Collective Bargaining and Technological Investment: The Case of Nurses’ Unions and the Transition from Paper-Based to Electronic Health Records

Does the presence of a unionized nursing workforce retard U.S. hospitals’ transition from paper-based to electronic health records (EHRs)? After tying archival data on hospitals’ structural features and health information technology (IT) investment patterns to self-gathered data on unionism, I find that hospitals that bargain collectively with their registered nurses (RNs) appear to delay or forego the transition away from paper, consistent with existing theory and research in industrial relations and institutional economics. However, this relationship is fully mediated by a hospital’s payer mix: those serving a larger share of less lucrative, elderly, disabled, and indigent patients are more likely to adopt EHRs if they are unionized than if they are not, a result that holds even at the median payer mix. Indeed, this accords with research on the interplay of labour and technology as the aforementioned dynamics are driven entirely by RN-exclusive bargaining units for whom the new IT serves as a complement rather than as a substitute in production. Given the outsized role that unions play in the U.S. healthcare sector, the overall sluggish performance of the sector, and the expectations that policymakers have for EHRs, evidence that these unions are welfare-enhancing should be welcome news

Not Featherbedding, but Feathering the Nest: Human Resource Management and Investments in Information Technology

This study draws on employment relations and management theory, claiming that certain innovative employment practices and work structures pave the way for organizational innovation, namely investments in information technology (IT). It then finds support for the theory in a cross-section of UK workplaces. The findings suggest that firms slow to adopt IT realize that their conventional employment model hinders their ability to make optimal use of new technologies. Therefore, the paper advances the literature beyond studies of unionization’s impact on business investment to a broader set of issues on the employment relations features that make organizations ripe for innovation

Complementary or Conflictual? Formal Participation, Informal Participation, and Organizational Performance

Most studies of worker participation examine either formal participatory structures or informal participation. Yet, increasingly, works councils and other formal participatory bodies are operating in parallel with collective bargaining or are filling the void left by its decline. Moreover, these bodies are sprouting in workplaces in which workers have long held a modicum of influence, authority, and production- or service-related information. This study leverages a case from the healthcare sector to examine the interaction between formal and informal worker participation. Seeking to determine whether or not these two forces—each independently shown to benefit production or service delivery—complement or undermine one another, we find evidence for the latter. In the case of the 27 primary care departments that we study, formal structures appeared to help less participatory departments improve their performance. However, these same structures also appeared to impede those departments with previously high levels of informal participation. While we remain cautious with respect to generalizability, the case serves as a warning to those seeking to institute participation in an environment in which some workers have long felt they had the requisite authority, influence, and information necessary to perform their jobs effectively

Explaining the Health Information Technology Paradox

Excerpt] The substantial gap between the promise inherent in upgrading information systems in health care and the documented reality has baffled health care scholars. Why is a technology so clearly capable of creating efficiencies, increasing safety, and promoting greater information sharing and coordination across professionals failing to live up to expectations

Review of \u3ci\u3eCleaning Up: How Hospital Outsourcing is Hurting Workers and Endangering Patients\u3c/i\u3e

[Excerpt] Researchers sensitive to the plight of low-wage workers in advanced industrialized economies have long sought to convey the magnitude of the problem by retelling sorrowful tales of worker exploitation. Sadly, even their most sympathetic readers have numbed to these accounts. Author Dan Zuberi has found a clever way to transcend this apathy in his new monograph based on about 100 interviews plus behind-the- scenes observations of the impact of hospital support staff outsourcing on patients and workers. Through a well-developed understanding of the work process and changes in the employment relationship, he ties outsourcing and the resulting exploitation of hospital cleaners and food service workers to the spread of viruses, antibiotic-resistant bacteria, and other deadly pathogens. In so doing, he succeeds in delivering his intended take-home message that “worker exploitation hurts us all” (p. 124)

Measurement Error in Performance Studies of Health Information Technology: Lessons from the Management Literature

Just as researchers and clinicians struggle to pin down the benefits attendant to health information technology (IT), management scholars have long labored to identify the performance effects arising from new technologies and from other organizational innovations, namely the reorganization of work and the devolution of decision-making authority. This paper applies lessons from that literature to theorize the likely sources of measurement error that yield the weak statistical relationship between measures of health IT and various performance outcomes. In so doing, it complements the evaluation literature’s more conceptual examination of health IT’s limited performance impact. The paper focuses on seven issues, in particular, that likely bias downward the estimated performance effects of health IT. They are 1.) negative self-selection, 2.) omitted or unobserved variables, 3.) mis-measured contextual variables, 4.) mismeasured health IT variables, 5.) lack of attention to the specific stage of the adoption-to-use continuum being examined, 6.) too short of a time horizon, and 7.) inappropriate units-of-analysis. The authors offer ways to counter these challenges. Looking forward more broadly, they suggest that researchers take an organizationally-grounded approach that privileges internal validity over generalizability. This focus on statistical and empirical issues in health IT-performance studies should be complemented by a focus on theoretical issues, in particular, the ways that health IT creates value and apportions it to various stakeholders

Why Don't Docs Digitize? The Adoption of Health Information Technology in Primary Care Medicine

