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

Effect of electronic records on mortality among patients in hospital and primary healthcare settings: a systematic review and meta-analyses

Background

Electronic medical records or electronic health records, collectively called electronic records, have significantly transformed the healthcare system and service provision in our world. Despite a number of primary studies on the subject, reports are inconsistent and contradictory about the effects of electronic records on mortality. Therefore, this review examined the effect of electronic records on mortality.

Methods

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guideline. Six databases: PubMed, EMBASE, Scopus, CINAHL, Cochrane Library, and Google Scholar, were searched from February 20 to October 25, 2023. Studies that assessed the effect of electronic records on mortality and were published between 1998 and 2022 were included. Joanna Briggs Institute quality appraisal tool was used to assess the methodological quality of the studies. Narrative synthesis was performed to identify patterns across studies. Meta-analysis was conducted using fixed effect and random-effects models to estimate the pooled effect of electronic records on mortality. Funnel plot and Egger's regression test were used to assess for publication bias.

Results

Fifty-four papers were found eligible for the systematic review, of which 42 were included in the meta-analyses. Of the 32 studies that assessed the effect of electronic health record on mortality, eight (25.00%) reported a statistically significant reduction in mortality, 22 (68.75%) did not show a statistically significant difference, and two (6.25%) studies reported an increased risk of mortality. Similarly, among the 22 studies that determined the effect of electronic medical record on mortality, 12 (54.55%) reported a statistically significant reduction in mortality, and ten (45.45%) studies didn't show a statistically significant difference. The fixed effect and random effects on mortality were OR = 0.95 (95% CI: 0.93-0.97) and OR = 0.94 (95% CI: 0.89-0.99), respectively. The associated I-squared was 61.5%. Statistical tests indicated that there was no significant publication bias among the studies included in the meta-analysis.

Conclusion

Despite some heterogeneity among the studies, the review indicated that the implementation of electronic records in inpatient, specialized and intensive care units, and primary healthcare facilities seems to result in a statistically significant reduction in mortality. Maturity level and specific features may have played important roles.

Systematic Review Registration

PROSPERO (CRD42023437257).

The unfulfilled promises of electronic health records

We provide a brief update on the current evidence on electronic health records' benefits, risks, and potential harms through a rapid narrative review. Many of the promised benefits of electronic health records have not yet been realised. Electronic health records are often not user-friendly. To enhance their potential, electronic health record platforms should be continuously evaluated and enhanced by carefully considering feedback from all stakeholders.

Understanding the impacts of health information systems on patient flow management: A systematic review across several decades of research

Background

Patient flow describes the progression of patients along a pathway of care such as the journey from hospital inpatient admission to discharge. Poor patient flow has detrimental effects on health outcomes, patient satisfaction and hospital revenue. There has been an increasing adoption of health information systems (HISs) in various healthcare settings to address patient flow issues, yet there remains limited evidence of their overall impacts.

Objective

To systematically review evidence on the impacts of HISs on patient flow management including what HISs have been used, their application scope, features, and what aspects of patient flow are affected by the HIS adoption.

Methods

A systematic search for English-language, peer-review literature indexed in MEDLINE and EMBASE, CINAHL, INSPEC, and ACM Digital Library from the earliest date available to February 2022 was conducted. Two authors independently scanned the search results for eligible publications, and reporting followed the PRISMA guidelines. Eligibility criteria included studies that reported impacts of HIS on patient flow outcomes. Information on the study design, type of HIS, key features and impacts was extracted and analysed using an analytical framework which was based on domain-expert opinions and literature review.

Results

Overall, 5996 titles were identified, with 44 eligible studies, across 17 types of HIS. 22 studies (50%) focused on patient flow in the department level such as emergency department while 18 studies (41%) focused on hospital-wide level and four studies (9%) investigated network-wide HIS. Process outcomes with time-related measures such as ‘length of stay’ and ‘waiting time’ were investigated in most of the studies. In addition, HISs were found to address flow problems by identifying blockages, streamlining care processes and improving care coordination.

Conclusion

HIS affected various aspects of patient flow at different levels of care; however, how and why they delivered the impacts require further research.

Electronic health records using a resource advantage theory perspective: an interdisciplinary literature review

Purpose

Warren Buffett asserted that the greatest issue confronting American business and the economy is rising health-care costs, which have risen to 17% of gross domestic product. Public policymakers, health-care providers and other stakeholders grapple with cost-containment and increased health-care delivery efficiencies. There exists a paucity of theory-driven research addressing how information technology vis-à-vis electronic health records (EHR) may supply a managerial mechanism for increasing bottom-line hospital performance, thereby attaining competitive advantage.

Design/methodology/approach

A systematic interdisciplinary literature review motivated by resource advantage theory (RAT) offers a conceptual foundation for analyzing the financial, informational and physical workflows that are core elements of supply chain management in a hospital.

Findings

RAT links how EHR impacts profitability, competitive advantage and macromarketing factors in hospital supply chains. The literature review provides a research synthesis of the implementation and adoption of EHR to reveal its impact on a hospital’s competitive advantage. Although legislative initiatives like the 2009 Health Information Technology for Economic and Clinical Health Act and the Affordable Care Act encourage EHR adoption, there remains a reluctance for hospitals to do so.

