REF] Pavlou | Consumer acceptance of electronic commerce: Integrating trust and risk with the technology acceptance model[END_REF]. Furthermore, there is no assistance offered to the citizens when they have problems using them [START_REF] Ahmad | Factors Influencing the Adoption of e-Government Services in Pakistan[END_REF][START_REF] Venkatesh | Designing e-Government Services: Key Service Attributes and Citizens' Preference Structures[END_REF].

In this article, we argue that enhancing government services with high definition (HD) video to video (V2V) has the potential to offer citizens better and more personalised services, similar to those offered by face-to-face, but maintaining the advantages of electronic services, i.e. citizens being able to access them regardless of their location and delivery channel. V2V will be used to facilitate service delivery (such as teaching from a remote location, connecting a patient with a specialist), but also in assisting citizens with their queries, or with the usage of an online service. The potential benefits of facilitating public services through V2V range from an easier usage to saving someone's life by providing the relevant stakeholders with adequate information when it is needed. To be able to improve the delivery of HD V2V on public Internet infrastructure, a new technology has to be introduced to alleviate some of the shortcomings that current video communication faces. However, due to the novelty of such technology, an established method to evaluate it does not exist. In this paper, we draw from existing theories to evaluate technology adoption and diffusion in order to propose a framework of reference to evaluate the user experience for V2V facilitated services.

The rest of this paper is organised as follows. First, we briefly present how HD V2V can be used on public infrastructure and the potential of using high definition video on the Internet for providing public services and the associated benefits that they can offer society. Second, the existing literature on technology adoption and diffusion is presented. We draw conclusions from this literature in order to propose a framework of reference for evaluating user experience. The next section discusses the conceptual development in relation to the proposed V2V framework. Finally, we conclude by outlining future directions for the use of V2V services in the public sector.

High Definitions Video to Video and its Applications on Public Infrastructure

Although V2V communication has been previously used in public infrastructure by using applications such as Skype, FaceTime etc., it is often limited by technological constraints that affect delivery and have as consequences low image definition, delays in delivery etc. that put strain on user experience. In this article, we propose a LiveCity environment, where citizens communicate with each other and their governments anytime, anywhere using HD V2V on public infrastructure. HD V2V delivery will be implemented by using Right of Way (RoW) to guarantee a lack of interference from non-desired traffic, hence alleviating some of the problems imposed by current video delivery over public infrastructure. The LiveCity environment will be community driven and aims at improving core public services such as education, health, and city experience, empowering the citizens of a city to interact with each other in a more productive, efficient and socially useful way by using HD V2V. Several public services could benefit from being enhanced with HD V2V. Some such services are Health, City Experience/Administration, and Education. For example, in health, a V2V service will be used for communicating live video images from the scene of a fatal accident to the emergency room of a hospital where an expert consultant can guide (real time) the paramedics on the ground on the best course of life saving treatment. Likewise, HD V2V can be used in tele-medicine where a doctor based in his/her surgery room can be guiding a patient at home on self-treatment (such as using eye drops to treat glaucoma). V2V will also be used to improve city administration where a municipality worker can assist a citizen with their service needs by guiding the citizen over the video link. Similarly, V2V can be used in education scenarios where teachers can assist pupils to complete their homework using a video link; or groups of students can have interactive debates (between schools) using a high definition video link. Furthermore, HD video will be used to promote the cultural heritage and art in a museum environment where people can view and interact with museum artefacts while at the same time interacting with museum workers regardless of their location.

Framework of Reference for Evaluating the User Experience in LiveCity

Due to the innovative nature of V2V usage in the context of the LiveCity environment, the evaluation is considered complex due to the difficulty of quantifying the benefits and inefficiencies. There does not exist an established way of evaluation yet. Therefore, we draw from existing theories on evaluating technology adoption and diffusion in order to propose an evaluation framework for LiveCity. Drawing on the dominant theories applied in Information and Communication Technology (ICT), a proposal for an integrated model of evaluation of V2V services is developed, based on the Unified Theory of Acceptance and Use of Technology 2 [START_REF] Venkatesh | Consumer acceptance and use of information technology: extending the unified theory of acceptance and use of technology[END_REF], the Information Systems success model [START_REF] Delone | Information systems success: The quest for the dependent variable[END_REF] and inclusion of the perception on information privacy. The information privacy concept is introduced due to the fact that in the event of wide adoption of V2V on the Internet, potential users may be exposed to information security and privacy concerns. State of the art key performance indicators for LiveCity are developed from a behavioural perspective. Hence, the related performance indexes refer to the assessment of LiveCity services from an end-users' viewpoint, and specifically with regards to the acceptance of using the V2V service and satisfaction from the service. As a result, we draw from the state of the art for technology adoption and associated behavioural evaluation.

Several researchers have proposed indicators for evaluating user satisfaction with innovative and/or new technology based services. [START_REF] Johnston | The determinants of service quality: satisfiers and dissatisfies[END_REF] compiled 18 determinants of service quality that have been used for assessing electronic services' (eservices) quality including availability, reliability, friendliness, functionality, access, aesthetics, etc. [START_REF] Parasuraman | SERVQUAL: A multiple-item scale for measuring customer perceptions of service quality[END_REF] have developed a widely accepted model namely SERVQUAL for measuring service quality that includes five dimensions: tangibles, reliability, responsiveness, assurance, and empathy. Information system researchers have adopted and modified the SERVQUAL model for e-service quality, including dimensions of website design, reliability, fulfilment, security, responsiveness, personalization, information (accuracy, comprehensibility, etc.) and empathy [START_REF] Li | A proposed scale for measuring e-service quality[END_REF]. Similarly, [START_REF] Zeithaml | A conceptual framework for understanding e-service quality: implications for future research and managerial practice[END_REF] adopts the SERVQUAL model for e-service quality evaluation and proposes 11 dimensions: access, ease of navigation, efficiency, flexibility, reliability, personalization, security/privacy, responsiveness, assurance/trust, site aesthetics, and price knowledge. Moreover, several information system researchers have applied technology acceptance theories in order to evaluate e-services from a user's perspective. During the past three decades there have been numerous studies regarding ICT acceptance and numerous information system (IS) acceptance studies have focused on the reasons why potential users accept or do not accept technology. Many research models have been developed and empirically validated, mainly including: The theory of Reasoned Action (TRA) [START_REF] Fishbein | Belief, Attitude, Intention, and Behavour: An Introduction to Theory and Research[END_REF], Social Cognitive Theory (SCT) [START_REF] Bandura | The Explanatory and Predictive Scope of Self-Efficacy Theory[END_REF], Technology Acceptance Model (TAM) [START_REF] Davis | Perceived Usefulness, Perceived Ease of Use, and User Acceptance of Information Technology[END_REF] and extended TAM 2 [START_REF] Venkatesh | A Theorieical Extension of the Technology Acceptance Model: Four Longitudinal Field Studies[END_REF], TAM 3 [START_REF] Venkatesh | Technology Acceptance Model 3 and a Research Agenda on Interventions[END_REF], Theory of Planned Behaviour (TPB) [START_REF] Ajzen | The Theory of Planned Behavior[END_REF], Model of PC Utilisation (Thompson et al, 1991), Motivation Model [START_REF] Davis | Extrinsic and intrinsic motivation to use computers in the workplace1[END_REF], the model combining TAM and the TPB [START_REF] Taylor | Assessing IT Usage: The Role of Prior Experience[END_REF], the Innovation Diffusion Theory (IDT) [START_REF] Rogers | Diffusion of Innovations[END_REF]. The line of research in technology acceptance models culminates with the Unified Theory of Acceptance and Use of Technology (UTAUT) that was developed by [START_REF] Venkatesh | User Acceptance of Information Technology: Toward a Unified View[END_REF]. The UTAUT aims to explain user intentions for using an information system. The subsequent usage behaviour and the model have been empirically examined by numerous studies. The UTAUT model integrates eight previously developed models and theories that relate to technology acceptance and use. [START_REF] Venkatesh | User Acceptance of Information Technology: Toward a Unified View[END_REF] observed that IT researchers had a choice among a multitude of models and were confronted to choose constructs across models or choose an ideal model, thus ignoring the contribution from alternative ones. Therefore researchers compared the eight dominant models in explaining technology acceptance behaviour that have been previously used by researchers and scholars. The eight prominent models included are outlined in Table 1.