Reformers in the US have earmarked substantial resources towards encouraging the adoption of electronic health records (EHRs). However, studies have yet to explain why physicians resist adoption and why the investments resulting from a policy push may prove ineffective for improving the efficiency of healthcare delivery. I theorize that health information technology (IT) facilitates certain outcomes that bolster industry-level efficiency, but that the conventional, “fee-for-service” financing of primary care prevents many physicians from appropriating these benefits. Those physicians financing care delivery from a prepaid premium, on the other hand, are positioned to internalize what are otherwise external economies attendant to health IT investment. I find strong statistical support for this theory in a unique panel of US-practicing primary care physicians that allows us to examine health IT adoption as far back as 2001 - long before it garnered policymakers’ attention. The results imply that reformers should focus not on encouraging health IT adoption per se, but on reforms that enable physicians to internalize what are presently socialized benefits

The Quality of Jobs Created by Entrepreneurs

Few dare to challenge the conventional wisdom that small business is the engine of job creation. Indeed, in the United States, the image of the small business owner left largely unfettered to create novel products and services sits on the same cultural plane as baseball and apple pie, and one would be hard-pressed to find a policymaker who would openly question the wisdom that most new jobs arise either directly or indirectly from these small businesses. This near religious belief in the small business owner as job creator yields a steady stream of policies offering tax relief to small businesses, often specifically tied to their behavior as job creators, as well as broader proposals that aim to cut the red tape that could hinder a business’s ability to raise capital or to safeguard its intellectual property. Not surprisingly, these policies and their potential to improve macroeconomic outcomes become particularly salient during times of high unemployment. Luckily, there are still those who refuse to accept this conventional wisdom. They usually point to meticulous research on job creation that shows that the large share of employment growth typically ascribed to small businesses more rightly belongs to new businesses—entrepreneurs. And, of course, while most new businesses start out small, most small businesses are not all that young. However, even astute observers are likely to miss the second flaw in the notion that policy that props up small business will necessarily improve our nation’s economic health. That is, after one sorts out the issue of the quantity of jobs created by new businesses, one should consider the quality of these jobs. Are these really the sorts of jobs that will materially improve the lives of their incumbents, thereby setting off a chain reaction that ultimately ends in higher aggregate demand and greater economic activity

Examination of the adoption and use of EHRs

Thesis (Ph. D.)--Massachusetts Institute of Technology, Sloan School of Management, 2008.This electronic version was submitted by the student author. The certified thesis is available in the Institute Archives and Special Collections.Includes bibliographical references.This dissertation advances theory on the interplay of workplace technological change and features of the employment relationship to inform an active policy debate. In particular, many connect US healthcare's lackluster economic performance -- both historically and relative to other industries -- to its apparent reluctance to adopt electronic health record (EHR) systems. Drawing on management and employment relations theory as well as a multi-method field study of a large-scale healthcare provider, I first demonstrate that performance improvements depend not on the technology per se, but rather on the concomitant adoption of both the information technology (IT) and the rest of its reinforcing work system. In line with prior research, the work system includes workplace-level employment practices like teamwork and training. However, I advance our understanding of these complementarities by showing that their emergence depends on the scope of participatory structures included in the work system. Irrespective of how engaged workers are in the IT initiative, participation only complements the effectiveness of the EHR system where workers could 1.) renegotiate IT-engendered changes in the terms and conditions of employment, and 2.) influence the configuration and deployment of the technology. Based on these findings, IT adoption does not ensure improved performance, implying a shortcoming in policies promoting the diffusion of EHRs rather than the adoption of EHR-inclusive work systems. Drawing once again on both theory and the field study, I propose that only certain medical practices -- most notably, those that finance patient care on a prepaid or "capitated" basis -- internalize the benefits of EHR investment.(cont.) Therefore, physicians affiliated with such organizations are more likely to report that their practice adopted the technology along with financial incentives to encourage its optimal use. Those practices whose IT adoption cannot be explained by their business strategy will be less likely to introduce the requisite incentives. Econometric evidence derived from a nationwide sample of physicians finds strong support for these hypotheses. Therefore, this dissertation warns of the imminent decoupling of EHR technology from its work system while advancing management and employment relations theory.by Adam Seth Litwin.Ph.D

Ducks and Decoys: Revisiting the Exit-Voice-Loyalty Framework in Assessing the Impact of a Workplace Dispute Resolution System

Until now, empirical research has been unable to reliably identify the impact of organizational dispute resolution systems (DRSs) on the workforce at large, in part because of the dearth of data tracking employee perceptions pre- and post- implementation. This study begins to fill this major gap by exploiting survey data from a single, geographically-expansive, US firm with well over 100,000 employees in over a thousand locations. The research design allows us to examine employment relations and human resource (HR) measures, namely, perceptions of justice, organizational commitment, and perceived legal compliance, in the same locations before and after the implementation of a typical, multistep DRS that begins with informal reporting to local managers and culminates with mandatory arbitration. Even after holding all time-constant, location-level variables in place, we find that introduction of the DRS is associated with elevated perceptions of informal procedural justice and interactive justice, but diminished perceptions of formal procedural justice. We also find no discernible effect on organizational commitment, but a significant boost to perceived legal compliance by the company, raising important questions about the tradeoff between voice and exit and formal versus informal aspects of dispute resolution mechanisms.