Originality/value

The extant literature precedes the relevant legislation, has incomplete data or focuses solely on patient outcomes.

Higher Electronic Health Record Functionality Is Associated with Lower Operating Costs in Urban—but Not Rural—Hospitals

Objectives  The aim of the study is to examine the relationship between electronic health record (EHR) use/functionality and hospital operating costs (divided into five subcategories), and to compare the results across rural and urban facilities.

Methods  We match hospital-level data on EHR use/functionality with operating costs and facility characteristics to perform linear regressions with hospital- and time-fixed effects on a panel of 1,596 U.S. hospitals observed annually from 2016 to 2019. Our dependent variables are the logs of the various hospital operating cost categories, and alternative metrics for EHR use/functionality serve as the primary independent variables of interest. Data on EHR use/functionality are retrieved from the American Hospital Association's (AHA) Annual Survey of Hospitals Information Technology (IT) Supplement, and hospital operating cost and characteristic data are retrieved from the American Hospital Directory. We include only hospitals classified as “general medical and surgical,” removing specialty hospitals.

Results  Our results suggest, first, that increasing levels of EHR functionality are associated with hospital operating cost reductions. Second, that these significant cost reductions are exclusively seen in urban hospitals, with the associated coefficient suggesting cost savings of 0.14% for each additional EHR function. Third, that urban EHR-related cost reductions are driven by general/ancillary and outpatient costs. Finally, that a wide variety of EHR functions are associated with cost reductions for urban facilities, while no EHR function is associated with significant cost reductions in rural locations.

Conclusion  Increasing EHR functionality is associated with significant hospital operating cost reductions in urban locations. These results do not hold across geographies, and policies to promote greater EHR functionality in rural hospitals will likely not lead to short-term cost reductions.

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.

Value of the Electronic Medical Record for Hospital Care: Update From the Literature

Background

Electronic records could improve quality and efficiency of health care. National and international bodies propagate this belief worldwide. However, the evidence base concerning the effects and advantages of electronic records is questionable. The outcome of health care systems is influenced by many components, making assertions about specific types of interventions difficult. Moreover, electronic records itself constitute a complex intervention offering several functions with possibly positive as well as negative effects on the outcome of health care systems.

Objective

The aim of this review is to summarize empirical studies about the value of electronic medical records (EMRs) for hospital care published between 2010 and spring 2019.

Methods

The authors adopted their method from a series of literature reviews. The literature search was performed on MEDLINE with “Medical Record System, Computerized” as the essential keyword. The selection process comprised 2 phases looking for a consent of both authors. Starting with 1345 references, 23 were finally included in the review. The evaluation combined a scoring of the studies’ quality, a description of data sources in case of secondary data analyses, and a qualitative assessment of the publications’ conclusions concerning the medical record’s impact on quality and efficiency of health care.

Results

The majority of the studies stemmed from the United States (19/23, 83%). Mostly, the studies used publicly available data (“secondary data studies”; 17/23, 74%). A total of 18 studies analyzed the effect of an EMR on the quality of health care (78%), 16 the effect on the efficiency of health care (70%). The primary data studies achieved a mean score of 4.3 (SD 1.37; theoretical maximum 10); the secondary data studies a mean score of 7.1 (SD 1.26; theoretical maximum 9). From the primary data studies, 2 demonstrated a reduction of costs. There was not one study that failed to demonstrate a positive effect on the quality of health care. Overall, 9/16 respective studies showed a reduction of costs (56%); 14/18 studies showed an increase of health care quality (78%); the remaining 4 studies missed explicit information about the proposed positive effect.

Conclusions

This review revealed a clear evidence about the value of EMRs. In addition to an awesome majority of economic advantages, the review also showed improvements in quality of care by all respective studies. The use of secondary data studies has prevailed over primary data studies in the meantime. Future work could focus on specific aspects of electronic records to guide their implementation and operation.

Understanding nurses' perceptions of barriers and enablers to use of a new electronic medical record system in Australia: A qualitative study

BACKGROUND

Electronic medical record system implementations impact nurses, their work and workflows. The aim of this study was to understand nurses' perceptions of barriers and enablers to using a new electronic medical record in an acute hospital environment.

METHODS

Data were collected just prior to an organisation-wide new electronic medical record implementation at a large tertiary healthcare organization in Victoria, Australia. Sixty-three nurses from five hospital sites participated in 12 focus group interviews. Transcripts were transcribed and deductive content analysis used the 14-domain Theoretical Domains Framework to identify barriers and enablers.

RESULTS

Coded data mapped to 13 of the 14 domains. Nurse motivation emerged as a dominant theme among both barriers and enablers. Nurses' most common perceived barriers related to emotions (24.1%) and environmental context and resources (21.3%). Conversely, the most common enablers related to social influences (21%) and reinforcement (20.8%).

DISCUSSION

In addition to effecting changes in their work and workflows, the dominance of nurses' emotional responses reveals the potential for implementation of a new electronic medical record to negatively affect nurses' psychological well-being. Using data aligned to the Theoretical Domains Framework assisted identification of behavior change strategies to target the barriers and enablers perceived by nurses. Strategies aligned with nine behavioral intervention categories are recommended for successful implementation and optimization of an electronic medical record by nurses.

