Hospital quality of care: Does information technology matter? The relationship between information technology adoption and quality of care

Quality of Care in Hospitals and the Use of Mobile-Based Personal Health Record Applications: An Exploratory Study Using National Hospital Evaluation Data

The use of mobile-based personal health record (m-PHR) applications at the hospital level has been minimally studied. This study aimed to investigate the relationship between m-PHR use and quality of care. A cross-sectional study design was employed, analyzing data from 99 hospitals. Two data sources were utilized: a previous m-PHR investigation conducted from 26 May to 30 June 2022 and a hospital evaluation dataset on quality of care. The use of m-PHR applications was measured by the number of m-PHR application downloads. Three independent variables were assessed: quality of care in the use of antibiotic drugs, injection drugs, and polypharmacy with ≥6 drugs. A generalized linear model was used for the analysis. The hospitals providing high-quality care, as evaluated based on the rate of antibiotic prescription (relative risk [RR], 3.328; 95% confidence interval [CI], 1.840 to 6.020; p < 0.001) and polypharmacy (RR, 2.092; 95% CI, 1.027 to 4.261; p = 0.042), showed an increased number of m-PHR downloads. Among the hospital covariates, public foundation status and being part of multi-hospital systems were associated with the number of m-PHR downloads (p < 0.05). This exploratory study found a positive relationship between quality of care and m-PHR use. Hospitals providing high-quality care may also excel in various activities, including m-PHR application use.

Failure to Rescue and Mortality Differences After Appendectomy in a Low-Middle-Income Country and the United States

BACKGROUND

Major disparities in complications and mortality after appendectomy between countries with different income levels have not been well characterized, as comparative studies at patient level between countries are scant. This study aimed to investigate variations in postoperative complications, mortality, and failure to rescue after appendectomy between a high-income country and a low-to-middle-income country.

METHODS

Hospital discharges on adult patients who underwent appendectomy were extracted from administrative databases from Colombia and 2 states of the United States (Florida and New York). Outcomes included major postoperative complications, in-hospital mortality, and failure to rescue. Univariate analyses were conducted to compare outcomes between the 2 countries. Multivariable logistic regression analyses were conducted to examine the independent effect of country on outcomes after adjustment for patient age, sex, comorbidity index, severity of appendicitis, and appendectomy route (laparoscopic/open).

RESULTS

A total of 62,338 cases from Colombia and 57,987 from the United States were included in the analysis. Patients in Colombia were significantly younger and healthier but had a higher incidence of peritonitis. Use of laparoscopy was significantly lower in Colombia (5.9% vs 89.4%; P < .0001). After adjustment for covariates, multivariable logistic regression analyses revealed that compared to the United States, Colombia had lower complication rates (2.8% vs 6.6%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.39-0.44; P < .0001) but higher mortality (0.44% vs 0.08%; OR, 8.92; 95% CI, 5.69-13.98; P < .0001) and failure to rescue (13.6% vs 1.0%; OR, 17.01; 95% CI, 10.66-27.16; P < .0001).

CONCLUSIONS

Despite lower rates of postoperative complications, in-hospital mortality after appendectomy was higher in Colombia than in the United States. This difference may be explained by higher rates of failure to rescue in the low-to-middle-income country (ie, decreased ability of Colombian hospitals to rescue patients from complications).

Perioperative Risk Assessment of Patients Using the MyRISK Digital Score Completed Before the Preanesthetic Consultation: Prospective Observational Study

BACKGROUND

The ongoing COVID-19 pandemic has highlighted the potential of digital health solutions to adapt the organization of care in a crisis context.

OBJECTIVE

Our aim was to describe the relationship between the MyRISK score, derived from self-reported data collected by a chatbot before the preanesthetic consultation, and the occurrence of postoperative complications.

METHODS

This was a single-center prospective observational study that included 401 patients. The 16 items composing the MyRISK score were selected using the Delphi method. An algorithm was used to stratify patients with low (green), intermediate (orange), and high (red) risk. The primary end point concerned postoperative complications occurring in the first 6 months after surgery (composite criterion), collected by telephone and by consulting the electronic medical database. A logistic regression analysis was carried out to identify the explanatory variables associated with the complications. A machine learning model was trained to predict the MyRISK score using a larger data set of 1823 patients classified as green or red to reclassify individuals classified as orange as either modified green or modified red. User satisfaction and usability were assessed.

RESULTS

Of the 389 patients analyzed for the primary end point, 16 (4.1%) experienced a postoperative complication. A red score was independently associated with postoperative complications (odds ratio 5.9, 95% CI 1.5-22.3; P=.009). A modified red score was strongly correlated with postoperative complications (odds ratio 21.8, 95% CI 2.8-171.5; P=.003) and predicted postoperative complications with high sensitivity (94%) and high negative predictive value (99%) but with low specificity (49%) and very low positive predictive value (7%; area under the receiver operating characteristic curve=0.71). Patient satisfaction numeric rating scale and system usability scale median scores were 8.0 (IQR 7.0-9.0) out of 10 and 90.0 (IQR 82.5-95.0) out of 100, respectively.

CONCLUSIONS

The MyRISK digital perioperative risk score established before the preanesthetic consultation was independently associated with the occurrence of postoperative complications. Its negative predictive strength was increased using a machine learning model to reclassify patients identified as being at intermediate risk. This reliable numerical categorization could be used to objectively refer patients with low risk to teleconsultation.

Were hospitals with sustained high performance more successful at reducing mortality during the pandemic's second wave?

BACKGROUND

In 2019, the COVID-19 pandemic emerged. Variation in COVID-19 patient outcomes between hospitals was later reported.

PURPOSE

This study aims to determine whether sustainers-hospitals with sustained high performance on Hospital Value-Based Purchasing Total Performance Score (HVBP-TPS)-more effectively responded to the pandemic and therefore had better patient outcomes.

