The relationship between hospital and ehr vendor market dynamics on health information organization presence and participation

Abstract Background Health Information Organizations (HIOs) are third party organizations that facilitate electronic health information exchange (HIE) between providers in a geographic area. Despite benefits from HIE, HIOs have struggled to form and subsequently gain broad provider participation. We sought to assess whether market-level hospital and EHR vendor dynamics are associated with presence and level of hospital participation in HIOs. Methods 2014 data on 4523 hospitals and their EHR vendors were aggregated to the market level. We used multivariate OLS regression to analyze the relationship between hospital and vendor dynamics and (1) probability of HIO presence and (2) percent of hospitals participating in an HIO. Results 298 of 469 markets (64%) had HIO presence, and in those markets, 47% of hospitals participated in an HIO on average. In multivariate analysis, four characteristics were associated with HIO presence. Markets with more hospitals, markets with more EHR vendors, and markets with an EHR vendor-led HIE approach were more likely to have an HIO. Compared to markets with low hospital competition, markets with high hospital competition had a 25 percentage point lower probability of HIO presence. Two characteristics were associated with level of hospital HIO participation. Markets with more hospitals as well as markets with high vendor competition (compared to low competition) had lower participation. Conclusion Both hospital and EHR vendor dynamics are associated with whether a market has an HIO as well as the level of hospital participation in HIOs.https://deepblue.lib.umich.edu/bitstream/2027.42/143537/1/12911_2018_Article_605.pd

Health Information Exchange Use in Primary Care

Indiana University-Purdue University Indianapolis (IUPUI)The United States has invested over $40 billion in digitizing the health care system, yet the anticipated gains in improved care coordination, quality, and cost savings remain largely unrealized. This is due in part to limited interoperability and low rates of health information exchange (HIE) use, which can support care coordination and improve provider decision-making. Primary care providers are central to the US health care delivery system and frequently function as care coordinators, yet capability and HIE use gaps among these providers limit the potential of these digital systems to achieve their intended goals. I study HIE use in the context of primary care to examine 1) factors associated with provider HIE use, 2) the extent and nature of team-based HIE use, and 3) differences in HIE system use patterns across discrete groups of system users. First, I use a national sample of primary care providers to analyze market and practice factors related to HIE use for patient referrals. Overall, I find that only 43% of primary care provider referrals used HIE. Furthermore, I find substantial variation in HIE use rates across electronic health record (EHR) vendors. Second, I use HIE system log data to understand the breadth and depth of HIE use among teams, a care model underpinning primary care delivery reform efforts. I find that although use of HIE systems remains low, in primary care settings it overwhelmingly takes place in a manner consistent with team-based care workflows. Furthermore, team-based use does not differ in breadth from single provider HIE use, but illustrates less depth before and after visits. Third, I apply cluster analysis to 16 HIE use measures representing 7 use attributes, and identify 5 discrete user groups. I then compare two of these user groups and find user-level variation in volume and efficiency of use, both of which have implications for HIE system design and usability improvements. Ultimately, these findings help to inform how HIE use can be increased and improved in primary care, moving the US health care system closer to realizing the coordination, quality, and cost savings made possible by a digitized delivery system

New Organizational Challenges in a Digital World: Securing Cloud Computing Usage and Reacting to Asset-Sharing Platform Disruptions

Information technology (IT) and IT-enabled business models are transforming the business ecosystem and posing new challenges for existing companies. This two-essay dissertation examines two such challenges: cloud security and the disruption of asset-sharing business models.The first essay examines how an organizations usage of cloud storage affects its likelihood of accidental breaches. The quasi-experiment in the U.S. healthcare sector reveals that organizations with higher levels of digitalization (i.e., Electronic Health Records levels) or those with more IT applications running on their internal data center are less likely to experience accidental breaches after using public cloud storage. We argue that digitalization and operational control over IT applications increase organizations awareness and capabilities of establishing a company-wide security culture, thereby reducing negligence related to physical devices and unintended disclosure after adopting cloud storage. The usage of cloud storage is more likely to cause accidental breaches for organizations contracting to more reputable or domain expert vendors. We explain this result as the consequence of less attention being focused on securing personally accessible data and physical devices given high reliance on reputed and knowledgeable cloud providers. This research is among the first to empirically examine the actual security impacts of organizations cloud storage usage and offers practical insights for cloud security management.The second essay examines how Asset-Sharing Business Model Prevalence (ASBMP) affects the performance implications of industry incumbent firms competitive actions when faced with entrants with asset-sharing business models, like Airbnb. ASBMP represents the amount of third-party products and services that originally were unavailable inside the traditional business model but now are orchestrated by asset-sharing companies in an industry. We use texting mining and econometrics approaches to analyze a longitudinal dataset in the accommodation industry. Our results demonstrate that incumbents competitive action repertoires (i.e., action volume, complexity, and heterogeneity) increase their performance when the ASBMP is high but decrease incumbents performance when the ASBMP is low. Practically, incumbents who are facing greater threat from asset-sharing firms can implement more aggressive competitive action repertoires and strategically focus on new product and M&A strategies. This research contributes to the literature of both competitive dynamics and asset-sharing business models