CONCLUSIONS

Multifaceted strategies targeting multiple behaviors are required to support adoption of the electronic medical record by nurses, and reduce the risk for nurse attrition in the workforce.

Nurse Motivation, Engagement and Well-Being before an Electronic Medical Record System Implementation: A Mixed Methods Study

Implementation of an electronic medical record (EMR) is a significant workplace event for nurses in hospitals. Understanding nurses' key concerns can inform EMR implementation and ongoing optimisation strategies to increase the likelihood of nurses remaining in the nursing workforce. This concurrent mixed-methods study included surveys from 540 nurses (response rate 15.5%), and interviews with 63 nurses to examine their perceptions of using a new EMR prior to implementation at a single healthcare organisation. Survey findings revealed 32.2% (n = 174) of nurses reported low well-being scores and 28.7% (n = 155) were experiencing burnout symptoms. In contrast, 40.3% (n = 216) of nurses reported high work satisfaction, 62.3% (n = 334) had high intentions of staying in their role, and 34.3% (n = 185) were engaged in their work. Nearly half (n = 250, 46.3%) reported intrinsic motivation towards EMR use. Thematic analysis of focus group interviews revealed two themes, each with three subthemes: (1) Us and Them, detailed the juxtaposition between nurses' professional role and anticipated changes imposed on them and their work with the EMR implementation; and (2) Stuck in the middle, revealed nurses' expectations and anticipations about how the EMR may affect the quality of nurse-patient relationships. In conclusion, anticipation of the EMR implementation emerged as a stressor for nursing staff, with some groups of nurses particularly vulnerable to negative consequences to their well-being.

Electronic Health Record Adoption and Rates of In-hospital Adverse Events

OBJECTIVE

Nationwide initiatives have focused on improving patient safety through greater use of health information technology. We examined the association of hospitals' electronic health record (EHR) adoption and occurrence rates of adverse events among exposed patients.

METHODS

We conducted a retrospective analysis of patient discharges using data from the 2012 and 2013 Medicare Patient Safety Monitoring System. The sample included patients age 18 and older that were hospitalized for one of 3 conditions: acute cardiovascular disease, pneumonia, or conditions requiring surgery. The main outcome measures were in-hospital adverse events, including hospital-acquired infections, adverse drug events (based on selected medications), general events, and postprocedural events. Adverse event rates and patient exposure to a fully electronic EHR were determined through chart abstraction.

RESULTS

Among the 45,235 patients who were at risk for 347,281 adverse events in the study sample, the occurrence rate of adverse events was 2.3%, and 13.0% of patients were exposed to a fully electronic EHR. In multivariate modeling adjusted for patient and hospital characteristics, patient exposure to a fully electronic EHR was associated with 17% to 30% lower odds of any adverse event for cardiovascular (odds ratio [OR], 0.80; 95% confidence interval [CI], 0.72-0.90), pneumonia (OR, 0.70; CI, 0.62-0.80), and surgery (OR, 0.83; CI, 0.72-0.96) patients. The associations of EHR adoption and adverse events varied by event type and by medical condition.

CONCLUSIONS

Cardiovascular, pneumonia, and surgery patients exposed to a fully electronic EHR were less likely to experience in-hospital adverse events.

A taxonomy of hospitals participating in Medicare accountable care organizations

BACKGROUND

Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants.

PURPOSE

Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time.

METHODOLOGY/APPROACH

Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society.

RESULTS

Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology.

CONCLUSION

Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals.

PRACTICE IMPLICATIONS

ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

Staff expectations for the implementation of an electronic health record system: a qualitative study using normalisation process theory

BACKGROUND

Global evidence suggests a range of benefits for introducing electronic health record (EHR) systems to improve patient care. However, implementing EHR within healthcare organisations is complex and, in the United Kingdom (UK), uptake has been slow. More research is needed to explore factors influencing successful implementation. This study explored staff expectations for change and outcome following procurement of a commercial EHR system by a large academic acute NHS hospital in the UK.

METHODS

Qualitative interviews were conducted with 14 members of hospital staff who represented a variety of user groups across different specialities within the hospital. The four components of Normalisation Process Theory (Coherence, Cognitive participation, Collective action and Reflexive monitoring) provided a theoretical framework to interpret and report study findings.

RESULTS

Health professionals had a common understanding for the rationale for EHR implementation (Coherence). There was variation in willingness to engage with and invest time into EHR (Cognitive participation) at an individual, professional and organisational level. Collective action (whether staff feel able to use the EHR) was influenced by context and perceived user-involvement in EHR design and planning of the implementation strategy. When appraising EHR (Reflexive monitoring), staff anticipated short and long-term benefits. Staff perceived that quality and safety of patient care would be improved with EHR implementation, but that these benefits may not be immediate. Some staff perceived that use of the system may negatively impact patient care. The findings indicate that preparedness for EHR use could mitigate perceived threats to the quality and safety of care.