METHODOLOGY

We calculated hospital-specific risk-standardized event rates using deidentified patient-level data from the UnitedHealth Group Clinical Discovery Database. HVBP-TPS from 2016 to 2019 were obtained from Centers for Medicare & Medicaid Services. Hospital characteristics were obtained from the American Hospital Association Annual Survey Database (2019), and county-level predictors were obtained from the Area Health Resource File. We use a repeated-measures regression model assuming an AR(1) type correlation structure to test whether sustainers had lower mortality rates than nonsustainers during the first wave (spring 2020) and the second wave (October to December 2020) of the pandemic.

RESULTS

Sustainers did not have significantly lower COVID-19 mortality rates during the first wave of the pandemic, but they had lower COVID-19 mortality rates during the second wave compared to nonsustainers. Larger hospitals, teaching hospitals, and hospitals with higher occupancy rates had higher mortality rates.

CONCLUSION

During the first wave of the pandemic, mortality rates did not differ between sustainers and nonsustainers. However, sustainers had lower mortality rates than nonsustainers in the second wave, most likely because of their knowledge management capabilities and existing structures and resources that enable them to develop new processes and routines to care for patients in times of crisis. Therefore, a consistently high level of performance over the years on HVBP-TPS is associated with high levels of performance on COVID-19 patient outcomes.

PRACTICE IMPLICATIONS

Investing in identifying the knowledge, processes, and resources that foster the dynamic capabilities needed to achieve superior performance in HVBP might enable hospitals to utilize these capabilities to adapt more effectively to future changes and uncertainty.

Functional IT Complementarity and Hospital Performance in the United States: A Longitudinal Investigation

For healthcare practitioners and policymakers, one of the most challenging problems is understanding how to implement health information technology (HIT) applications in a way that yields the most positive impacts on quality and cost of care. We identify four clinical HIT functions which we label as order entry and management (OEM), decision support (DS), electronic clinical documentation (ECD), and results viewing (RV). We view OEM and DS as primary clinical functions and ECD and RV as support clinical functions. Our results show that no single combination of applications uniformly improves clinical and experiential quality and reduces cost for all hospitals. Thus, managers must assess which HIT interactions improve which performance metric under which conditions. Our results suggest that synergies can be realized when these systems are implemented simultaneously. Additionally, synergies can occur when support HIT is implemented before primary HIT and irrespective of the order in which primary HITs are implemented. Practitioners should also be aware that the synergistic effects of HITs and their impact on cost and quality are different for chronic and acute diseases. Our key message to top managers is to prioritize different combinations of HIT contingent on the performance variables they are targeting for their hospitals but also to realize that technology may not impact all outcomes.

Factors of quality of care and their association with smartphone based PHR adoption in South Korean hospitals

BACKGROUND

Healthcare organizations have begun to adopt personal health records (PHR) systems to engage patients, but little is known about factors associated with the adoption of PHR systems at an organizational level. The objective of this study is to investigate factors associated with healthcare organizations' adoption of PHR systems in South Korea.

METHODS

The units of analysis were hospitals with more than 100 beds. Study data of 313 hospitals were collected from May 1 to June 30, 2020. The PHR adoption status for each hospital was collected from PHR vendors and online searches. Adoption was then confirmed by downloading the hospital's PHR app and the PHR app was examined to ascertain its available functions. One major outcome variable was PHR adoption status at hospital level. Data were analysed by logistic regressions using SAS 9.4 version.

RESULTS

Out of 313 hospitals, 103 (32.9%) hospitals adopted PHR systems. The nurse-patient ratio was significantly associated with PHR adoption (OR 0.758; 0.624 to 0.920, p = 0.005). The number of health information management staff was associated with PHR adoption (OR 1.622; 1.228 to 2.141, p = 0.001). The number of CTs was positively associated with PHR adoption (OR 5.346; 1.962 to 14.568, p = 0.001). Among the hospital characteristics, the number of beds was significantly related with PHR adoption in the model of standard of nursing care (OR 1.003; 1.001 to 1.005, p < 0.001), HIM staff (OR 1.004; 1.002 to 1.006, p < 0.001), and technological infrastructure (OR 1.050; 1.003 to 1.006, p < 0.001).

CONCLUSIONS

One-third of study hospitals had adopted PHR systems. Standard of nursing care as well as information technology infrastructure in terms of human resources for health information management and advanced technologies were significantly associated with adoption of PHR systems. A favourable environment for adopting new technologies in general may be associated with the adoption and use of PHR systems.

Resource-based view on safety culture's influence on hospital performance: The moderating role of electronic health record implementation

BACKGROUND

Patient safety and safety culture have received increasing attention from agencies such as the Agency of Healthcare Research and Quality and the Institute of Medicine. Safety culture refers to the fundamental values, attitudes, and perceptions that provide a unique source of competitive advantage to improve performance. This study contributes to the literature and expands understanding of safety culture and hospital performance outcomes when considering electronic health record (EHR) usage.

PURPOSE

Based on the resource-based view of the firm, this study examined the association between safety culture and hospital quality and financial performance in the presence of EHR.

METHODOLOGY/APPROACH

Data consist of the 2016 Hospital Survey on Patient Safety, Hospital Compare, American Hospital Association's annual survey, and the American Hospital Association's Information Technology supplement. Our final analytic sample consisted of 154 hospitals. We used a two-part nested regression model approach.

RESULTS/CONCLUSION

Safety culture has a direct positive relationship with financial performance (operating margin). Furthermore, having basic EHR as compared to not having EHR further enhances this positive relationship. On the other hand, safety culture does not have a direct association with quality performance (readmissions) in most cases. However, safety culture coupled with basic EHR functionalities, compared to not having EHR, is associated with lower readmissions.

PRACTICE IMPLICATIONS

Hospitals should strive to improve patient safety culture as part of their strategic plan for quality improvement. In addition, hospital managers should consider implementing EHR as a resource that can support safety culture's effect on outcomes such as financial and quality performance indicators. Future studies can examine the differences between basic and advanced EHR presence in relation to safety culture.