Modeling the Adoption of Identification Standards Within the Healthcare Supply Chain

The adoption of identification standards and its associated technology in the healthcare supply chain has been slow over the past twenty five years, despite the evidence of the benefits that can be achieved. The widespread use of identification standards in the form of barcode labeled medical products can contribute to the reduction of point of care errors and can increase the efficiency of healthcare supply chain related processes. This research is focused on the analysis of the adoption of identification standards in the healthcare supply chain with a particular focus on the healthcare provider adoption challenges. The research is divided into two phases. The first phase develops an extensive literature review on technology adoption with a particular focus on data standards. This adoption process is compared with the adoption of Electronic Health Records (EHR) and Electronic Data Interchange (EDI); main conclusions from the identification standards literature are presented, and a conceptual model to explain the identification-standards adoption process is proposed. The second phase proposes a model for identification standards adoption using a system dynamics modeling approach. The model builds on previous findings associated to the factors affecting identification standards adoption and relates the specific elements to the adoption rate via a causal loop diagram (CLD). The model is formulated in two stages. In the first stage, the Bass Diffusion Model (BDM) of technology adoption is adapted to simulate the adoption of identification standards supporting technologies. The second stage uses most of the factors defined in the CLD to develop a simulation model. A sensitivity analysis identifies relevant model parameters that facilitated the design of interventions to move the adoption process forward. Finally, the effects of some possible interventions are simulated using the validated model. The model provides an illustration of the use of system dynamics models and diffusion theory to understand an important policy problem reported in the literature and not yet solved. Also this research informs real world practitioners and the academic community on issues like the lack of data and other challenging aspects of empirical research that can be addressed with the proposed model and methodology

Implementing electronic health records in hospitals:a systematic literature review

Background: The literature on implementing Electronic Health Records (EHR) in hospitals is very diverse. The objective of this study is to create an overview of the existing literature on EHR implementation in hospitals and to identify generally applicable findings and lessons for implementers. Methods: A systematic literature review of empirical research on EHR implementation was conducted. Databases used included Web of Knowledge, EBSCO, and Cochrane Library. Relevant references in the selected articles were also analyzed. Search terms included Electronic Health Record (and synonyms), implementation, and hospital (and synonyms). Articles had to meet the following requirements: (1) written in English, (2) full text available online, (3) based on primary empirical data, (4) focused on hospital-wide EHR implementation, and (5) satisfying established quality criteria. Results: Of the 364 initially identified articles, this study analyzes the 21 articles that met the requirements. From these articles, 19 interventions were identified that are generally applicable and these were placed in a framework consisting of the following three interacting dimensions: (1) EHR context, (2) EHR content, and (3) EHR implementation process. Conclusions: Although EHR systems are anticipated as having positive effects on the performance of hospitals, their implementation is a complex undertaking. This systematic review reveals reasons for this complexity and presents a framework of 19 interventions that can help overcome typical problems in EHR implementation. This framework can function as a reference for implementers in developing effective EHR implementation strategies for hospitals

The Successful Implementation of Electronic Health Records at Small Rural Hospitals

Electronic health records (EHRs) have been in use since the 1960s. U.S. rural hospital leaders and administrators face significant pressure to implement health information technology because of the American Recovery and Reinvestment Act of 2009. However, some leaders and managers of small rural hospital lack strategies to develop and implement EHRs. The focus of this descriptive phenomenological study was to explore lived experiences of hospital leaders and administrators who have used successful strategies to implement EHRs in small rural hospitals. Diffusion of innovation theory shaped the theoretical framework of this study. Data were collected through telephone interviews conducted with participants who successfully deployed EHRs at 10 hospitals in the Appalachian regions of Maryland, Virginia, and West Virginia. Data analysis occurred using a modified Husserlian approach in search of common themes from interview transcripts. The main themes were strategies to address standards and incentives, implementation, and challenges. The exploration of these strategies provides insight that small rural hospital leaders and administrators could consider for implementing EHRs. The study findings might enable small rural hospital leaders and administrators to contribute to positive social change by engaging communities in using EHRs; these findings may also expand information sharing among individuals and organizations and build social relationships with an expectation of future benefits. Results from this study are designed to inform other small rural hospital leaders and administrators to conduct further research on successful strategies for implementation of EHRs