CONCLUSIONS

Health professionals looked forward to reaping the benefits from EHR use. Variations in level of engagement suggest early components of the implementation strategy were effective, and that more work was needed to involve users in preparing them for use. A clearer understanding as to how staff groups and services differentially interact with the EHR as they go about their daily work was required. The findings may inform other hospitals and healthcare systems on actions that can be taken prior to EHR implementation to reduce concerns for quality and safety of patient care and improve the chance of successful implementation.

Electronic health records systems and hospital clinical performance: a study of nationwide hospital data

OBJECTIVE

Electronic health records (EHRs) were expected to yield numerous benefits. However, early studies found mixed evidence of this. We sought to determine whether widespread adoption of modern EHRs in the US has improved clinical care.

METHODS

We studied hospitals reporting performance measures from 2008-2015 in the Centers for Medicare and Medicaid Services Hospital Compare database that also reported having an EHR in the American Hospital Association 2015 IT supplement. Using interrupted time-series analysis, we examined the association of EHR implementation, EHR vendor, and Meaningful Use status with 11 process measures and 30-day hospital readmission and mortality rates for heart failure, pneumonia, and acute myocardial infarction.

RESULTS

A total of 1246 hospitals contributed 8222 hospital-years. Compared to hospitals without EHRs, hospitals with EHRs had significant improvements over time on 5 of 11 process measures. There were no substantial differences in readmission or mortality rates. Hospitals with CPSI EHR systems performed worse on several process and outcome measures. Otherwise, we found no substantial improvements in process measures or condition-specific outcomes by duration of EHR use, EHR vendor, or a hospital's Meaningful Use Stage 1 or Stage 2 status.

CONCLUSION

In this national study of hospitals with modern EHRs, EHR use was associated with better process of care measure performance but did not improve condition-specific readmission or mortality rates regardless of duration of EHR use, vendor choice, or Meaningful Use status. Further research is required to understand why EHRs have yet to improve standard outcome measures and how to better realize the potential benefits of EHR systems.

Development and application of a closed-loop medication administration system in University of Hongkong-Shenzhen Hospital

Objective

This study aimed to develop and apply a closed-loop medication administration system in a hospital in order to reduce medication administration errors (MAEs).

Methods

The study was implemented in four pilot general wards. We used a before-and-after design to collect oral medication administration times before and after the implementation of the closed-loop medication administration system, evaluated MAE alert logs after the intervention, and conducted a survey of the nurses’ satisfaction with the system in the pilot wards.

Results

(a) Nursing time of oral medication administration: before the adoption of the closed-loop medication administration system, the average nursing time was 31.56 ± 10.88 minutes (n = 78); after the adoption of the system, the time was 18.74 ± 5.60 minutes (n = 54). Independent sample t-tests showed a significant difference between two groups (t = 8.85, P <0.00). (b) Degree of nurses’ satisfaction with the closed-loop medication administration system: 60.00% (n = 42) of nurses considered the system to be helpful for their work and nearly half of the nurses (47.14%, n = 33) believed that the system could facilitate clinical work and reduce workload; 51.43% (n = 36) believed that the system could reduce checking time and enhance work efficiency; 82.86% (n = 58) believed that the system was helpful in improving checking accuracy to reduce MAEs and ensure patient safety. More than 60% of the nurses considered the system to be a method that could help to track MAEs to improve nursing quality. (c) The MAE alert logs during observation period: it revealed only 27 alerts from the repeated scans of 3,428 instances of medication administration.

Conclusions

The nurses were satisfied with the closed-loop medication administration system because it improved their work efficiency and reduced their workload. The current investigation was limited by time; therefore, further research is needed to more closely examine the relationship between the system and MAEs.

The Effect of Access to Electronic Health Records on Throughput Efficiency and Imaging Utilization in the Emergency Department

STUDY OBJECTIVE

To evaluate whether the availability of Electronic Health Records (EHRs) reduces throughput time and utilization of advanced imaging for patients in an academic ED.

DATA SOURCES

All patients arriving at an academic Emergency Department (ED) via ambulance between June 1, 2011, and June 4, 2012, were included in the study. This accounted for 9,970 unique ambulance patient visits.

STUDY DESIGN

Retrospective noninterventional analysis of patients in an academic ED. The primary independent variable was whether the patient had a prior EHR at the study hospital. Main outcomes were throughput time, number of advanced diagnostic imaging studies (CT, MRI, ultrasound), and the associated cost of these imaging studies. A set of controls, including age, gender, ICD9 codes, acuity measures, and NYU ED algorithm case severity classifications, was used in an ordinary least-squares (OLS) regression framework to estimate the association between EHR availability and the outcome measures.

PRINCIPAL FINDINGS

A patient with a prior EHR experienced a mean reduction in CT scans of 13.9 percent ([4.9, 23.0]). There was no material change in throughput time for patients with a prior EHR and no difference in utilization of other imaging studies across patients with a prior EHR and those without. Cost savings associated with prior EHRs are $22.52 per patient visit.

CONCLUSION

EHR availability for ED patients is associated with a reduction in CT scans and cost savings but had no impact on throughput time or order frequency of other imaging studies.

Do Years of Experience With Electronic Health Records Matter for Productivity in Community Health Centers?