Another dominant stream of research in information systems and technology evaluation focuses on information system (IS) success. This includes several conceptual and empirical studies. In 1979, an assessment of IS research factors was conducted by Zmud (1979) to review issues addressed by most academics and practitioners concerning the influence of individual differences upon management information system design, implementation, and usage. In 1983, [START_REF] Bailey | Development of a tool for measuring and analyzing computer user satisfaction[END_REF] outlined that evaluating and analysing computer user satisfaction is performed as an aspiration to improve the productivity of information systems by organizational management. According to the authors, productivity in computer services means both efficiently supplied and effectively utilized data processing outputs [START_REF] Bailey | Development of a tool for measuring and analyzing computer user satisfaction[END_REF]. In 1984, a study was conducted by [START_REF] Ives | User involvement and MIS success: a review of research[END_REF] that emphasizes the importance of user involvement. After a decade, a study followed by [START_REF] Davis | Perceived Usefulness, Perceived Ease of Use, and User Acceptance of Information Technology[END_REF] developed TAM. This explained the relationship among information system beliefs (e.g. perceived usefulness and ease of use, attitudes, and behavioural intentions and systems usage). [START_REF] Delone | Information systems success: The quest for the dependent variable[END_REF] reviewed over 180 articles and came up with the information systems success model that consisted of information quality, system quality, use, user satisfaction, individual impact, and organizational impact. In 1995, [START_REF] Goodhue | Task-Technology Fit and Individual Performance[END_REF] developed the task-technology fit model. The authors argued that the model services as the basis for a strong indicative tool to assess whether an information system including systems, policies, IS staff, and services in a given organization are meeting user needs. Among the above mentioned studies, DeLone and McLean's IS success model (1992) has gained great attention from scholars and widespread attention in the information success literature.

Given the above discussed context for the study of information technology and systems adoption, we present the two most widely accepted evaluation models, UTAUT and IS success model, which will be used to investigate the Key Performance Indicators (KPIs) for LiveCity from a behavioural perspective.

The Unified Theory of Acceptance and Use of Technology

The Additionally, the UTAUT model suggests the following: (1) gender and age moderate the relationship between performance expectancy and behavioural intention, (2) gender, age, and experience moderate the relationship between effort expectancy and behavioural intention, (3) gender, age, experience and voluntariness are suggested to moderate the relationship between social influence and behavioural intention, and (4) age and experience are declared to moderate the relationship between facilitating conditions and behaviour intention.

UTAUT2 (Figure 2) is an extension of UTAUT "to study acceptance and use of technology in the consumer context" [START_REF] Venkatesh | Consumer acceptance and use of information technology: extending the unified theory of acceptance and use of technology[END_REF]. UTAUT2 adds three more constructs that affect BI: (1) hedonic motivation, (2) price value, and (3) habit. Voluntariness use is no longer kept as one of the moderators, as in the consumer context most activities are voluntary; hence no variation will occur by including it [START_REF] Venkatesh | Consumer acceptance and use of information technology: extending the unified theory of acceptance and use of technology[END_REF]. A link is also added between facilitating conditions and behavioural intention. The IS success taxonomy and its six success categories are based on a process model of information systems [START_REF] Delone | Information systems success: The quest for the dependent variable[END_REF]. Additionally, strong cause and effect relations exist among the six dependent variables. The six dimensions are interrelated, resulting in a success model that illustrates that causality flows in the same direction as the information process does (DeLone & McLean, 2002). The six major variables of the IS success model are:

1. system quality 2. information quality 3. use 4. user satisfaction 5. individual impact 6. organizational impact

In the IS Success model, system quality measures technical success, information quality measures semantic success and use, user satisfaction, individual impact, and organizational impact measure effectiveness success of the system measured. Figure 3 illustrates the IS Success model. One of the strongest criticisms about the IS Success model is the lack of service quality among variables. According to [START_REF] Pitt | Service quality: a measure of information systems effectiveness[END_REF], there is a danger that researchers will mis-measure IS effectiveness if they do not include in their assessment criteria a measure of IS service quality. Service is an important part of information systems departments; thus, service quality is a critical measure of information system effectiveness (Van Dyke, Kappelman and Prybutok, 1997). As a result, in order to measure information system effectiveness properly, many researchers believed that service quality should be included in the IS success model as a success measure [START_REF] Kettinger | Perspectives on the Measurement of Information Systems Service Quality[END_REF][START_REF] Myers | A comprehensive model for assessing the quality and productivity of the information systems function: Toward a theory for information systems assessment[END_REF][START_REF] Pitt | Measuring Information Systems Service Quality: Concerns for a Complete Canvas[END_REF]. Pitt, Watson and Kavan (1997, p.210) posit that "the IS community needs to be aware of problems that might be experienced in using an instrument to measure so critical a construct as IS service quality".

