Essays on the Impacts of Health Information Technology Open Access

Hah, Hye Young (2016)

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The purpose of this dissertation is to investigate the emerging role of health information technology in influencing various measures of hospital performance from a multilevel perspective. While there are extensive studies on this matter, it is quite inconclusive as to why implementation of EHR is not automatically linked to enhanced performance. In continuing discussion on the impacts of Electronic Health Records as a special type of HIT, this dissertation calls for more attention on largely overlooked aspect of HIT implementation -"the context." Three essays in this dissertation explore how the existing contextual factors can modify the expected benefits of EHR using various econometrics techniques. The first essay of my dissertation investigates whether US hospitals are ready for new EHR implementation. As a first step toward governmental EHR incentive program (HITECH Act), I viewed the existing HIT infrastructures in administrative and clinical units can be meaningful indicators for their technical readiness toward EHR implementation. Results indicate that the current HIT infrastructure among US hospitals only supports for much basic functionalities of EHR and as EHR becomes more complicated, US hospitals seem to employ intangible non-HIT resources to cope with EHR-induced challenges. The second essay of my dissertation examines how the value of EHR is translated into individual patients' length of stay within a hospital. By considering "a care service triad" in which a care provider, a patient, and EHR features are encountered, I investigate the impacts of interactions of such entities on a patient's length of stay. Results suggest that as hospitals selectively adopted EHR features, the benefits of each feature of EHR are differentially moderated by the focal hospital's existing care conditions- hospital care focus, physician workload, care complexity and patient severity. Such results also largely vary with patient heterogeneity with short-medium-long length of stay. The third essay of my dissertation explores how department level EHR implementation can enhance emergency department (ED) performance. I particularly look at the existing ED information capability as a key mediation mechanism in the link between EHR and ED performance. Results show that in the first round of wait time upon arrival, HIE-mediated EHR is shown to reduce some measures of wait time. In another round of wait time for final disposition, clinical process integration-mediated EHR is likely to reduce wait time for hospital admission. However, such performance effects selectively arise under certain mediation mechanisms.

Table of Contents

Chapter 1. Introduction and Background 1

1.1. Introduction 1

1.2. Overview on Health Information Technology 2

1.3. Agenda of the Dissertation 4

Chapter 2. Measuring the Impacts of HIT on Hospital Productivity and Profitability 6

2.1. Introduction 6

2.2 Theoretical Background 9

2.2.1. Review of the Literature on HIT Infrastructure 9

2.2.2. Review of the Literature on Electronic Health Records 13

2.2.3. Hospital Performance 19

2.2.4. The Complementarity Effects of Electronic Health Records 20 Complementarities of EHR with AHIT Infrastructure 20 Complementarities of EHR with CHIT Infrastructure 21 Complementarities of EHR with the Two HIT Infrastructures 22

2.3. Methods 23

2.3.1. Data and Measures 23

2.3.2. HIT Variables 25

2.3.3. Dependent Variables 27

2.3.4. Control Variables 28

2.4. Model Specification and Identification 30

2.5. Results 34

2.5.1. The Correlation Test 34

2.5.2. The Performance Test 38

2.5.3. Robustness Checks 40

2.6. Discussion 45

2.7. Conclusions 49

Chapter 3. Measuring the Impacts of Feature-based HIT on Individual Patients' Length of Stay (LOS) 51

3.1. Introduction 51

3.2. Theoretical Background 52

3.2.1. IT Use 52

3.2.2. Feature Use of IT 53

3.2.3. Feature-centric IT Artifact: The Feature Use of EHR 56

3.2.4. Dimensions of Hospital-level Clinical Outcome 58

3.2.5. Linking the Feature Use of EHR to Hospital Outcome 59

3.2.6. Hypotheses 61 Hospital Focus 61 Patient Severity 62 Care Complexity 62 Physician Workload 63

3.3. Methods 64

3.4. Model Specification 67

3.5. Results 69

3.6. Post-hoc Analysis 76

3.7. Discussion and Conclusion 82

Chapter 4. Measuring the Impacts of HIT on ED Efficiency Outcomes 84

4.1. Introduction 84

4.2. Theoretical Foundation 86

4.2.1. Information Processing View of ED 86

4.2.2. EHR and Information Processing Needs in EDs 88

4.2.3. ED Efficiency Outcomes 90

4.2.4. Mediated Impacts of EHR on ED Efficiency Outcomes 91

4.3. Methods 93

4.3.1. Data Source 93

4.3.2. Research Variables 94 Dependent Variables 94 Independent Variable 95 Mediator Variables 96 Control Variables 98

4.4. Empirical Analysis 100

4.5. Results 101

4.5.1. Mediation Relationships of EHR-ED mediator-First Stage Wait Time 105

4.5.2. Mediation Relationships of EHR-ED Mediator-Second Stage Wait Time 109

4.6. Discussion and Conclusion 115

Chapter 5. Conclusion 117

Bibliography 119

Appendix I 139

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