This study investigated how years of experience with an electronic health record (EHR) related to productivity in community health centers (CHCs). Using data from the 2012 Uniform Data System, we regressed average annual medical visits, weighted for service intensity, as a function of full-time equivalent medical staff controlling for CHC size and location. Physician productivity significantly improved. Although the productivity of all other staff types was not significantly different by years of EHR experience, the trends showed lower productivity among nurses and other medical staff in CHCs with fewer years of EHR experience versus more years of experience.

Meaningful Use of Electronic Health Records and Medicare Expenditures: Evidence from a Panel Data Analysis of U.S. Health Care Markets, 2010-2013

OBJECTIVE

To determine if recent growth in hospital and physician electronic health record (EHR) adoption and use is correlated with decreases in expenditures for elderly Medicare beneficiaries.

DATA SOURCES

American Hospital Association (AHA) General Survey and Information Technology Supplement, Health Information Management Systems Society (HIMSS) Analytics survey, SK&A Information Services, and the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions Data Warehouse Geographic Variation Database for 2010 through 2013.

STUDY DESIGN

Fixed effects model comparing associations between hospital referral region (HRR) level measures of hospital and physician EHR penetration and annual Medicare expenditures for beneficiaries with one of four chronic conditions. Calculated hospital penetration rates as the percentage of Medicare discharges from hospitals that satisfied criteria analogous to Meaningful Use (MU) Stage 1 requirements and physician rates as the percentage of physicians using ambulatory care EHRs.

PRINCIPAL FINDINGS

An increase in the hospital penetration rate was associated with a small but statistically significant decrease in total Medicare and Medicare Part A acute care expenditures per beneficiary. An increase in physician EHR penetration was also associated with a significant decrease in total Medicare and Medicare Part A acute care expenditures per beneficiary as well as a decrease in Medicare Part B expenditures per beneficiary. For the study population, we estimate approximately $3.8 billion in savings related to hospital and physician EHR adoption during 2010-2013. We also found that an increase in physician EHR penetration was associated with an increase in lab test expenses.

CONCLUSIONS

Health care markets that had steeper increases in EHR penetration during 2010-2013 also had steeper decreases in total Medicare and acute care expenditures per beneficiary. Markets with greater increases in physician EHR had greater declines in Medicare Part B expenditures per beneficiary.

Connecting Professional Practice and Technology at the Bedside: Nurses' Beliefs about Using an Electronic Health Record and Their Ability to Incorporate Professional and Patient-Centered Nursing Activities in Patient Care

The purpose of this research is to determine the effects of implementing an electronic health record on medical-surgical registered nurses' time spent in direct professional patient-centered nursing activities, attitudes and beliefs related to implementation, and changes in level of nursing engagement after deployment of the electronic health record. Patient-centered activities were categorized using Watson's Caritas Processes and the Relationship-Based Care Delivery System. Methods included use of an Attitudes and Beliefs Assessment Questionnaire, Nursing Engagement Questionnaire, and Rapid Modeling Corporation's personal digital assistants for time and motion data collection. There was a significant difference in normative belief between nurses with less than 15 years' experience and nurses with more than 15 years' experience (t₂₁ = 2.7, P = .01). While nurses spent less time at the nurses' station, less time charting, significantly more time in patients' rooms and in purposeful interactions, time spent in relationship-based caring behavior categories actually decreased in most categories. Nurses' engagement scores did not significantly increase. These results serve to inform healthcare organizations about potential factors related to electronic health record deployment which create shifts in nursing time spent across care categories and can be used to explore further patient centered care practices.

Texas hospitals with higher health information technology expenditures have higher revenue: A longitudinal data analysis using a generalized estimating equation model

BACKGROUND

The benefits of health information technology (IT) adoption have been reported in the literature, but whether health IT investment increases revenue generation remains an important research question.

METHODS

Texas hospital data obtained from the American Hospital Association (AHA) for 2007-2010 were used to investigate the association of health IT expenses and hospital revenue. The generalized estimation equation (GEE) with an independent error component was used to model the data controlling for cluster error within hospitals.

RESULTS

We found that health IT expenses were significantly and positively associated with hospital revenue. Our model predicted that a 100% increase in health IT expenditure would result in an 8% increase in total revenue. The effect of health IT was more associated with gross outpatient revenue than gross inpatient revenue.

CONCLUSION

Increased health IT expenses were associated with greater hospital revenue. Future research needs to confirm our findings with a national sample of hospitals.

Adoption and Barriers to Adoption of Electronic Health Records by Nurses in Three Governmental Hospitals in Eastern Province, Saudi Arabia

Although electronic health records (EHRs) have been implemented in many hospitals and healthcare providers benefit from their effective and efficient data processing, their evaluation from nurses has received little attention. This project aimed to assess the adoption and barriers to the use of an EHR system by nurses at three governmental hospitals implementing the same EHR software and functionalities in Eastern Province, Saudi Arabia. The study was a cross-sectional, paper-based questionnaire study. SPSS version 20 was used for data entry and analysis, and descriptive statistics were calculated. The study found underutilization of almost all functionalities among all hospitals and no utilization of any communication tools with patients. In addition, there were no instances of "allowing patients to use the Internet to access parts of their health records." The most frequently cited barrier among all hospitals was "loss of access to medical records transiently if computer crashes or power fails" (88.6 percent). This was followed by "lack of continuous training/ support from information technology staff in hospital" (85.9 percent), "additional time required for data entry" (84.9 percent), and "system hanging up problem" (83.8 percent). Complexity of technology (81.6 percent) and lack of system customizability (81.1 percent) were also frequently reported problems. The formation of an EHR committee to discuss problems with the system in Saudi hospitals is recommended.