Having realised the importance of e-services, [START_REF] Delone | The DeLone and McLean model of information systems success: A ten-year update[END_REF] outlined that in frequently used systems not only the benefits to the users, but also the quality of the system should be considered as well. In response to the calls of other researchers that criticized the original model, and due to the advent and growth of Internet based e-services, [START_REF] Delone | The DeLone and McLean model of information systems success: A ten-year update[END_REF] decided to add service quality to their new model as an important dimension of IS success noting the significance of customer service in the e-services environment. Therefore, in an attempt to contribute towards a universal model, [START_REF] Delone | The DeLone and McLean model of information systems success: A ten-year update[END_REF] introduced their updated model after ten years of its first induction in 1992. The model includes six success dimensions, and holds that the constructs of information quality, system quality, and service quality individually jointly affect the factors of use and user satisfaction, whereas user satisfaction and use jointly affect net benefit. Figure 4 1. System quality, which measures the desired characteristics of an e-Commerce system. It refers to the quality of (usability, availability, reliability, adaptability, and response time (e.g., download time), 2. Information quality, which measures the e-Commerce content issues, the dimension of this variable are (personalization, currency, relevance, reliability, completeness, easy to understand and secured for (to gain user's trust when conducting a transaction via the internet), 3. Service quality, which is the "overall support delivered by the service provider, applies regardless of whether the support is delivered by the information systems' department or a new organizational unit or is outsourced to an internet service provider" (DeLone & McLean, 2004, p. 34), 4. Usage, which measures everything from a visit to a web site and navigation within the site to information retrieval and execution of a transaction, 5. User satisfaction, which measures customers' opinions of an e-Commerce system and should cover the entire experience cycle of customers from information retrieval to purchase, payment, receipt, and service, and 6. Net benefits that capture the balance of the positive and negative impacts of e-Commerce on customers, suppliers, employees, organizations, markets and even society as a whole. [START_REF] Hu | A research on the framework of egovernment project success[END_REF] attempted to establish a suitable and systematic appraisal framework of public sector e-services success based on the IS Success Model presented by DeLone and McLean in 1992, which is relevant to the LiveCity project. Table 2 summarizes the relevant KPIs for evaluating the LiveCity project.

Reliability

The dependability of system operations [START_REF] Wixom | A Theoretical Integration of User Satisfaction and Technology Acceptance[END_REF] Flexibility The way the system adapts to changing demands of the user

Integration

The way the system allows data to be integrated from various sources

Accessibility

The ease with which information can be accessed or extracted from the system

Timeliness

The degree to which the system offers timely responses to requests for information or action Information Quality

Completeness

The degree to which the system provides all necessary information [START_REF] Wixom | A Theoretical Integration of User Satisfaction and Technology Acceptance[END_REF] Accuracy The user's perception that the information is correct

Usefulness

The degree to which a person believes that a particular information system would enhance his or her job performance [START_REF] Davis | Perceived Usefulness, Perceived Ease of Use, and User Acceptance of Information Technology[END_REF] Ease of Use The degree to which a person believes that using a particular system would be free of effort User Satisfaction

Information Satisfaction

The application of that information useful in enhancing work performance [START_REF] Wixom | A Theoretical Integration of User Satisfaction and Technology Acceptance[END_REF]) System Satisfaction A degree of favourableness with respect to the system and the mechanics of interaction The integrated research model presented in Figure 5 attempts to merge quality dimensions from the IS Success model together with the UTAUT2 model as antecedents for the intention to use with an attempt to reveal the role of perceived service quality towards intention to use the LiveCity application. The acceptance of the Live-City application is defined through the behaviour intention to use the associated services. The proposed integrated research framework consists of thirteen constructs; one dependent variable and ten independent variables. The dependent variable is behaviour intention to use LiveCity services, while the independent variables are: (1) in-formation quality, (2) information satisfaction, (3) system quality, (4) system satisfaction, (5) service quality, (6) service satisfaction, (7) social influence, (8) performance expectancy, (9) effort expectancy, (10) facilitating conditions, (11) hedonic motivation, (12) price value, and (13) habit.

Moreover, a key for adopting Internet based (V2V) services is the perceived customer or end-user perception on information security and privacy. Therefore, information privacy should be an assessment variable integrated in the model as an independent variable. For that purpose we adopt the research of [START_REF] Dinev | An extended privacy calculus model for e-commerce transactions[END_REF] who identify the factors representing elements of a privacy calculus in the ecommerce domain. Therefore, under the user satisfaction variables, we add the parameter of willingness to provide personal information (Figure 6). The model proposed in Figure 6 endeavour to merge UTAUT2 model, IS Success model and enhance them with the willingness to provide personal information. The framework consists of one dependent variable (the behaviour intention to use LiveCity services) and fourteen constructs; one dependent variable and ten independent variables. The dependent variable is behaviour intention to use LiveCity services, while the independent variables are: (1) information quality, (2) information satisfaction, (3) system quality, (4) system satisfaction, (5) service quality, (6) service satisfaction, (7) social influence, (8) performance expectancy, (9) effort expectancy, (10) facilitating conditions, (11) hedonic motivation, (12) price value, (13) habit and, ( 14) willingness to provide personal information. This reference model will serve as an evaluation framework for LiveCity users' experience.

Discussion

Taking into consideration that the use of high definition, uninterrupted V2V oriented platforms is new and yet to evolve, and limited normative literature exists specifically for the evaluation of such services. For that reason we drew upon existing literature and added constructs that are particularly important for the diffusion and adoption of Internet Based e-services such as V2V as well as other socio economic and information privacy factors that may influence the V2V offered on the Internet. As the V2V platform will offer mostly consumer services, we draw from UTAU2 that is an extension of UTAUT to reflect the acceptance and use of technology in the consumer context. As the services covered in the LiveCity project are public services we refer to [START_REF] Hu | A research on the framework of egovernment project success[END_REF] that show results from their attempt to establish a suitable and systematic appraisal framework of public sector e-services based on the IS Success Model presented by DeLone and McLean in 1992. However, the user will not adopt a service in general, hence a V2V service in particular, if they do not perceive the information exchanged as secure and private. Therefore, in the LiveCity context, for V2V services to be successfully adopted, we considered it necessary that the user is willing to provide personal information. The proposed framework will be used to evaluate behavioural intentions when using V2V services.