Hospital Networks of Shared Patients and Engagement in Health Information Exchange

Although the healthcare delivery system is composed of an array of organizations that are linked through important, enduring, and complex ties, the healthcare delivery system is rarely explicitly conceptualized or measured as a network. In consequence, we know little about how the enduring but often informal relationships between organizations shape their behavior in terms of the decisions that they make, the quality of care that they provide, and the efficiency of that care. Using techniques developed in the multidisciplinary field of network analysis, I sought to better understand two important facets of health care that are intrinsically linked to the network perspective: the fragmentation of patients’ treatments between multiple hospitals, and hospitals engagement in electronically sharing patient information. By analyzing networks of shared Medicare patients treated at multiple hospitals, I first identified dense networks of hospitals that are closely interlinked through many high volume shared patient connections and are therefore likely linked through complex collaborative and competitive relationships. I then characterized these networks to identify arrangements of patient sharing that allowed hospitals to better manage care fragmentation. I found that more concentrated networks, in which hospitals shared most of their patients with few important partners rather than a large number of other hospitals, and more centralized networks, in which the network is arranged in a hub-and-spoke model, were associated with more efficient, higher quality care. I next described three different approaches to health information exchange and the logic of participation in each approach with specific emphasis on the value of the enterprise approach for connecting a smaller number of providers and the community approach for facilitating broader connections between more partners. I then investigated whether the choice that hospitals made about how to electronically share patient information was shaped by their networks. I found that hospitals with and within more concentrated patient sharing networks were more likely to engage in enterprise exchange while hospitals with and within less concentrated networks engaged in community exchange more frequently. Together, these findings offer novel insights into the network features of hospitals and how they relate to important healthcare processes and outcomes. More concentrated, centralized networks appear to perform better and these features may be one reason for variation in the cost and quality of care across the nation. Similarly, policy changes designed to shape how healthcare organizations interact and who they interact with—like accountable care organizations, bundled payment initiatives and patient center medical homes—may be more successful if they reinforce beneficial network attributes. Further, as policy efforts designed to facilitate the sharing of information between healthcare providers continue, it will be crucial to allow flexible adoption of different approaches to health information exchange and to support hospitals that engage in an approach to information exchange that benefits communities.PHDHealth Services Organization & PolicyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttps://deepblue.lib.umich.edu/bitstream/2027.42/137104/1/jeverson_1.pd

The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente.

BackgroundPatient portals may lead to enhanced disease management, health plan retention, changes in channel utilization, and lower environmental waste. However, despite growing research on patient portals and their effects, our understanding of the organizational dynamics that explain how effects come about is limited.MethodsThis paper uses qualitative methods to advance our understanding of the organizational dynamics that influence the impact of a patient portal on organizational performance and patient health. The study setting is Kaiser Permanente, the world's largest not-for-profit integrated delivery system, which has been using a portal for over ten years. We interviewed eighteen physician leaders and executives particularly knowledgeable about the portal to learn about how they believe the patient portal works and what organizational factors affect its workings. Our analytical framework centered on two research questions. (1) How does the patient portal impact care delivery to produce the documented effects?; and (2) What are the important organizational factors that influence the patient portal's development?ResultsWe identify five ways in which the patient portal may impact care delivery to produce reported effects. First, the portal's ability to ease access to services improves some patients' satisfaction as well as changes the way patients seek care. Second, the transparency and activation of information enable some patients to better manage their care. Third, care management may also be improved through augmented patient-physician interaction. This augmented interaction may also increase the 'stickiness' of some patients to their providers. Forth, a similar effect may be triggered by a closer connection between Kaiser Permanente and patients, which may reduce the likelihood that patients will switch health plans. Finally, the portal may induce efficiencies in physician workflow and administrative tasks, stimulating certain operational savings and deeper involvement of patients in medical decisions. Moreover, our analysis illuminated seven organizational factors of particular importance to the portal's development--and thereby ability to impact care delivery: alignment with financial incentives, synergy with existing IT infrastructure and operations, physician-led governance, inclusive decision making and knowledge sharing, regional flexibility to implementation, continuous innovation, and emphasis on patient-centered design.ConclusionsThese findings show how organizational dynamics enable the patient portal to affect care delivery by summoning organization-wide support for and use of a portal that meets patient needs