The interaction between high-level electronic medical record adoption and hospitalist staffing levels: A focus on value-based purchasing

OBJECTIVE

This study sought to understand the relationship of hospital performance with high-level electronic medical record (EMR) adoption, hospitalists staffing levels, and their potential interaction.

MATERIALS AND METHODS

We evaluated 2,699 non-federal, general acute hospitals using 2016 data merged from four data sources. We performed ordinal logistic regression of hospitals' total performance score (TPS) on their EMR capability and hospitalists staffing level while controlling for other market- and individual-level characteristics.

RESULTS

Hospitalists staffing level is shown to be positively correlated with TPS. High-level EMR adoption is associated with both short-term and long-term improvement on TPS. Large, urban, non-federal government hospitals, and academic medical centers tend to have lower TPS compared to their respective counterparts. Hospitals belonging to medium- or large-sized healthcare systems have lower TPS. Higher registered nurse (RN) staffing level is associated with higher TPS, while higher percentage of Medicare or Medicaid share of inpatient days is associated with lower TPS.

DISCUSSION

Although the main effects of hospitalists staffing level and EMR capability are significant, their interaction is not, suggesting that hospitalists and EMR act through separate mechanisms to help hospitals achieve better performance. When hospitals are not able to invest on both simultaneously, given financial constraints, they can still reap the full benefits from each.

CONCLUSION

Hospitalists staffing level and EMR capability are both positively correlated with hospitals' TPS, and they act independently to bolster hospital performance.

Factors affecting the use of clinical practice guidelines by hospital physicians: the interplay of IT infrastructure and physician attitudes

Background

Compliance with clinical practice guidelines (CPGs) remains insufficient around the world, despite frequent updates and continuing efforts to disseminate and implement these guidelines through a variety of strategies. We describe the current status of young resident physician practices towards CPGs and investigate the multiple factors associated with the active use of CPGs, including the physician’s knowledge, attitudes, behaviours, CPG-related education received, and the hospital’s IT infrastructures. The aim is to identify a more effective point for intervention to promote CPG implementation.

Methods

We conducted a questionnaire survey among resident physicians working at 111 hospitals across Japan in 2015 and used results with hospital IT score data collected from a prior survey. Multivariable logistic regression analysis was performed to examine the determinants of frequent use of CPGs (defined at least once per week). The independent variables were selected based on physician demographics, clinical speciality and careers, daily knowledge and behaviour items, CPG-related education received, digital preference, and hospital IT score (high/medium/low), with and without interaction terms.

Results

Responses from 535 resident physicians, at 61 hospitals, were analysed. The median hospital IT score was 6 out of a possible 10 points. Physicians who had learned about CPGs tended to work at hospitals with medium to high IT scores, had easier access to paywalled medical databases, and had better knowledge of the guideline network ‘Minds’. In addition, these physicians tended to use CPGs electronically. A physician’s behaviour towards using CPGs for therapeutic decision-making was strongly associated with frequent use of CPGs (odds ratio [95% CI] 6.1 [3.6–10.4]), which indicated that a physician’s habit strongly promotes CPG use. Moreover, CPG-related education was associated with active use of CPGs (OR1.7 [1.1–2.5]). The interaction effects between individual digital preferences and higher hospital IT score were also observed for frequent CPG use (OR2.9 [0.9–8.8]).

Conclusions

A physician’s habitual behaviours, CPG-related education, and a combination of individual digital preference and superior hospital IT infrastructure are key to bridging the gap between the use and implementation of CPGs.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s13012-020-01056-1.

Analysis of Platforms and Functions of Mobile-Based Personal Health Record Systems

OBJECTIVES

Little is known about the platforms and functionalities of mobile-based personal health record (PHR) applications. The objective of this study was to investigate these two features of PHR systems.

METHODS

The unit of analysis was general hospitals with more than 100 beds. This study was based on a PHR survey conducted from May 1 to June 30, 2020 and the National Health Insurance administrative data as of March 31, 2020. The study considered the platform, Android and iPhone operation system (iOS), and types of functionalities of PHR systems. Among the 316 target hospitals, 103 hospitals had adopted PHR systems. A logistic regression analysis was used.

RESULTS

This study found that 103 hospitals had adopted mobile-based PHR systems for their patients. Sixty-four hospitals (62.1%) were adopting both Android and iOS, but 36 (35.0%) and 3 (2.9%) hospitals were adopting Android only or iOS only, respectively. The PHR systems of hospitals adopting both platforms were more likely to have functions for viewing prescriptions, clinical diagnostic test results, and upcoming appointment status compared to those adopting a single platform (p < 0.001). The number of beds (odds ratio [OR] = 1.004; confidence interval [CI], 1.001-1.007; p = 0.0029) and the number of computed tomography systems (CTs) per 100 beds (OR = 6.350; CI, 1.006-40.084; p = 0.0493) were significantly associated with the adoption of both platforms.

CONCLUSIONS

More than 60% of hospitals had adopted both Android and iOS platforms for their patients in Korea. Hospitals adopting both platforms had additional functionalities and significant association with the number of beds and CTs.

Impact of Patient Census and Admission Mortality on Pediatric Intensive Care Unit Attending Electronic Health Record Activity: A Preliminary Study

BACKGROUND

Physicians may spend a significant amount of time using the electronic health record (EHR), but this is understudied in the pediatric intensive care unit (PICU). The objective of this study is to quantify PICU attending physician EHR usage and determine its association with patient census and mortality scores.

METHODS

During the year 2016, total EHR, chart review, and documentation times of 7 PICU physicians were collected retrospectively utilizing an EHR-embedded time tracking software package. We examined associations between documentation times and patient census and maximum admission mortality scores. Odds ratios (ORs) are reported per 1-unit increase in patient census and mortality scores.