Impact of CPOE usage on medication management process costs and quality outcomes

We assess the impact of computerized physician order entry (CPOE) systems usage on cost and process quality in the medication management process. Data are compiled from 1,014 U.S. acute-care hospitals that have already implemented CPOE. Data sources include the American Hospital Association, HIMSS Analytics, and the Centers for Medicare and Medicaid Services. We examine the association of CPOE usage with nursing and pharmacy salary costs, and evidence-based medication process compliance. Empirical findings controlling for endogeneity in usage show that benefits accrue even when 100 percent usage is not achieved. We demonstrate that the relationship of CPOE usage with cost and compliance is non-linear.

The influence of institutional pressures on hospital electronic health record presence

Electronic health records (EHR) are a promising form of health information technology that could help US hospitals improve on their quality of care and costs. During the study period explored (2005-2009), high expectations for EHR diffused across institutional stakeholders in the healthcare environment, which may have pressured hospitals to have EHR capabilities even in the presence of weak technical rationale for the technology. Using an extensive set of organizational theory-specific predictors, this study explored whether five factors - cause, constituents, content, context, and control - that reflect the nature of institutional pressures for EHR capabilities motivated hospitals to comply with these pressures. Using information from several national data bases, an ordered probit regression model was estimated. The resulting predicted probabilities of EHR capabilities from the empirical model's estimates were used to test the study's five hypotheses, of which three were supported. When the underlying cause, dependence on constituents, or influence of control were high and potential countervailing forces were low, hospitals were more likely to employ strategic responses that were compliant with the institutional pressures for EHR capabilities. In light of these pressures, hospitals may have acquiesced, by having comprehensive EHR capabilities, or compromised, by having intermediate EHR capabilities, in order to maintain legitimacy in their environment. The study underscores the importance of our assessment for theory and policy development, and provides suggestions for future research.

The combined effect of the electronic health record and hospitalist care on length of stay

OBJECTIVES

To assess the combined impact of electronic health record (EHR) adoption and hospitalist care on length of stay (LOS).

STUDY DESIGN

Retrospective cohort study using data from the Healthcare Information and Management Systems Society and a 5% national sample of Medicare beneficiaries. Patients included 20,862 admissions for respiratory disease cared for by hospitalists, and 28,714 admissions for respiratory disease cared for by nonhospitalists in 2985 general and surgical hospitals in the United States.

METHODS

The interaction effect of EHR and hospitalist care on LOS was evaluated using generalized linear models with log-link normal distribution after controlling for patient and hospital characteristics.

RESULTS

In multivariable analyses controlling for patient and hospital characteristics, we found that the reduced LOS associated with complete EHR was 0.166 days and was statistically significant in the hospitals in which 50% or less of patients were cared for by hospitalists. Moreover, we found that reductions in LOS associated with hospitalist care were greater in hospitals that had not adopted a complete EHR. LOS was 0.599 days shorter for patients cared for by hospitalists versus nonhospitalists in hospitals with incomplete EHR adoption; in hospitals with complete EHR adoption, the stay was 0.433 days shorter.

CONCLUSIONS

The reduced LOS associated with hospitalist care is greater than that associated with EHR adoption. However, the combined reduction in LOS with both EHR adoption and hospitalist care may be substantial.

Lower rates of EMR use in rural hospitals represent a previously unexplored child health disparity

OBJECTIVES

Rural hospitals face significant barriers to adoption of advanced-stage electronic medical records (EMRs), which may translate to an unexplored disparity for children in rural hospitals. Our objective was to determine whether children hospitalized in rural settings are less likely to be cared for using advanced-stage EMRs.

METHODS

We merged the 2009 Healthcare Cost and Utilization Project Kids Inpatient Dataset with the 2009 Healthcare Information and Management Systems Society database. Logistic regression determined the independent relationship between receiving care in a rural hospital and advanced-stage EMRs.

RESULTS

A total of 430 055 (9.3%) of the 4 605 454 pediatric discharges were rural. Logistic regression analysis determined that even when an extensive list of various patient and hospital characteristics are accounted for, rurality continues to be a strong predictor of a child's care without advanced-stage EMRs (odds ratio 0.3; 95% confidence interval, 0.2-0.5).

CONCLUSIONS

Children hospitalized in a rural hospital are less than half as likely to be treated using advanced-stage EMRs. A focus of government and hospital policies to expand the use of EMRs among rural hospitals may reduce this child health care disparity.

Did budget cuts in Medicaid disproportionate share hospital payment affect hospital quality of care?

BACKGROUND

Medicaid Disproportionate Share Hospital (DSH) payments are one of the major sources of financial support for hospitals providing care to low-income patients. However, Medicaid DSH payments will be redirected from hospitals to subsidize individual health insurance purchase through US national health reform.