Conclusion

Electronic services have the potential of allowing citizens and service providers to get involved to jointly shape the design and delivery of public services facilitating openness, participation, accountability, effectiveness, and coherence of government services. However, public service adoption has not had the expected take off due to various reasons such as trust, lack of access, usability etc. This article presented how HD V2V can be utilised to create a LiveCity environment, in which citizens can actively be engaged in government service delivery processes. HD V2V can be realised on the public infrastructure by using a RoW that has the potential to alleviate some of the consequences of the technical constraints that currently affect video delivery. This article offers an insight on how using HD V2V can enhance public services such as health, education, and city experience and what the potential benefits and impact added by the video communication. However, due to the novelty of the technology involved, there is no established method to quantify its benefits. Therefore, we draw from previous literature and we propose a framework of reference for evaluating user experience on LiveCity by drawing from previous literature on technology adoption.

  Acceptance and Theory of Planned Behaviour models (combined TAM -TPB) Taylor and Todd (1995b) Model of PC Utilization (MPCU) Thompson, Higgins and Howell (1991) Innovation Diffusion Theory (IDT) Moore and Benbasat (1991) Social Cognitive Theory (SCT)[START_REF] Compeau | Application of social cognitive theory to training for computer skills[END_REF]

  Unified Theory of Acceptance and Use of Technology provides a useful tool for managers that aim at assessing the likelihood of success for new technology introduction and helps them understand the drivers of technology acceptance in order to proactively design interventions targeted at users that might be less inclined to adopt and use new systems respectively (such as, training, marketing, etc.). The UTAUT model consists of three indirect determinants of behavioural intention, and two direct determinants of use behaviour. The three core constructs in the UTAUT model that declare to impact behavioural intention (BI) directly are: (1) performance expectancy, (2) effort expectancy, and (3) social influence. Intention to use and facilitating conditions (FC) are declared to impact indirectly on use behaviour. UTAUT includes four mod-erators (i.e. age, gender, experience and voluntariness of use), which contribute to a better understanding of the complexity of technology acceptance by individuals. Figure 1 illustrates UTAUT's core constructs.

Fig. 11 .

 11 Fig. 11. UTAUT's Constructs and Root Core of Constructs

Fig. 22 .

 22 Fig. 22. UTAUT2[START_REF] Venkatesh | Consumer acceptance and use of information technology: extending the unified theory of acceptance and use of technology[END_REF]

Fig. 33 .

 33 Fig. 33. DeLone and McLean IS Success Model (1992)

  illustrates the updated DeLone and McLean Success Model.

Fig. 44 .

 44 Fig. 44. Updated DeLone and McLean IS Success Model The updated model of DeLone and McLean (2003) includes six success dimensions to measure the success of a system in the e-services domain. The six major variables of the 2003 IS success model are:

Format

  Evaluating User Experience of LiveCityFor the purpose of evaluating the user experience related to LiveCity technology and services, the two noteworthy models, UTAUT2 and DeLone and McLean IS Success model, are integrated based on theoretical evidence presented in the previous two sections as depicted in Figure5below.

Fig. 55 .

 55 Fig. 55. Integrated Model of UTAUT and IS success model

Fig. 66 .

 66 Fig. 66. Integrated model for V2V services on the Internet incorporating Trust

Table 11 .

 11 Prominent Models used to study User Behaviour in Technology Adoption

Table 22 .

 22 IS Success Model Factors

	System
	Quality

Table 33 .

 33 Information privacy construct (adopted by[START_REF] Dinev | An extended privacy calculus model for e-commerce transactions[END_REF]

			Perceived risk related to the disclosure of
		Perceived Inter-	personal information submitted by the relent
		net privacy risk	stakeholders in their specific context (use
			cases) in general
	Willingness to provide personal in-	Internet privacy concerns	Concerns related to the personal information submitted over the internet by the respond-ent in particular
	formation to		Trust beliefs that personal information sub-
	an e-service	Internet trust	mitted to V2V based services will be han-
			dled competently, reliably, and safely
		Personal Internet interest	Personal interest or cognitive attraction to V2V internet content overriding privacy concerns

Formatted: Font: Bold, English (U.K.), Do not check spelling or grammar

Acknowledgements:

The authors wish to acknowledge the contributions made to this article by the LiveCity consortium of partners and the European commission.


Ann Séror
email: annseror@eresearchcollaboratory.com

Designing Sustainable Open Source Systems: The Cuban National Health Care Network and Portal (INFOMED)

Keywords: Cuba, national health care systems, INFOMED, qualitative research methods, virtual infrastructures, open source software

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

Introduction

Recent literature in development, sustainability and health care has recognized the importance of comparative research on large systems for understanding of complexity and performance at the national and global levels of analysis [START_REF] Reimers | The Difficulty of Studying Inter-Organisational IS Phenomena on Large Scales: Critical Reflections on a Research Journey[END_REF]. Despite recognition of the importance of systems science in medical informatics [START_REF] Coiera | Guide to health informatics[END_REF], only fragmented progress has been made in theory development and research methods to address issues of critical importance in large scale health care system reform. The objective of this research is to contribute to an interdisciplinary perspective on theory and methods for this emerging scientific domain.

possess the capability to grow and self-organize through sharing of tools and resources. The self-organizing system adapts to its environment with the capacity to replicate and renew itself from within. These systems may be considered closed by virtue of the rules of interaction, while at the same time they are open as they extend for examplefrom one national entity to another. Coevolution of INFOMED and other national health information systems within BIREME also affects the distribution of roles at regional and nested national levels of analysis. As nested entities coevolve, emergent features transform the larger system. [START_REF] Morrison | Educational Philosophy and the Challenge of Complexity Theory[END_REF] Open access publication remodels information flows across virtual spaces with no exchange of physical materials or financial transactions in a process of shared content development and ever reduced restrictions on access to health information. [START_REF] Packer | The Virtual Health Library and the Remodeling of the Health Scientific and Technical Information Flow in Latin America and the Caribbean[END_REF] While online publication extends global access to both international and local scientific journals, the linkage between these resources may be configured to contextualize user knowledge and practice. [START_REF] Ofori-Adjei | Have Online International Medical Journals made Local Journals Obsolete[END_REF] The shared space linked through virtual infrastructures of the health information system is defined here as a knowledge ecology -including institutional and network portals, electronic journals and other resources, online courses, collaborative spaces, human resources, and search engines arranged according to language, knowledge domain, or geographical location.