RESULTS

Overall, total daily EHR usage time (median time [hh:mm] [25th, 75th percentile]) was 2:10 (1:31, 3:08). For all hours (8 a.m.-8 a.m.), no strong association was noted between total EHR time, chart review, and documentation times and patient census, Pediatric Index of Mortality 2 (PIM2), or Pediatric Risk of Mortality 3 (PRISM3) scores. For regular hours (8 a.m.-7 p.m.), no strong association was noted between total EHR, chart review, and documentation times and patient census, PIM2, or PRISM3 scores. When patient census was higher, the odds of EHR after-hour usage (7 p.m.-8 a.m.) was higher (OR 1.262 [1.135, 1.403], p < 0.0001), but there were no increased odds with PIM2 (OR 1.090 [0.956, 1.242], p = 0.20) and PRISM3 (OR 1.010 [0.984, 1.036], p = 0.47) scores. A subset of physicians spent less time performing EHR-related tasks when patient census and admission mortality scores were elevated.

CONCLUSION

We performed a novel evaluation of physician EHR workflow in our PICU. Our pediatric critical care physicians spend approximately 2 hours (out of an expected 10-hour shift) each service day using the EHR, but there was no strong or consistent association between EHR usage and patient census or mortality scores. Future larger scale studies are needed to ensure validity of these results.

Does hospital information technology infrastructure promote the implementation of clinical practice guidelines? A multicentre observational study of Japanese hospitals

OBJECTIVES

It remains unclear whether insufficient information technology (IT) infrastructure in hospitals hinders implementation of clinical practice guidelines (CPGs) and affects healthcare quality. The objectives of this study were to describe the present state of IT infrastructure provided in acute care hospitals across Japan and to investigate its association with healthcare quality.

METHODS

A questionnaire survey of hospital administrators was conducted in 2015 to gather information on hospital-level policies and elements of IT infrastructure. The number of positive responses by each respondent to the survey items was tallied. Next, a composite quality indicator (QI) score of hospital adherence to CPGs for perioperative antibiotic prophylaxis was calculated using administrative claims data. Based on this QI score, we performed a chi-squared automatic interaction detection (CHAID) analysis to identify correlates of hospital healthcare quality. The independent variables included hospital size and teaching status in addition to hospital policies and elements of IT infrastructure.

RESULTS

Wide variations were observed in the availability of various IT infrastructure elements across hospitals, especially in local area network availability and access to paid evidence databases. The CHAID analysis showed that hospitals with a high level of access to paid databases (p<0.05) and internet (p<0.05) were strongly associated with increased care quality in larger or teaching hospitals.

CONCLUSIONS

Hospitals with superior IT infrastructure may provide higher-quality care. This allows clinicians to easily access the latest information on evidence-based medicine and facilitate the dissemination of CPGs. The systematic improvement of hospital IT infrastructure may promote CPG use and narrow the evidence-practice gaps.

Hospital Characteristics and the Agency for Healthcare Research and Quality Inpatient Quality Indicators: A Systematic Review

BACKGROUND

The Agency for Healthcare Research and Quality Inpatient Quality Indicators (IQIs) include inpatient mortality for selected procedures and medical conditions. They have assumed an increasingly prominent role in hospital comparisons. Healthcare delivery and policy-related decisions need to be driven by reliable research that shows associations between hospital characteristics and quality of inpatient care delivered.

OBJECTIVES

To systematically review the literature on associations between hospital characteristics and IQIs.

METHODS

We systematically searched PubMed and gray literature (2000-2012) for studies relevant to 14 hospital characteristics and 17 IQIs. We extracted data for study characteristics, IQIs analyzed, and hospital characteristics (e.g., teaching status, bed size, patient volume, rural vs. urban location, and nurse staffing).

RESULTS

We included 16 studies, which showed few significant associations. Four hospital characteristics (higher hospital volume, higher nurse staffing, urban vs. rural status, and higher hospital financial resources) had statistically significant associations with lower mortality and selected IQIs in approximately half of the studies. For example, there were no associations between nurse staffing and four IQIs; however, approximately 50% of studies showed a statistically significant relationship between nurse staffing and lower mortality for six IQIs. For two hospital characteristics-higher bed size and disproportionate share percentage-all statistically significant associations had higher mortality. Five hospital characteristics (teaching status, system affiliation, ownership, minority-serving hospitals, and electronic health record status) had some studies with significantly positive and some with significantly negative associations, and many studies with no association.

CONCLUSIONS

We found few associations between hospital characteristics and mortality IQIs. Differences in study methodology, coding across hospitals, and hospital case-mix adjustment may partly explain these results. Ongoing research will evaluate potential mechanisms for the identified associations.

Hospital heterogeneity: what drives the quality of health care

A major feature of health care systems is substantial variation in health care quality across hospitals. The quality of stroke care widely varies across NHS hospitals. We investigate factors that may explain variations in health care quality using measures of quality of stroke care. We combine NHS trust data from the National Sentinel Stroke Audit with other data sets from the Office for National Statistics, NHS and census data to capture hospitals' human and physical assets and organisational characteristics. We employ a class of non-parametric methods to explore the complex structure of the data and a set of correlated random effects models to identify key determinants of the quality of stroke care. The organisational quality of the process of stroke care appears as a fundamental driver of clinical quality of stroke care. There are rich complementarities amongst drivers of quality of stroke care. The findings strengthen previous research on managerial and organisational determinants of health care quality.

Meaningful Use and Hospital Performance on Post-Acute Utilization Indicators

OBJECTIVES

To examine trends in hospital post-acute utilization indicators and to determine whether improvement in these indicators is associated with attesting to meaningful use (MU).

DATA SOURCES

Medicare claims-based, repeated measures on 30-day hospital-wide all-cause readmission and emergency department (ED) utilization rates for 160 short-stay hospitals (2009-2012); Medicare EHR Incentive Program Payments files (2011-2012); and other hospital and market data.

STUDY DESIGN

Interrupted time series with concurrent comparison group.