OBJECTIVES

The purpose of this study is to examine the association between Medicaid DSH payment reductions and nursing-sensitive and birth-related quality of care among Medicaid/uninsured and privately insured patients.

METHODS

Economic theory of hospital behavior was used as a conceptual framework, and longitudinal data for California hospitals from 1996 to 2003 were examined. Hospital-fixed effects regression models were estimated. The unit of analysis is at the hospital level, examining 2 aggregated measures based on the payer category of discharged patients (ie, Medicaid/uninsured and privately insured).

PRINCIPAL FINDINGS

The overall study findings provide at best weak evidence of an association between net Medicaid DSH payments and hospital quality of care for either Medicaid/uninsured or the privately insured patients. The magnitudes of the effects are small and only a few have significant DSH effects.

CONCLUSIONS

Although this study does not find evidence suggesting that reducing Medicaid DSH payments had a strong negative impact on hospital quality of care for Medicaid/uninsured or privately insured patients, the results are not necessarily predictive of the impact national health care reform will have. Research is necessary to monitor hospital quality of care as this reform is implemented.

The effect of electronic medical record application on the length of stay in a Chinese general hospital: a department- and disease-focused interrupted time-series study

A key purpose of electronic medical records (EMR) introduced in medical institutions is to improve work efficiency. The average length of stay (LOS) is just an important indicator to evaluate work efficiency of medical care in hospitals. Recently, there have been reports about effects of EMR application on LOS in medical institutions, but they have been mostly based on the overall analysis of a region or a hospital and not of specific clinical departments and diseases or based on longer time periods. Therefore, in this study, we selected four clinical departments and four diseases with the largest number of inpatients from January 2004 to December 2012 in a Chinese 3A general hospital and used an interrupted time-series method by the departments and diseases to analyze the relationship of EMR application and LOS. Through our analyses, we concluded that, under unadjusted condition, LOS were all reduced (P < 0.001) after EMR application in four departments and for four diseases. After adjustment by gender, age or admission condition, LOS still all decreased after EMR application (P < 0.05) regardless of departments or diseases. The trend changes in LOS reversed from increasing to decreasing in the orthopedics department (coefficient: 0.016 to -0.079), the cardiovascular surgery department (coefficient: 0.007 to -0.126) and all departments overall (coefficient: 0.004 to -0.070), as well as for the intervertebral disc disorders (coefficient: 0.026 to -0.068). Furthermore, the decreasing trend gained a larger slope in the cardiology department (coefficient: -0.017 to -0.023), the neurology department (coefficient: -0.012 to -0.043) and for the coronary heart disease (coefficient: -0.010 to -0.018), the ventricular septal defect (coefficient: -0.024 to -0.059), and the cerebral infarction (coefficient: -0.031 to -0.040). Together, these findings indicate that EMR application coincided with a decrease in LOS and may have a contribution to the decrease.

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.

Health information technology vendor selection strategies and total factor productivity

OBJECTIVE

The aim of this study was to compare health information technology (HIT) adoption strategies' relative performance on hospital-level productivity measures.

DATA SOURCES

The American Hospital Association's Annual Survey and Healthcare Information and Management Systems Society Analytics for fiscal years 2002 through 2007 were used for this study.

STUDY DESIGN

A two-stage approach is employed. First, a Malmquist model is specified to calculate hospital-level productivity measures. A logistic regression model is then estimated to compare the three HIT adoption strategies' relative performance on the newly constructed productivity measures.

PRINCIPAL FINDINGS

The HIT vendor selection strategy impacts the amount of technological change required of an organization but does not appear to have either a positive or adverse impact on technical efficiency or total factor productivity.

CONCLUSIONS

The higher levels in technological change experienced by hospitals using the best of breed and best of suite HIT vendor selection strategies may have a more direct impact on the organization early on in the process. However, these gains did not appear to translate into either increased technical efficiency or total factor productivity during the period studied. Over a longer period, one HIT vendor selection strategy may yet prove to be more effective at improving efficiency and productivity.

Effect of health information technology expenditure on patient level cost

OBJECTIVES

This study investigate the effect of health information technology (IT) expenditure on individual patient-level cost using California Office of Statewide Health Planning and Development (OSHPD) data obtained from 2000 to 2007.

METHODS

We used a traditional cost function and applied hospital fixed effect and clustered error within hospitals.

RESULTS

We found that a quadratic function of IT expenditure best fit the data. The quadratic function in IT expenditure predicts a decrease in cost of up to US$1,550 of IT labor per bed, US$27,909 of IT capital per bed, and US$28,695 of all IT expenditure per bed. Moreover, we found that IT expenditure reduced costs more quickly in medical conditions than surgical diseases.

CONCLUSIONS

Interest in health IT is increasing more than ever before. Many studies examined the effect of health IT on hospital level cost. However, there have been few studies to examine the relationship between health IT expenditure and individual patient-level cost. We found that IT expenditure was associated with patient cost. In particular, we found a quadratic relationship between IT expenditure and patient-level cost. In other word, patient-level cost is non-linearly (or a polynomial of second-order degree) related to IT expenditure.