Trist suggested as early as 1977 the importance of "clustering" in social ecologies and the need for inquiry into the cognitive mapping of large scale socio-ecological systems characterized by network structures expressing negotiated rather than bureaucratic order. [START_REF] Trist | A Concept of Organizational Ecology[END_REF] He identified conceptual and methodological difficulties posed by this new area of inquiry. First, the ecological domain is difficult to identify -requiring a "figure-ground reversal" to render its features observable or measurable. Second, the structure of middle-level fields -bridging the divide between local and global [START_REF] Barrett | Building Bridges between Local and Global Knowledge: New Ways of Working at the World Health Organisation[END_REF] -is particularly elusive, as singular institutions are generally more visible in networks than -for examplechambers of commerce or regulatory councils. Virtual infrastructures made visible on the Internet reflect the resources of the knowledge ecology. These institutional infrastructures may control access to associated resources through regulatory or certification processes, or they may be created and controlled by their constituencies through membership and democratic governance. Where no referent structures order the system, market dynamics and ideologies determine the configuration of the ecological domain [START_REF] Séror | Virtual Health Care Infrastructures: Markets and Hierarchies[END_REF].

Virtual infrastructures of INFOMED -accessible on the Internet -offer visible evidence of ecological domains for mapping and analysis of their configurations at micro-, meso-and meta-levels of structure. The research objectives here are to describe INFOMED in the context of BIREME as a complex knowledge ecology using qualitative case analysisand to make some recommendations regarding national strategies for model transferability.

This case analysis contributes to a broad research program designed to develop a framework for comparative analysis of national health care system infrastructures using qualitative case research methods. ( ror, 2012, 2011, 2002, 2006a, 2006b). The next section of the paper describes the methodology for study of the Cuban National Health Care Network and Portal (INFOMED).

Research methodology

The research methodology used for this study is embedded qualitative case analysis [START_REF] Hannan | Ecologies of Organizations: Diversity and Identity[END_REF][START_REF] Yin | Enhancing the Quality of Case Studies in Health Services Research[END_REF][START_REF] Yin | Case study research: Design and methods[END_REF].

The regional and national infrastructures selected for study -the Latin American and Caribbean Health Sciences System (BIREME) as a context for the Cuban National Health Care Network and Portal (INFOMED)form a complex interorganizational information system [START_REF] Byrne | Working within a Complexity Frame of Reference-the Potential of 'Integrated Methods' for Understanding Transformation in Complex Social Systems[END_REF][START_REF] Reimers | The Difficulty of Studying Inter-Organisational IS Phenomena on Large Scales: Critical Reflections on a Research Journey[END_REF] [START_REF] Dagnino | Complex Systems as Key Drivers for the Emergence of a Resourceand Capability-Based Interorganizational Network[END_REF]. Such large, complex systems pose significant challenges to design of research methods for a number of reasons. First, the degree of interrelatedness and the evolutionary nature of system change make it very difficult to identify a nomological model [START_REF] Kannampallil | Considering Complexity in Healthcare Systems[END_REF]. Second, the process definition of causality associated with the scientific method [START_REF] Morrison | Searching for Causality in the Wrong Places[END_REF] cannot be applied in development of theoretical frameworks, nor can it be the objective of research designs focused on complexity. Rather, the lens of complexity theory suggests an interconnected system with reciprocal relationships for mutual constitution of the observed characteristics of the system [START_REF] Reimers | The Difficulty of Studying Inter-Organisational IS Phenomena on Large Scales: Critical Reflections on a Research Journey[END_REF].

Specifically this is an embedded case according to the typology suggested by [START_REF] Yin | Case study research: Design and methods[END_REF] where the regional BIREME forms the context in which INFOMED has grown and developed at the Cuban country level of analysis. This choice of case is revelatory of the reciprocal roles of regional and country level leadership in health information system development. The Cuban case is unique, in some ways offering a natural experiment in the values of social medicine. While this study may not yield generalizable conclusions, it sheds light on the critical coevolution of regional and national knowledge ecologies and the ideological role of the social medicine model shared among countries of the Latin American region [START_REF] Collier | Insights and Pitfalls: Selection Bias in Qualitative Research[END_REF]. Historical description of the institutional context shows how virtual infrastructures have emerged over time and how this temporal evolution has affected the forms and functions expressed in the system ecology [START_REF] Bennett | Complex Causal Relations and Case Study Methods: The Example of Path Dependence[END_REF].

Data include published accounts of system development and the websites of the constituent organizations, networks and services to describe the configuration of virtual infrastructures [START_REF] Vidal Ledo | Mapas Conceptuales[END_REF]. The mapping methodology reveals complex infrastructural patterns of health care information system management and control [START_REF] Rodriguez Pina | Mapas Conceptuales y Geo-Referencias En Productos y Servicios De Inteligencia Empresarial[END_REF]. Qualitative interpretation facilitates identification of complex and sometimes paradoxical effects of information and communication technologies on knowledge ecologies [START_REF] Robey | Accounting for the Contradictory Organizational Consequences of Information Technology: Theoretical Directions and Methodological Implications[END_REF]). Emapping software3 is used to visualize maps of the linkages among resources identified in the knowledge ecology of the Cuban National Health Care Network and Portal (INFOMED) in the context of the regional Virtual Health Library of the Latin American and Caribbean Health Sciences System [START_REF] Egbu | Knowledge Mapping and Bringing about Change for the Sustainable Urban Environment[END_REF][START_REF] Ruffini | Using E-Maps to Organize and Navigate Online Content[END_REF]. The maps generated using this methodology show how global, regional and national resources are shared and integrated in the virtual infrastructure [START_REF] Ebener | Knowledge Mapping as a Technique to Support Knowledge Translation[END_REF][START_REF] Lavis | Assessing Country-Level Efforts to Link Research to Action[END_REF]. Figure 1 below shows a partial view of a map of INFOMED. Nodes in this map identify virtual organizations and resources. Edges represent Internet linkages among these virtual entities. The resulting configuration reveals the relational logic of the system as well as patterns of connectedness and self-organization both within INFOMED and among emergent entities of BIREME. Figure 1 below shows a partial view of a map of INFOMED. This database is available online for review.

Case analysis

According to Article 4 of the Cuban Public Health Law No. 43, the ideological principles underpinning Cuban health care services include (Asamblea Nacional del Poder Popular de la República de Cuba, 1983): adequate health care defined as a human right, free and universal access to health care services offered by the state, emphasis on preventive care, and active participation of the population in public health promotion. The performance of this national system is reflected in statistics for population life expectancy of 78 years ( 2009) and infant mortality of 5 per thousand live births -indicating standards similar to those observed in the developed countries. Expenditure per capita of $495 contrasts sharply with the US expenditure of $7,164 in 2008, particularly in light of poor US performance among other OECD countries [START_REF] Davis | Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally 2010 Update[END_REF]. Also significant is the concentration of 64 physicians per 10,000 population (2000-2010)the highest in the world (World Health Organization, 2011).