PRINCIPAL FINDINGS

Propensity score-weighted multilevel models for change demonstrate that 30-day readmission rates (unadjusted) fell from 13.4 percent in 2009 to 12.1 percent in 2012. Similarly, 30-day ED utilization declined from 18.9 percent to 17.3 percent during the same period. However, MU and non-MU hospitals were indistinguishable vis-à-vis performance. Controlling for hospital and market characteristics, MU was unrelated to 30-day readmission. In contrast, 30-day ED utilization deteriorated.

CONCLUSIONS

Hospitals with MU Stage 1 designation did not show significantly higher improvement on post-acute utilization compared to their counterparts without. To achieve gains in quality and safety, potentially associated with EHRs, and to advance care coordination and patient engagement, the regulators should strengthen accountability by linking comprehensive, outcomes-based performance measures to specific MU objectives.

Overcoming counter-knowledge through telemedicine communication technologies

Purpose Knowledge acquired from sources of unverified information such as gossip, partial truths or lies, in this paper it is termed as "counter-knowledge." The purpose of this paper is to explore this topic through an exploration of the links between a Hospital-in-the-Home Units (HHUs) learning process (LP), counter-knowledge, and the utilization of communication technologies. The following two questions are addressed: Does the reduction of counter-knowledge result in the utilization of communication technologies? Does the development of counter-knowledge hinder the LP? Design/methodology/approach This paper examines the relevance of communication technologies to the exploration and exploitation of knowledge for 252 patients of a (HHU) within a Spanish regional hospital. The data collected was analyzed using the PLS-Graph. Findings To HHU managers, this study offers a set of guidelines to assist in their gaining an understanding of the role of counter-knowledge in organizational LPs and the potential contribution of communication technologies. Our findings support the proposition that the negative effects of counter-knowledge can be mitigated by using communication technologies. Originality/value It is argued in this paper that counter-knowledge may play a variety of different roles in the implementation of LPs. Specifically, the assignment of communication technologies to homecare units has given them the means to filter counter-knowledge and prevent users from any possible problems caused by such counter-knowledge.

Big Data Analytics in Healthcare

The rapidly expanding field of big data analytics has started to play a pivotal role in the evolution of healthcare practices and research. It has provided tools to accumulate, manage, analyze, and assimilate large volumes of disparate, structured, and unstructured data produced by current healthcare systems. Big data analytics has been recently applied towards aiding the process of care delivery and disease exploration. However, the adoption rate and research development in this space is still hindered by some fundamental problems inherent within the big data paradigm. In this paper, we discuss some of these major challenges with a focus on three upcoming and promising areas of medical research: image, signal, and genomics based analytics. Recent research which targets utilization of large volumes of medical data while combining multimodal data from disparate sources is discussed. Potential areas of research within this field which have the ability to provide meaningful impact on healthcare delivery are also examined.

A nationwide survey of trauma center information technology leverage capacity for mental health comorbidity screening

BACKGROUND

Despite evidence that electronic medical record (EMR) information technology innovations can enhance the quality of trauma center care, few investigations have systematically assessed United States (US) trauma center EMR capacity, particularly for screening of mental health comorbidities.

STUDY DESIGN

Trauma programs at all US level I and II trauma centers were contacted and asked to complete a survey regarding health information technology (IT) and EMR capacity.

RESULTS

Three hundred ninety-one of 525 (74%) US level I and II trauma centers responded to the survey. More than 90% of trauma centers reported the ability to create custom patient tracking lists in their EMR. Forty-seven percent of centers were interested in automating a blood alcohol content screening process; only 14% reported successfully using their EMR to perform this task. Marked variation was observed across trauma center sites with regard to the types of EMR systems used as well as rates of adoption and turnover of EMR systems.

CONCLUSIONS

Most US level I and II trauma centers have installed EMR systems; however, marked heterogeneity exists with regard to EMR type, available features, and turnover. A minority of centers have leveraged their EMR for screening of mental health comorbidities among trauma inpatients. Greater attention to effective EMR use is warranted from trauma accreditation organizations.

The effect of health information technology implementation in Veterans Health Administration hospitals on patient outcomes

BACKGROUND

The impact of health information technology (HIT) in hospitals is dependent in large part on how it is used by nurses. This study examines the impact of HIT on the quality of care in hospitals in the Veterans Health Administration (VA), focusing on nurse-sensitive outcomes from 1995 to 2005.

METHODS

Data were obtained from VA databases and original data collection. Fixed-effects Poisson regression was used, with the dependent variables measured using the Agency for Healthcare Research and Quality Inpatient Quality Indicators and Patient Safety Indicators software. Dummy variables indicated when each facility began and completed implementation of each type of HIT. Other explanatory variables included hospital volume, patient characteristics, nurse characteristics, and a quadratic time trend.

RESULTS

The start of computerized patient record implementation was associated with significantly lower mortality for two diagnoses but significantly higher pressure ulcer rates, and full implementation was associated with significantly more hospital-acquired infections. The start of bar-code medication administration implementation was linked to significantly lower mortality for one diagnosis, but full implementation was not linked to any change in patient outcomes.

CONCLUSIONS

The commencement of HIT implementation had mixed effects on patient outcomes, and the completion of implementation had little or no effect on outcomes.

IMPLICATIONS

This longitudinal study provides little support for the perception of VA staff and leaders that HIT has improved mortality rates or nurse-sensitive patient outcomes. Future research should examine patient outcomes associated with specific care processes affected by HIT.

Health information technology and hospital patient safety: a conceptual model to guide research

BACKGROUND

The literature indicates that health information technology (IT) use may lead to some gains in the quality and safety of care in some situations but provides little insight into this variability in the results that has been found. The inconsistent findings point to the need for a conceptual model that will guide research in sorting out the complex relationships between health IT and the quality and safety of care.

METHODS

A conceptual model was developed that describes how specific health IT functions could affect different types of inpatient safety errors and that include contextual factors that influence successful health IT implementation. The model was applied to a readily available patient safety measure and nationwide data (2009 AHA Annual Survey Information Technology Supplement and 2009 Healthcare Cost and Utilization Project State Inpatient Databases).