Electronic medical record adoption in hospitals that care for children

OBJECTIVE

Hospitals that care for children face unique barriers in electronic medical records (EMR) use that may affect their ability to meaningfully use EMR. The purpose of this study was to investigate hospitals that care for children, both freestanding and adult hospitals with children's services, to determine progress toward advanced stages of EMR use.

METHODS

The American Hospital Association survey described hospitals across the United States. Healthcare Information and Management Systems Society 2006 and 2010 databases identified hospitals' EMR use. EMR stage was classified according to previous studies. Multivariable analysis was used to determine independent predictors of EMR use.

RESULTS

The analysis included 2794 hospitals. During the study time frame, a significant increase occurred for hospitals moving into any stage of EMR in adult hospitals with children's services (47% to 75%; P < .001), while improvements for freestanding children's hospitals were modest at best (46% to 59%; P = .3). Conversely, freestanding children's hospitals had the largest gain in advance stage 3 adoption (6% to 39%; P < .001) compared to adult hospitals with children's services (6% to 23%; P < .001). Freestanding children's hospitals were less likely to use pharmacy information systems but more likely to use computerized provider order entry.

CONCLUSIONS

In 2010, freestanding children's hospitals had the highest percentage use of advanced stage EMR (39%), but the lowest improvements in percentage of hospitals entering into any stage of adoption over the study period. This trend created a digital divide among freestanding children's hospitals that may improve with pediatric-specific electronic medication management products.

Meaningful use of electronic health record systems and process quality of care: evidence from a panel data analysis of U.S. acute-care hospitals

OBJECTIVE

To estimate the incremental effects of transitions in electronic health record (EHR) system capabilities on hospital process quality.

DATA SOURCE

Hospital Compare (process quality), Health Information and Management Systems Society Analytics (EHR use), and Inpatient Prospective Payment System (hospital characteristics) for 2006-2010.

STUDY SETTING

Hospital EHR systems were categorized into five levels (Level_0 to Level_4) based on use of eight clinical applications. Level_3 systems can meet 2011 EHR "meaningful use" objectives. Process quality was measured as composite scores on a 100-point scale for heart attack, heart failure, pneumonia, and surgical care infection prevention. Statistical analyses were conducted using fixed effects linear panel regression model for all hospitals, hospitals stratified on condition-specific baseline quality, and for large hospitals.

PRINCIPAL FINDINGS

Among all hospitals, implementing Level_3 systems yielded an incremental 0.35-0.49 percentage point increase in quality (over Level_2) across three conditions. Hospitals in bottom quartile of baseline quality increased 1.16-1.61 percentage points across three conditions for reaching Level_3. However, transitioning to Level_4 yielded an incremental decrease of 0.90-1.0 points for three conditions among all hospitals and 0.65-1.78 for bottom quartile hospitals.

CONCLUSIONS

Hospitals transitioning to EHR systems capable of meeting 2011 meaningful use objectives improved process quality, and lower quality hospitals experienced even higher gains. However, hospitals that transitioned to more advanced systems saw quality declines.

Measure of clinical information technology adoption

Objectives

The objective of this study was to create a new measure for clinical information technology (IT) adoption as a proxy variable of clinical IT use.

Methods

Healthcare Information and Management Systems Society (HIMSS) data for 2004 were used. The 18 clinical IT applications were analyzed across 3,637 acute care hospitals in the United States. After factor analysis was conducted, the clinical IT adoption score was created and evaluated.

Results

Basic clinical IT systems, such as laboratory, order communication/results, pharmacy, radiology, and surgery information systems had different adoption patterns from advanced IT systems, such as cardiology, radio picture archiving, and communication, as well as computerized practitioner order-entry. This clinical IT score varied across hospital characteristics.

Conclusions

Different IT applications have different adoption patterns. In creating a measure of IT use among various IT components in hospitals, the characteristics of each type of system should be reflected. Aggregated IT adoption should be used to explain technology acquisition and utilization in hospitals.

The effect of electronic medical record adoption on outcomes in US hospitals

BACKGROUND

The electronic medical record (EMR) is one of the most promising components of health information technology. However, the overall impact of EMR adoption on outcomes at US hospitals remains unknown. This study examined the relationship between basic EMR adoption and 30-day rehospitalization, 30-day mortality, inpatient mortality and length of stay.

METHODS

Our overall approach was to compare outcomes for the two years before and two years after the year of EMR adoption, at 708 acute-care hospitals in the US from 2000 to 2007. We looked at the effect of EMR on outcomes using two methods. First, we compared the outcomes by quarter for the period before and after EMR adoption among hospitals that adopted EMR. Second, we compared hospitals that adopted EMR to those that did not, before and after EMR adoption, using a generalized linear model.

RESULTS

Hospitals adopting EMR experienced 0.11 (95% CI: -0.218 to -0.002) days' shorter length of stay and 0.182 percent lower 30-day mortality, but a 0.19 (95% CI: 0.0006 to 0.0033) percent increase in 30-day rehospitalization in the two years after EMR adoption. The association of EMR adoption with outcomes also varied by type of admission (medical vs. surgical).

CONCLUSIONS

Previous studies using observational data from large samples of hospitals have produced conflicting results. However, using different methods, we found a small but statistically significant association of EMR adoption with outcomes of hospitalization.