Lawrence V. Fulton

Factors Associated With Adoption of Health Information Technology: A Conceptual Model Based on a Systematic Review

Background The Health Information Technology for Economic and Clinical Health Act (HITECH) allocated

Two-Stage Stochastic Optimization for the Allocation of Medical Assets in Steady State Combat Operations

19.2 billion to incentivize adoption of the electronic health record (EHR). Since 2009, Meaningful Use Criteria have dominated information technology (IT) strategy. Health care organizations have struggled to meet expectations and avoid penalties to reimbursements from the Center for Medicare and Medicaid Services (CMS). Organizational theories attempt to explain factors that influence organizational change, and many theories address changes in organizational strategy. However, due to the complexities of the health care industry, existing organizational theories fall short of demonstrating association with significant health care IT implementations. There is no organizational theory for health care that identifies, groups, and analyzes both internal and external factors of influence for large health care IT implementations like adoption of the EHR. Objective The purpose of this systematic review is to identify a full-spectrum of both internal organizational and external environmental factors associated with the adoption of health information technology (HIT), specifically the EHR. The result is a conceptual model that is commensurate with the complexity of with the health care sector. Methods We performed a systematic literature search in PubMed (restricted to English), EBSCO Host, and Google Scholar for both empirical studies and theory-based writing from 1993-2013 that demonstrated association between influential factors and three modes of HIT: EHR, electronic medical record (EMR), and computerized provider order entry (CPOE). We also looked at published books on organizational theories. We made notes and noted trends on adoption factors. These factors were grouped as adoption factors associated with various versions of EHR adoption. Results The resulting conceptual model summarizes the diversity of independent variables (IVs) and dependent variables (DVs) used in articles, editorials, books, as well as quantitative and qualitative studies (n=83). As of 2009, only 16.30% (815/4999) of nonfederal, acute-care hospitals had adopted a fully interoperable EHR. From the 83 articles reviewed in this study, 16/83 (19%) identified internal organizational factors and 9/83 (11%) identified external environmental factors associated with adoption of the EHR, EMR, or CPOE. The conceptual model for EHR adoption associates each variable with the work that identified it. Conclusions Commonalities exist in the literature for internal organizational and external environmental factors associated with the adoption of the EHR and/or CPOE. The conceptual model for EHR adoption associates internal and external factors, specific to the health care industry, associated with adoption of the EHR. It becomes apparent that these factors have some level of association, but the association is not consistently calculated individually or in combination. To better understand effective adoption strategies, empirical studies should be performed from this conceptual model to quantify the positive or negative effect of each factor.

Financial performance monitoring of the technical efficiency of critical access hospitals: a data envelopment analysis and logistic regression modeling approach.

In this study we describe a stochastic optimization model for the relocation of deployable military hospitals, the reallocation of hospital beds, and the emplacement of tactical medical evacuation assets (medical evacuation helicopters and ground ambulances) during steady-state military combat operations (stability operations). The network model is built around an intuitive objective function, one that is derived from military doctrine. The objective to be minimized is the time traveled, weighted by patient severity, from the evacuation site to the point of injury and onward to the hospital location. The optimal solution also determines the number of air and ground ambulances and the hospital beds of each type required at each selected site. Since future casualty locations, numbers, and severities are uncertain, this information is treated as a number of casualty scenarios with assigned scenario probabilities. The number, location, and severities of casualties can be randomly generated, or provided as part of a planning process. The model then seeks a single set of hospital and vehicle locations, plus the paths the evacuation assets should take in each scenario, which minimize expected travel time over all scenarios. The scenario generator is based on realistic historical data from Operation Iraqi Freedom. Since mobile hospitals provide the primary surgical treatment intervention while dedicated ground and air evacuation assets provide the transportation along evacuation paths, the study objective is important for military medical planners, especially those involved in tactical medical evacuation and treatment planning.

Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness.

EXECUTIVE SUMMARY From 1980 to 1999, rural designated hospitals closed at a disproportionally high rate. In response to this emergent threat to healthcare access in rural settings, the Balanced Budget Act of 1997 made provisions for the creation of a new rural hospital— the critical access hospital (CAH). The conversion to CAH and the associated cost‐based reimbursement scheme significantly slowed the closure rate of rural hospitals. This work investigates which methods can ensure the long‐term viability of small hospitals. This article uses a two‐step design to focus on a hypothesized relationship between technical efficiency of CAHs and a recently developed set of financial monitors for these entities. The goal is to identify the financial performance measures associated with efficiency. The first step uses data envelopment analysis (DEA) to differentiate efficient from inefficient facilities within a data set of 183 CAHs. Determining DEA efficiency is an a priori categorization of hospitals in the data set as efficient or inefficient. In the second step, DEA efficiency is the categorical dependent variable (efficient = 0, inefficient = 1) in the subsequent binary logistic regression (LR) model. A set of six financial monitors selected from the array of 20 measures were the LR independent variables. We use a binary LR to test the null hypothesis that recently developed CAH financial indicators had no predictive value for categorizing a CAH as efficient or inefficient, (i.e., there is no relationship between DEA efficiency and fiscal performance).

A Monte Carlo simulation of air ambulance requirements during major combat operations.