FINDINGS

The model was difficult to operationalize because (1) available health IT adoption data did not characterize health IT features and extent of usage, and (2) patient safety measures did not elucidate the process failures leading to safety-related outcomes. The sample patient safety measure--Postoperative Physiologic and Metabolic Derangement Rate--was not significantly related to self-reported health IT capabilities when adjusted for hospital structural characteristics.

CONCLUSION

These findings illustrate the critical need for collecting data that are germane to health IT and the possible mechanisms by which health IT may affect inpatient safety. Well-defined and sufficiently granular measures of provider's correct use of health IT functions, the contextual factors surrounding health IT use, and patient safety errors leading to health care-associated conditions are needed to illuminate the impact of health IT on patient safety.

Information technology strategy and alignment issues in health care organizations

BACKGROUND

Information technology (IT) plays a key role in public health care management because it could improve quality, efficiency, and patient care. Researchers and practitioners repeatedly contend that a health care organization's information systems strategy should be aligned with its objectives and strategies, a notion commonly known as IT alignment.

PURPOSE

Actor-related IT alignment issues in health care institutions were explored in this study. More specifically, it explores the possibility of moving beyond the current IT alignment perspective and, in so doing, explores whether IT alignment-as currently conceptualized in the dominant body of research-is sufficient for attaining improved quality, efficiency, and patient care in health care organizations.

METHODS

The findings are based on a qualitative and longitudinal study of six health care organizations in the Stockholm metropolitan area. The empirical data were gathered over the 2005-2011 period from interviews, a focus group, observations, and archival material.

FINDINGS

The data suggest recurrent misalignments between IT strategy and organizational strategy and operations due to the failure to deconstruct the IT artifact and to the existence of various levels of IT maturity.

CONCLUSIONS

A more complex picture of IT alignment in health care that goes beyond the current perspective is being offered by this study. It argues that the previously common way of handling IT as a single artifact and applying one IT strategy to the entire organizational system is obsolete. MANAGERIAL IMPLICATIONS: The article suggests that considerable benefits can be gained by assessing IT maturity and its impact on IT alignment. The article also shows that there are different kinds of IT in medical care that requires diverse decisions, investments, prioritizations, and implementation approaches.

Understanding patient e-loyalty toward online health care services

BACKGROUND

Public health institutions are making a great effort to develop patient-targeted online services in an attempt to enhance their effectiveness and reduce expenses. However, if patients do not use those services regularly, public health institutions will have wasted their limited resources. Hence, patients' electronic loyalty (e-loyalty) is essential for the success of online health care services.

PURPOSES

In this research, an extended Technology Acceptance Model was developed to test e-loyalty intent toward online health care services offered by public health institutions.

METHODOLOGY

Data from a survey of 256 users of online health care services provided by the public sanitary system of a region in Spain were analyzed. The research model was tested by using the structural equation modeling approach.

FINDINGS

The results obtained suggest that the core constructs of the Technology Acceptance Model (perceived usefulness, ease of use, and attitude) significantly affected users' behavioral intentions (i.e., e-loyalty intent), with perceived usefulness being the most decisive antecedent of affective variables (i.e., attitude and satisfaction). This study also reveals a general support for patient satisfaction as a determinant of e-loyalty intent in online health care services.

IMPLICATIONS

Policy makers should focus on striving to get the highest positive attitude in users by enhancing easiness of use and, mainly, perceived usefulness. Because through satisfaction of patients, public hospitals will enlarge their patient e-loyalty intent, health care providers must always work at obtaining satisfied users and to encourage them to continue using the online services.

Hospital IT Sophistication Profiles and Patient Safety Outcomes

Information technology (IT) sophistication of acute care hospitals in Texas was measured to explore the relationships between IT infrastructure and patient outcomes using Donabedian’s framework. The sample was acute care hospitals (n=175) with an IT profile using HIMSS, demographic and operations data. Three dimensions of hospital IT sophistication were measured and related to patient care outcomes using the AHRQ Patient Safety Indicators (PSI). Significant relationships (p < 0.05) using linear regression were found between hospital IT sophistication and three PSI measures. A review of similar studies during the same time period in Iowa, Georgia, and Florida compares findings from two instruments used to profile hospital IT infrastructure. This study adds to and confirms findings of positive relationships between IT sophistication of hospitals and patient care outcomes using the AHRQ safety indicators. Discussion of the conceptual model and the IT sophistication construct provides a theoretical framework for this line of research.

Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico

The findings of a case study assessing the design and implementation of an electronic health record (EHR) in the public health system of Colima, Mexico, its perceived benefits and limitations, and recommendations for improving the implementation process are presented. In-depth interviews and focus group discussions were used to examine the experience of the actors and stakeholders participating in the design and implementation of EHRs. Results indicate that the main driving force behind the use of EHRs was to improve reporting to the two of the main government health and social development programs. Significant challenges to the success of the EHR include resistance by physicians to use the ICD-10 to code diagnoses, insufficient attention to recurrent resources needed to maintain the system, and pressure from federal programs to establish parallel information systems. Operating funds and more importantly political commitment are required to ensure sustainability of the EHRs in Colimaima.

Health information technology and its effects on hospital costs, outcomes, and patient safety

Underlying many reforms in the Patient Protection and Affordable Care Act (ACA) is the use of electronic medical records (EMRs) to help contain costs. We use MarketScan claims data and American Hospital Association information technology (IT) data to examine whether EMRs can contain costs in the ACA's reforms to reduce patient safety events. We find EMRs do not reduce the rate of patient safety events. However, once an event occurs, EMRs reduce death by 34%, readmissions by 39%, and spending by $4,850 (16%), a cost offset of $1.75 per $1 spent on IT capital. Thus, EMRs contain costs by better coordinating care to rescue patients from medical errors once they occur.