ince the Cuban revolution in 1959, the country's leadership have pursued strategies to integrate national research and innovation policies through development of traditional institutions and, since 1990, information and telecommunication infrastructures [START_REF] Amaro | Anonymous: An Open-Source Shot in the Arm? The Economist[END_REF][START_REF] Capote | Surgimiento y Evolución De La Política De Ciencia y Tecnología En Cuba[END_REF][START_REF] Séror | Telecommunications Technology Transfer and the Development of Institutional Infrastructure : The Case of Cuba[END_REF]. In 1963, municipal polyclinics were first created to form the basic units of the Cuban health care system and to manage all health care activities within their jurisdictions, including workplaces, schools, and childcare centers. These activities were the first programs of the current community-based health care model [START_REF] Campion | A Different Model -Medical Care in Cuba[END_REF][START_REF] Keck | The Curious Case of Cuba[END_REF]Séror, 2006a). In 1965 the National Center for Scientific Research (Centro Nacional de Investigaciones Cientificas, CNIC) and the National Information Center for the Medical Sciences (Centro Nacional de Información de Ciencias Médicas de la República de Cuba-CNICM) were founded to serve the institutional needs of science and research in health care.

Coordinated by CNICM, The Cuban National Health Care Network and Portal (INFOMED) was founded in 1992 with support from the United Nations Development Program, the World Health Organization, the Pan-American Health Organization, and UNICEF. INFOMED serves the health information requirements of Cuban health care professionals. (Figure 2 shows a screenshot of the INFOMED Portal.) As the network was extended throughout the 14 Cuban provinces, it provided health care workers' access to information -connecting provincial information centers, research institutes, hospitals and universities (Séror, 2006a). While the Cuban Ministry of Public Health is generally responsible for hierarchical governance of the Cuban National Health Care System, the mission of INFOMED is to integrate research, education and evidence-based practice through telecommunications and information technologies(Rodríguez Pérez & Urra [START_REF] Rodríguez Pérez | Atención Primaria En La Red Electrónica De Información De Salud[END_REF][START_REF] Urra González | Las Redes De Computadoras Al Servicio De La Bibliotecología Médica : INFOMED[END_REF].

Largely developed with open source software, the virtual infrastructures associated with INFOMED support processes of information and communication throughout the system. The Cuban open source software development community collaborates closely with scientific and administrative communities of practice through shared ideological values expressed in open access to health information and universal health care services [START_REF] Schweik | The Institutional Design of Open Source Programming: Implications for Addressing Complex Public Policy and Management Problems[END_REF]. In particular, BIREME forms the context for development of national health information systems serving Latin America. It was founded in 1967 with the collaboration of the Brazilian Ministry of Education, Ministry of Health, Secretary of Health of the State of São Paulo, and the Federal University of São Paulo as a specialized center of the WHO regional office for the Americas, the Pan American Health Organization (PAHO). Recognizing that an important condition for the development of health is universal, equitable and cost-effective access to scientific and technical information in medicine and the health sciences, BIREME aims to promote the regional capacity for collaboration to through open access to data and research on medicine and the health sciences. Throughout its history, BIREME's technical operation has been motivated by the principles of decentralized networking, local capacity building, cooperative product development, and elaboration of common methodologies (BIREME, 1998;BIREME, 2008;Bireme, 2011).

Such cooperative projects linked to the INFOMED Portal include the Cuban VHL4 and the Virtual University5 offering online training in medicine and the health sciences. Since 1994, the Cuban National Library of Medicine (CNLM)6 has collaborated with BIREME to develop the Collective Catalogue of Periodical Publications on the Health Sciences (SeCiMed). 7 In 1998 when the regional VHL was created, the CNLM was converted into a network coordinating center-including 815 libraries and information centers -charged with compiling the Cuban medical bibliography for the regional LiLaCS project led by BIREME. 8 The CNLM played a critical role in the transition to new media for information dissemination to both real and virtual library users.

The Cuban VHL has grown to include more than 50 online Spanish-language journals in medicine and public health. These publications have been formally certified according to standards9 set by the Cuban Ministry of Science, Technology and the Environment (CITMA, 1994). In 2001, Cuba joined the SciELO Network, and adopted the SciELO methodology [START_REF] Packer | SciELO as a Model for Scientific Communication in Developing Countries: Origins, Evolution, Current Status, Management and Perspectives of the SciELO Network of Open Access Collections of Ibero-America Journals[END_REF]. 10 The SciELO network serves to promote selected Cuban journals in the international scientific information flow through network access, search tools, and article indexing [START_REF] Cañedo Andalia | Aproximaciones a La Visibilidad De La Ciencia y La Producción Científica De Cuba En El Sector De La Salud[END_REF]. The Cuban VHL links information and research from the Latin American region as well as international scientific research and accounts of medical experiences in developing countries. More than 25 countries of the Latin American region have appropriated models, methods and open source tools to create national virtual libraries connected to the regional network managed by BIREME. 11 Although English is the international language of science, other languages are essential to the culture and context of health care systems. The Virtual Health Library (VHL) linking BIREME and INFOMED embody an institutional commitment to Spanish and Portuguese languages and context while maintaining linkages to English and French language resources. Shared Spanish and Portugese languages as well as the values of open source systems contribute to growth and selforganization of BIREME and INFOMED. This commitment especially critical to the interests of Cuban scientists and practitioners as they adopt medical innovation from scientific communities of the developed world and identify topics of common concern for international collaboration [START_REF] Meneghini | International Versus National Oriented Brazilian Scientific Journals: A Scientometric Analysis Based on SciELO and JCR-ISI Databases[END_REF][START_REF] Meneghini | Is there Science Beyond English?[END_REF].

The Cuban Virtual University for the Health Sciences (UVS) was founded by the Ministry of Public Health in 1998 to improve continuing post graduate medical training for more than one hundred thousand Cuban health care professionals and to offer an international center for postgraduate education in medicine and related disciplines(Lalas [START_REF] Perea | Universidad Sin Fronteras: Mito o Realidad?[END_REF][START_REF] Machado | Plan Capacitante Para Desarrollar La Universidad Virtual De Salud En El Instituto Superior De Ciencias Médicas De Santiago De Cuba[END_REF]. This institution links the Cuban health care information and publication infrastructure with Cuban institutions for higher education as well as supercourses with Cuban12 and international content such as Epidemiology, the Internet, and Global Health13 hosted by the University of Pittsburgh. In 2004, a learning environment, the Virtual Classroom was created and in 2005, migrated to open-source Moodle, a scalable course management system also used in the Virtual Campus for Public Health.