Abstract Occipital neuralgia (ON) is characterized by lancinating pain and tenderness overlying the occipital nerves. Both steroid injections and pulsed radiofrequency (PRF) are used to treat ON, but few clinical trials have evaluated efficacy, and no study has compared treatments. We performed a multicenter, randomized, double-blind, comparative-effectiveness study in 81 participants with ON or migraine with occipital nerve tenderness whose aim was to determine which treatment is superior. Forty-two participants were randomized to receive local anesthetic and saline, and three 120 second cycles of PRF per targeted nerve, and 39 were randomized to receive local anesthetic mixed with deposteroid and 3 rounds of sham PRF. Patients, treating physicians, and evaluators were blinded to interventions. The PRF group experienced a greater reduction in the primary outcome measure, average occipital pain at 6 weeks (mean change from baseline −2.743 ± 2.487 vs −1.377 ± 1.970; P < 0.001), than the steroid group, which persisted through the 6-month follow-up. Comparable benefits favoring PRF were obtained for worst occipital pain through 3 months (mean change from baseline −1.925 ± 3.204 vs −0.541 ± 2.644; P = 0.043), and average overall headache pain through 6 weeks (mean change from baseline −2.738 ± 2.753 vs −1.120 ± 2.1; P = 0.037). Adverse events were similar between groups, and few significant differences were noted for nonpain outcomes. We conclude that although PRF can provide greater pain relief for ON and migraine with occipital nerve tenderness than steroid injections, the superior analgesia may not be accompanied by comparable improvement on other outcome measures.

Including Quality, Access, and Efficiency in Healthcare Cost Models

In this study, we evaluate rules of allocation and planning factors that have an effect on requirements for Army air ambulance companies. The Army uses rules of allocation in scenarios drawn from strategic planning documents to determine how many units of each type are required. Army planners use these rules for determining the number of units required to support specific operational and tactical scenarios. Unrealistic rules result in unrealistic unit requirements. We evaluate quantitatively (via Monte Carlo simulation) planning considerations for air ambulance units during major combat operations (MCO) and estimate that 0.4 airframes per admission would be a reasonable planning factor.

A Comparison of Disabled Veteran and Nonveteran Income Time to Revise the Law

The authors investigated cost models that incorporate quality, access, and efficiency to provide decision support for resource forecasting in the multi-billion-dollar U.S. Army health system. As the Army relocates thousands of troops, the medical system must plan for changes in demand; this study supports that effort. Loglinear cost models that include data envelopment analysis (DEA) efficiency scores were evaluated through ordinary least squares estimation, ridge regression, and robust regression, and serve as the analytical framework. Parsimonious models that incorporate a simple volume-complexity metric, a DEA metric, a quality metric, and medical center status variable provide superior forecasting capability.

The Future of Vertical Lift: Initial Insights for Aircraft Capability and Medical Planning

This study evaluates disabled veteran compensation law against its stated objective, equalizing the pay differential associated with disability. The significance of this study is that it provides insight into the efficacy of disabled veteran compensation policy, which derives from tables listed in the Code of Federal Regulations (38 CFR 4). In some cases, these tables have not been updated since 1945. Through regression analysis, personal income (appropriately transformed) is modeled as a function of four variable blocks (demographics, education, geographical, and veteran-related) using secondary data from the 2007 American Community Survey. The population includes working-age adults ages 18 to 64 (n = 1.8 million, representing N = 190 million U.S. citizens). Regression captured 37.2% of the variance in personal income. Veteran-related variables (entered last into the model) accounted for 2.2% of the unique variance. The sample size guaranteed statistical significance, but the analysis proved practically relevant. Disabled veteran status had a large and negative effect, especially as the number of disabilities increased. The results suggest that disabled veterans who have multiple categories of disabilities do not receive income on par with society or with disabled nonveterans reporting the same number of disabilities. This finding provides evidence that 38 CFR 4 is ineffective.

Analyzing the Future of Army Aeromedical Evacuation Units and Equipment: A Mixed Methods, Requirements-Based Approach

The U.S. Army continues to evaluate capabilities associated with the Future of Vertical Lift (FVL) program-a futures program (with a time horizon of 15 years and beyond) intended to replace the current helicopter fleet. As part of the FVL study, we investigated required capabilities for future aeromedical evacuation platforms. This study presents two significant capability findings associated with the future aeromedical evacuation platform and one doctrinal finding associated with medical planning for future brigade operations. The three results follow: (1) Given simplifying assumptions and constraints for a scenario where a future brigade is operating in a 300 x 300 km2, the zero-risk aircraft ground speed required for the FVL platform is 350 nautical miles per hour (knots); (2) Given these same assumptions and constraints with the future brigade projecting power in a circle of radius 150 km, the zero-risk ground speed required for the FVL platform is 260 knots; and (3) Given uncertain casualty locations associated with future brigade stability and support operations, colocating aeromedical evacuation assets and surgical elements mathematically optimizes the 60-minute set covering problem.

Evaluating the Impact of Hospital Efficiency on Wellness in the Military Health System

We utilize a mixed methods approach to provide three new, separate analyses as part of the development of the next aeromedical evacuation (MEDEVAC) platform of the Future of Vertical Lift (FVL) program. The research questions follow: RQ1) What are the optimal capabilities of a FVL MEDEVAC platform given an Afghanistan-like scenario and parameters associated with the treatment/ground evacuation capabilities in that theater?; RQ2) What are the MEDEVAC trade-off considerations associated with different aircraft engines operating under variable conditions?; RQ3) How does the additional weight of weaponizing the current MEDEVAC fleet affect range, coverage radius, and response time? We address RQ1 using discrete-event simulation based partially on qualitative assessments from the field, while RQ2 and RQ3 are based on deterministic analysis. Our results confirm previous findings that travel speeds in excess of 250 knots and ranges in excess of 300 nautical miles are advisable for the FVL platform design, thereby reducing the medical footprint in stability operations. We recommend a specific course of action regarding a potential engine bridging strategy based on deterministic analysis of endurance and altitude, and we suggest that the weaponization of the FVL MEDEVAC aircraft will have an adverse effect on coverage capability.