Improving quality of service of home healthcare units with health information technologies

Deployment of health information technologies (HITs) provides home care units with the means to generate improvements in accuracy and timeliness of information required to meet dynamic patient demands and provide high quality patient care. Increasing availability of information can also facilitate organisational learning, which leads to the invocation of processes that result in improved responses and decisions. This study examined crucial links between HITs and quality of service provided through an empirical investigation of 252 patients in a hospital-in-the-home unit (HHU) in a Spanish regional hospital. The study sought to test the relationship between HITs and the quality of service using factor analysis and structural equation modeling (SEM) to investigate how HITs mediate effects of organisational learning on quality of service. Findings support the notion that the relationship between organisational learning and quality of service can be mediated by HITs. This study provides HHU managers with guidelines for understanding the role of organisational learning processes with respect to HITs and quality of service.

The effect of hospital electronic health record adoption on nurse-assessed quality of care and patient safety

The aim of this study was to examine the effect of having a basic electronic health record (EHR) on nurse-assessed quality of care, including patient safety. Few large-scale studies have examined how adoption of EHRs may be associated with quality of care. A cross-sectional, secondary analysis of nurse and hospital survey data was conducted. The final sample included 16,352 nurses working in 316 hospitals in 4 states. Logistic regression models were used to evaluate the relationship between basic EHR adoption and nurse-assessed quality of care outcomes. Nurses working in hospitals with basic EHRs consistently reported that poor patient safety and other quality outcomes occurred less frequently than reported by nurses working in hospitals without an EHR. Our findings suggest that the implementation of a basic EHR may result in improved and more efficient nursing care, better care coordination, and patient safety.

The impact of health information exchange on health outcomes

BACKGROUND AND OBJECTIVE

Healthcare professionals, industry and policy makers have identified Health Information Exchange (HIE) as a solution to improve patient safety and overall quality of care. The potential benefits of HIE on healthcare have fostered its implementation and adoption in the United States. However,there is a dearth of publications that demonstrate HIE effectiveness. The purpose of this review was to identify and describe evidence of HIE impact on healthcare outcomes.

METHODS

A database search was conducted. The inclusion criteria included original investigations in English that focused on a HIE outcome evaluation. Two independent investigators reviewed the articles. A qualitative coding approach was used to analyze the data.

RESULTS

Out of 207 abstracts retrieved, five articles met the inclusion criteria. Of these, 3 were randomized controlled trials, 1 involved retrospective review of data, and 1 was a prospective study. We found that HIE benefits on healthcare outcomes are still sparsely evaluated, and that among the measurements used to evaluate HIE healthcare utilization is the most widely used.

CONCLUSIONS

Outcomes evaluation is required to give healthcare providers and policy-makers evidence to incorporate in decision-making processes. This review showed a dearth of HIE outcomes data in the published peer reviewed literature so more research in this area is needed. Future HIE evaluations with different levels of interoperability should incorporate a framework that allows a detailed examination of HIE outcomes that are likely to positively affect care.

The association between health information exchange and measures of patient satisfaction

OBJECTIVE

Health information exchange (HIE) is the interorganizational sharing of patient information and is one of many health information technology initiatives expected to transform the U.S. healthcare system. Two outcomes expected to be improved by HIE are patient-provider communication and patient satisfaction . This analysis examined the relationship between the level of HIE engagement and these two factors in a sample of U.S. hospitals.

METHODS

Independent variables came from existing secondary sources and the dependent measures were from the Hospital Consumer Assessment of Healthcare Providers and Systems. The analysis included 3,278 hospitals. Using ordinary least squares regression, implemented HIE was positively associated with the percentage of patients reporting nurses communicated well and higher satisfaction. Due to the potential for selection bias, results were further explored using a propensity score analysis.

RESULTS

Hospitals that had adopted HIE, but not yet implemented saw no benefits. Hospitals' level of HIE was not associated with the percentage of patients reporting doctors communicated well. According to propensity score corrected estimates, implemented HIE was associated with the percentage of patients who reported nurses always communicated well and who would definitely recommend the hospital.

CONCLUSION

Few studies have examined the impact of HIE at the organizational level. This examination provides some evidence that hospitals engaging in HIE are associated with higher patient satisfaction.

Environmental factors and health information technology management strategy

BACKGROUND

: Previous studies have provided theoretical and empirical evidence that environmental forces influence hospital strategy.

PURPOSES

: Rooted in resource dependence theory and the information uncertainty perspective, this study examined the relationship between environmental market characteristics and hospitals' selection of a health information technology (HIT) management strategy.

METHODOLOGY/APPROACH

: A cross-sectional design is used to analyze secondary data from the American Hospital Association Annual Survey, the Healthcare Information and Management Systems Society Analytics Database, and the Area Resource File. Univariate and multinomial logistic regression analyses are used.

FINDINGS

: Overall, 3,221 hospitals were studied, of which 60.9% pursed a single-vendor HIT management strategy, 28.9% pursued a best-of-suite strategy, and 10.2% used a best-of-breed strategy. Multivariate analyses controlling for hospital characteristics found that measures of environmental factors representing munificence, dynamism, and/or complexity were systematically associated with various hospital HIT management strategy use. Specifically, the number of generalist physicians per capita was positively associated with the single-vendor strategy (B = -5.64, p = .10). Hospitals in urban markets were more likely to pursue the best-of-suite strategy (B = 0.622, p < .001). Dynamism, measured as the number of managed care contracts for a given hospital, was negatively associated with the single-vendor strategy (B = 0.004, p = .049). Lastly, complexity, measured as market competition, was positively associated with the best-of-breed strategy (B = 0.623, p = .042).

PRACTICE IMPLICATIONS

: By and large, environmental factors are associated with hospital HIT management strategies in mostly theoretically supported ways. Hospital leaders and policy makers interested in influencing the adoption of hospital HIT should consider how market conditions influence HIT management decisions as part of programs to promote meaningful use.