In 2006 the Cuban Virtual University adopted Plone, an open-source content management system14 to extend university community participation through open courses, event management, and a repository for learning resources. [START_REF] Díaz Martínez | Congreso: Nuevo Producto De Plone Para Gestionar Un Evento Virtual*[END_REF] The collaborative environment for website development fosters service decentralization, user participation, and integration of technology, management and pedagogy. (Jardines Méndez, 2006a;Jardines Méndez, 2006b;[START_REF] González | Universidad Virtual De Salud: Una Nueva Etapa[END_REF] Members of Cuban university communities including professors and other users collaborate to create and publish content made available through the network. Essential components of the Virtual University are the Virtual Classroom, the Interactive Clinic, the Repository for documents of interest, and the network through which courses are offered. The Virtual Classroom supports medical training and education15 while the Interactive Clinic provides a forum for discussion on diagnostics and case studies. 16 The Repository is an electronic archive of documents such as courses, conference presentations and scientific articles made available to the university community. Courses may be offered through the network for medical education credit using the Moodle interface, or content may be made available for autonomous learning according to the MIT open courseware model. 17 Associated with the Virtual University is the Cuban Virtual Campus for Public Health (VCPH) 18 linked to the Latin American infrastructures created by PAHO. 19 This virtual infrastructure now links the VCPH in 11 countries of the region. This interactive community replicates the model of the regional VCPH in national health information systems, and connects Cuban institutions in health sciences research and education including the School of Public Health, 20 the Pedro Kourí Tropical Medicine Institute, 21 the for Hygiene, Epidemiology and Microbiology, 22 the Occupational Health Institute, 23 and the Center for Development of Pharmacoepidemiology. 24 Like the Cuban Virtual University, the VCPH promotes communities of practice through a collaborative environment for creating content, sharing and developing resources throughout the national network. These shared tools and infrastructures create synergies among local, national and regional health information systems.

INFOMED also offers networked infrastructures serving evidence-based practice of medical specialties including participation in clinical trials [START_REF] Reveiz | Avances y Retos En El Registro De Ensayos Clínicos En América Latina y El Caribe[END_REF]. The methodology for creation of the Paediatric Surgery National Network (Red Nacional de Cirugía Pediátrica -RENACIP) -the first such specialized network in Cuba -demonstrates how human resources and technology are integrated in the Cuban model (Séror, 2006a). The institution to lead the network, the Paediatric Teaching Hospital "Octavio de la Concepción de la Pedraja" of Holguín, was designated by the Cuban Ministry of Public Health in 2001 [START_REF] Soler | Origen, Estado Actual y Perspectivas De La Red Nacional De Cirugía Pediátrica[END_REF][START_REF] Soler | El Éxito De Una Red[END_REF]. During the initial phase, the local hospital network was developed to integrate the practice of other specialties essential to paediatric surgery, including radiology, endocrinology, and neurophysiology. The national network began with identification of experts in three regions of the country for consultation in complex cases. A discussion list was used as a tool to scale up the specialized health information system from the hospital to the national level for improved decision making, allocation of resources, and more efficient care. Figure 3 shows a screenshot of the RENACIP Portal. Consistent with the principles of evidence-based medicine, the specialists of the national RENACIP network have identified best practice protocols through professional meetings and virtual consultation. These protocols are available to health care practitioners on the Internet25 (Díaz Mastellari, 1999-2006). Other features of RENACIP include a portal, 26 a virtual library collection of scientific publications, and software tools for patient management. Software development and website design are closely adapted to the network activities of research and evidence based practice as scientists and physicians participate directly in website design and related communities of practice. 27 Within RENACIP, groups associated with subspecialties in paediatric surgery are also being formedincluding orthopedics, oncology, and urology. This evolution since the creation of RENACIP illustrates nesting of self-organizing entities.

The model first used for development of RENACIP has been extended to more than 45 medical specialties, linking provincial institutions and resources to the national health information system 28 and providing centralized web-based services through the INFOMED portal. The extension of networks for medical specialties illustrates the principles of self-organization as the methods and open source tools originally developed for the RENACIP network are appropriated for creation of national networks serving other medical specialties.

The participation of human resources and communities of practice at the provincial and national levels is critical as health care workers become active information and knowledge producers Since 2002 a process of consultation [START_REF] Earl | Outcome Mapping: Building Learning and Reflection into Development Programs[END_REF][START_REF] Persaud | The Utilization of Systematic Outcome Mapping to Improve Performance Management in Health Care[END_REF] engages institutions of the health care system including the Ministries of Public Health and Higher Education to identify the strategic objectives of INFOMED (Infomed, 2011;Ministerio de Salud Pública, 2010;[START_REF] Prietodíaz | Impacto De Las Tecnologías De La Información y Las Comunicaciones En La Educación y Nuevos Paradigmas Del Enfoque Educativo[END_REF]:

-To develop the Virtual Library as an interactive work space linking institutional resources of national, provincial and municipal libraries to respond to Cuban as well as international health care priorities. -To build technical, organizational and human resource infrastructures for sustainable institutional growth in information services. -To promote publication of Cuban research in the health sciences and related disciplines for access by national and international scientific communities. -To improve the technological and methodological infrastructures of the Virtual University serving a health education network. -To create a system-wide health information intranet linking the Center for Health Information Sciences and networks of provincial institutions. -To continue to develop the Cuban research base in the field of health information sciences and medical informatics. -To foster integration of INFOMED with other national and international health information networks and infrastructures. -To develop methodologies and protocols for continuous and systematic evaluation and control of INFOMED's performance. [START_REF] Cañedo Andalia | Infomed: Las Adversidades Despiertan Potencialidades Dormidas De La Red[END_REF][START_REF] Cañedo Andalia | Para Comprender y Tratar El Escaso Empleo De Los Recursos De Información Disponibles Vía Infomed Se Necesita Una Perspectiva Multidisciplinar[END_REF] These objectives guide concurrent processes of local system empowerment, centralized coordination and control through INFOMED, and growing integration of Cuban and regional infrastructures -the Virtual Library led by BIREME and the Virtual Campus for Public Health founded by PAHO. The emergence of these regional institutions has transformed the knowledge ecology of BIREME. Of particular importance for integration of regional and national health information systems is the coherence between system design and the social medicine values underpinning these infrastructures -including universal health care, open access to health information, and focus on collective social and environmental dimensions of health.

INFOMED effectively mediates a dual market system designed to protect these internal social values while creating links to external global markets beyond national boundaries. Strong research and innovation within the Cuban system contributes to productive evaluation, adaptation and integration of regional infrastructures as well as use of research results and evidence from external sources in Cuban health care.