Benefits and drawbacks of electronic health record systems

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 that was signed into law as part of the "stimulus package" represents the largest US initiative to date that is designed to encourage widespread use of electronic health records (EHRs). In light of the changes anticipated from this policy initiative, the purpose of this paper is to review and summarize the literature on the benefits and drawbacks of EHR systems. Much of the literature has focused on key EHR functionalities, including clinical decision support systems, computerized order entry systems, and health information exchange. Our paper describes the potential benefits of EHRs that include clinical outcomes (eg, improved quality, reduced medical errors), organizational outcomes (eg, financial and operational benefits), and societal outcomes (eg, improved ability to conduct research, improved population health, reduced costs). Despite these benefits, studies in the literature highlight drawbacks associated with EHRs, which include the high upfront acquisition costs, ongoing maintenance costs, and disruptions to workflows that contribute to temporary losses in productivity that are the result of learning a new system. Moreover, EHRs are associated with potential perceived privacy concerns among patients, which are further addressed legislatively in the HITECH Act. Overall, experts and policymakers believe that significant benefits to patients and society can be realized when EHRs are widely adopted and used in a "meaningful" way.

Electronic Medical Records, Nurse Staffing, and Nurse-Sensitive Patient Outcomes: Evidence From the National Database of Nursing Quality Indicators

Electronic medical records (EMR) have the potential to improve nursing care in the hospital setting. This study estimated the association of EMR implementation with nurse staffing levels, skill mix, contract/agency percent, and nurse-sensitive patient outcomes in U.S. hospitals. Data on nurse staffing and patient outcomes came from the 2004-2008 National Database of Nursing Quality Indicators. Data on EMR implementation came from the 2004-2008 HIMSS Analytics Database. The authors conducted a longitudinal analysis of an unbalanced panel of 3,048 medical/surgical units in 509 short-term, general acute care hospitals. EMR implementation was associated with lower total nurse hours per patient day, higher Registered Nurse percent and contract/agency percent, and higher adverse patient events in the short term. EMR may create a skill bias toward higher-skilled nurses. As more advanced EMR systems diffuse into practice, managers and policy makers should consider potential negative associations of EMR implementation with patient safety.

Electronic medical records, nurse staffing, and nurse-sensitive patient outcomes: evidence from California hospitals, 1998-2007

OBJECTIVE

To estimate the effects of electronic medical records (EMR) implementation on medical-surgical acute unit costs, length of stay, nurse staffing levels, nursing skill mix, nurse cost per hour, and nurse-sensitive patient outcomes.

DATA SOURCES

Data on EMR implementation came from the 1998-2007 HIMSS Analytics Databases. Data on nurse staffing and patient outcomes came from the 1998-2007 Annual Financial Disclosure Reports and Patient Discharge Databases of the California Office of Statewide Health Planning and Development (OSHPD).

METHODS

Longitudinal analysis of an unbalanced panel of 326 short-term, general acute care hospitals in California. Marginal effects estimated using fixed effects (within-hospital) OLS regression.

PRINCIPAL FINDINGS

EMR implementation was associated with 6-10 percent higher cost per discharge in medical-surgical acute units. EMR stage 2 increased registered nurse hours per patient day by 15-26 percent and reduced licensed vocational nurse cost per hour by 2-4 percent. EMR stage 3 was associated with 3-4 percent lower rates of in-hospital mortality for conditions.

CONCLUSIONS

Our results suggest that advanced EMR applications may increase hospital costs and nurse staffing levels, as well as increase complications and decrease mortality for some conditions. Contrary to expectation, we found no support for the proposition that EMR reduced length of stay or decreased the demand for nurses.

Choosing the right amount of healthcare information technologies investments

OBJECTIVES

Choosing and justifying the right amount of investment in healthcare information technologies (HITECH or HIT) in hospitals is an ever increasing challenge. Our objectives are to assess the financial impact of HIT on hospital outcome, and propose decision-helping tools that could be used to rationalize the distribution of hospital finances.

DESIGN

We used a production function and microeconomic tools on data of 21 Paris university hospitals recorded from 1998 to 2006 to compute the elasticity coefficients of HIT versus non-HIT capital and labor as regards to hospital financial outcome and optimize the distribution of investments according to the productivity associated with each input.

RESULTS

HIT inputs and non-HIT inputs both have a positive and significant impact on hospital production (elasticity coefficients respectively of 0.106 and 0.893; R(2) of 0.92). We forecast 2006 results from the 1998 to 2005 dataset with an accuracy of +0.61%. With the model used, the best proportion of HIT investments was estimated to be 10.6% of total input and this was predicted to lead to a total saving of 388 million Euros for the 2006 dataset.

CONCLUSION

Considering HIT investment from the point of view of a global portfolio and applying econometric and microeconomic tools allow the required confidence level to be attained for choosing the right amount of HIT investments. It could also allow hospitals using these tools to make substantial savings, and help them forecast their choices for the following year for better HITECH governance in the current stimulation context.

Practitioner approaches to the integration of clinical decision support system technology in critical care

OBJECTIVE

The aim of this study was to explore the experiences of nurses and physicians who use a clinical decision support system (CDSS) in the critical care area, focusing on clinicians' motives and values related to decisions to either use or not use this optional technology.

BACKGROUND

Information technology (IT) has been demonstrated to positively impact quality of patient care. Decision-support technology serves as an adjunct to, not as a replacement for, actual clinical decision making. Nurse administrators play an imperative role in the planning and implementation of IT projects and can benefit from understanding clinicians' affective considerations and approaches to the technology.

METHODS

This qualitative study used grounded theory methods. A total of 33 clinicians participated in in-depth structured interviews probing their professional concerns with how the technology is used. Data were analyzed using the constant comparative method.

RESULTS

Medical staff were frustrated by perceived lack of planning input before system implementation. Both nurse and physician cohort groups were dissatisfied with preimplementation education. Barriers to system use were identified in significant detail by the participants.

CONCLUSION

Both nurses and physicians should be involved in preimplementation planning and ongoing evaluation of CDSSs. There is a need for a systematic review or Cochrane meta-analysis describing the affective aspects of successful implementations of decisional technology in critical care, specifically from the perspective of nursing administrators.