Discussion and Conclusions

The embedded case analysis through the lens of complexity theory offers an understanding of the Cuban national strategy for development of virtual infrastructures supporting health care services and research. The historical evolution of both the regional and national virtual infrastructures suggests that the founding commitment to the Latin American ideological tradition of social medicineas expressed in Cuban legislation for public health -has shaped development of both INFOMED and BIREME, and made possible the effective integration of health information networks at the regional and national levels of analysis. These systems reflect the critical importance of traditional local institutions in coordinating the transition from paper media to the open access publication model embodied in the Cuban Virtual Health Library and the regional VHL. The Cuban Virtual University has also made possible effective linkage with the VCPH. The co-evolution of regional and national health information systems including virtual libraries and universities demonstrates how open source software systems, standards and methodologies for development of infrastructure offered at the regional level are appropriated at the national level to support local scientific capacity embodied in communities of practice for education and knowledge creation. This process effectively illustrates the dynamics of nested complex systems adapting to their environment and self-organizing in INFOMED and other national health information systems.

These complex dynamics are particularly evident in the way methodologies including SciELO -associated with the regional BIREME VHL -are appropriated for development of the Cuban VHL. The same process is identified in replication of VCPH collaborative spaces for virtual classrooms, document repositories, and wikis within the Cuban VCPH and Virtual University. This process of appropriation is facilitated by the shared ideology of open source software development and open access to health information and research. The collaborative spaces of the Virtual University, the Virtual Campus for Public Health and the Virtual Library integrate the open flow of health information with the creative dynamics of scientific and professional communities of practice. Situated learning in this context also challenges the linear model of research, development, learning and practice, where researchers and practitioners are mutually engaged [START_REF] Edwards | Epistemic Communities, Situated Learning and Open Source Software Development[END_REF][START_REF] Mcdonald | From Evidence-Based Practice Making to Practice-Based Evidence Making: Creating Communities of (Research) and Practice[END_REF].

While in other developing countries, virtual infrastructures for health care services are often designed to compensate for the lack of trained health care professionals; in the Cuban context, a high concentration of qualified multi-skilled human resources is a distinctive feature of the system. Throughout INFOMED, webmasters are often practicing physicians and scientists contributing their efforts according to a model similar to that for collaboration in open source software development. The Cuban experience suggests that this model may be useful for medical research, development and education supported by the culture of open source software communities [START_REF] Benkler | Freedom in the Commons, Towards a Political Economy of Information[END_REF]Committee for Economic Development (CED), 2006;[START_REF] Lanzara | The Knowledge Ecology of Open-Source Software Projects[END_REF][START_REF] Maurer | Finding Cures for Tropical Diseases: Is Open Source an Answer[END_REF][START_REF] Schweik | The Institutional Design of Open Source Programming: Implications for Addressing Complex Public Policy and Management Problems[END_REF].

The Cuban strategy for development of INFOMED and associated virtual infrastructures for health information, education, research and service delivery is thus founded on coherency among a strong national socialist ideology, shared culture including language and literacy, universal and free access to health care, open access to health information and research in the health sciences, as well as open source software, tools and methodologies to build infrastructures, products and services. Consistent with the view of a complex system as both an open and closed, INFOMED offers a strong centralized planning process and tools for development of networks and websites-essential for network membership and system growth. The development of the methodology for creation of RENACIP illustrates a successful strategy subsequently applied to extend the model to a growing number of medical specialties with networks on a national scale. This example also reveals application of the RENACIP model to develop subspecialties within paediatric surgery.

Strategies identified in this study for development of virtual infrastructures and a national health information system are unique to the Cuban context and their transferablility to other systems requires careful evaluation of contextual factors in other developing countries as well as the industrialized world. The social medicine model promotes centralized planning and public investment in every aspect of the health care system, including health information technology and virtual infrastructures. The single payer system effectively reduces the administrative burden in the health care sector. Market dynamics and transactions pose obstacles to the free flow of information and the ease of collaboration among medical scientists, technologists and practitionersas seen in a case comparison of the U.K. NHS and the U.S. Kaiser Permanente [START_REF] Séror | Internet Infrastructures and Health Care Systems: A Qualitative Comparative Analysis on Networks and Markets in the British National Health Service and Kaiser Permanente[END_REF]. Social, cultural and ideological diversity challenge the success of these strategiesas observed in the Indian national case. ( ror, 11 . Future research efforts should focus on innovative methodologies as well as theory development for the study of large scale health information systems. Particular attention needs to focus on coevolution and integration of ideological models for social medicine and capitalist market models of national health care systems. Embedded case studies will be also useful for understanding system dynamics between national and regional levels as well as the respective roles of virtual infrastructures and communities of practice in creation of health information and knowledge. Programs of comparative case studies across regional and national systems are essential to understanding of ideology, culture and technology as determinants of sustainable global system configuration.

Figure 1 .

 1 Figure 1. The virtual infrastructure of INFOMED

Figure 2 .

 2 Figure 2. The INFOMED Portal at http://www.sld.cu/ (accessed 15-3-2013)

Figure 3 .

 3 Figure 3. The RENACIP Portal at http://www.sld.cu/sitios/renacip/ (accessed 15-3-2013)

The ideology shared by these related communities of practice may also profoundly affect the broader functions of the knowledge ecology, including the conduct of research and delivery of care. (Anonymous,

2004;[START_REF] Benkler | Coase's Penguin,Or Linux and the Nature of the Firm[END_REF][START_REF] Maurer | Finding Cures for Tropical Diseases: Is Open Source an Answer[END_REF] 2 See the Public Library of Science definition of open access at http://www.plos.org/oa/definition.html (accessed 28 April 2008).

See The Brain -Visual Information Management at http://www.thebrain.com/

Cuban Virtual Health Library at http://www.bvscuba.sld.cu/html/es/home.html

Virtual University at http://www.uvs.sld.cu/

CNLM website at http://www.sld.cu/sitios/bmn/

SeCiMed website at http://bmn.sld.cu/secimed/msrc/secimed_home.php

See an account of the history of the CNLM at http://www.sld.cu/sitios/bmn/temas.php?idv=2381

These journal quality standards include national registration and accreditation by an appropriately formed national commission. Article evaluation must be completed by qualified referees and certified journals must include content of at least 60% original scientific research.

SciELO Cuba website -http://scielo.sld.cu/scielo.php

http://regional.bvsalud.org/php/bvsnet.php?lang=en&list=countries

Cuban Super Course site at http://supercurso.sld.cu/

Supercourse-Epidemiology, the Internet, and Global Health, University of Pittsburgh: http://www.pitt.edu/~super1/

14 www.plone.

org 15 Virtual Classroom -http://aulauvs.

sld.cu/ 16 Interactive Clinic -http://www.uvs.sld.cu/clinica

See the RENACIP best practice protocols at