Mark L. Diana

U.S. hospital efficiency and adoption of health information technology

This study empirically examines the association between hospital inefficiency and the decision to introduce electronic medical records (EMR) and computerized physician order entry (CPOE) in a national sample of U.S. general hospitals in urban areas in 2006. The main research question is whether the presence of hospital cost inefficiency or other factors driving inefficiency in the production process of a hospital explain low adoption rates of health information technology (HIT) in a hospital setting. We estimated a logistic regression of HIT adoption as a function of hospital cost inefficiency scores obtained using a stochastic frontier analysis. The results demonstrate that hospitals with a greater degree of cost inefficiency were more likely to introduce EMR, suggesting that the benefits of EMR implementation in terms of improved efficiency were likely to outweigh the costs of adoption compared to hospitals that are more efficient. The results showed no association between cost inefficiency and the CPOE adoption decision.

Hospital computerized provider order entry adoption and quality: An examination of the United States.

BACKGROUND There is increasing national interest in advancing health information technology use in hospitals, but there is little research about the impact on quality in a nationally representative sample. PURPOSES The purpose of this study was to investigate the relationship between hospital health information technology adoption and quality. Specifically, we examined the relationship between hospital computerized provider order entry (CPOE) and quality. METHODOLOGY We used a retrospective cross-sectional approach with multiple regression to examine the relationship between hospital CPOE adoption and 10 quality measures from the Hospital Quality Alliance. We used control variables and a propensity score approach to control for confounding factors. FINDINGS Hospital CPOE adoption is positively and significantly associated with five of the quality measures. A significant negative relationship exists between hospital CPOE adoption and another quality measure. When we controlled for confounding factors using the propensity score approach, the significant relationships remain. PRACTICE IMPLICATIONS Strategic adoption of health information technology applications in hospitals along with careful and inclusive implementation of such systems is needed for optimal performance. Universal gains in quality are not guaranteed with CPOE adoption.

Factors Related to Health Information Exchange Participation and Use

This study examines factors facilitating and delaying participation and use of the Health Information Exchange (HIE) in Louisiana. Semi-structured qualitative interviews were conducted with health care representatives throughout the state. Findings suggest that Meaningful Use requirements are a critical factor influencing the decision to participate in the HIE, specifically the mandate that hospitals be able to electronically transfer summary of care documents. Creating buy-in within a few large hospital networks legitimized the HIE and hastened interest in those markets. Fees charged by electronic health record (EHR) vendors to develop HIE interfaces have been prohibitive. Funding from the federal incentive program is intended to offset the costs associated with EHR implementation and increase the likelihood that HIEs can provide value to the population; however, costs and time delays of EHR interface development may be key barriers to fully integrated HIEs. State HIEs may benefit from targeted involvement of state health care leaders who can champion the potential value of the HIE.

Is electronic health record use associated with patient satisfaction in hospitals

PURPOSE The aim of this study was to examine the relationship between hospital electronic health record (EHR) use and patient satisfaction. DATA SOURCES/STUDY SETTING We used EHR and other data from the American Hospital Association and Area Resource File as well as all 10 measures of patient satisfaction from the Hospital Compare data from 2008. METHODOLOGY/APPROACH We used a retrospective cross-sectional approach and control for potential selection bias with propensity score matching. Ten regression models were used to measure the relationship between EHR use and patient satisfaction. Of these, 3 of the 10 patient satisfaction items were hypothesized to be amenable by EHR automation; the remaining 7 measures served as counterfactuals. FINDINGS Electronic health record use was positively and significantly associated with the 3 hypothesized measures and none of the counterfactual measures of patient satisfaction. The three measures associated with EHR use included (a) whether the staff gave the patient information on what to do for recovery at home, (b) whether the patient would rate the hospital as a 9 or a 10, and (c) whether the patient would recommend the hospital. The significant relationships persisted with propensity score adjustments. PRACTICE IMPLICATIONS Electronic health record use is positively associated with 3 of 10 measures of patient satisfaction. Policy and decision makers interested in EHR adoption should also consider the potential impact that such adoption can have on patient satisfaction.

Market factors and electronic medical record adoption in medical practices

Background: Previous studies identified individual or practice factors that influence practice-based physicians’ electronic medical record (EMR) adoption. Less is known about the market factors that influence physicians’ EMR adoption. Purpose: The aim of this study was to explore the relationship between environmental market characteristics and physicians’ EMR adoption. Methods: The Health Tracking Physician Survey 2008 and Area Resource File (2008) were combined and analyzed. Binary logistic regression was used to examine the relationship between three dimensions of the market environment (munificence, dynamism, and complexity) and EMR adoption controlling for several physician and practice characteristics. Results: In a nationally representative sample of 4,720 physicians, measures of market dynamism including increases in unemployment, odds ratio (OR) = 0.95, 95% confidence interval (CI) [0.91, 0.99], or poverty rates, OR = 0.93, 95% CI [0.89, 0.96], were negatively associated with EMR adoption. Health maintenance organization penetration, OR = 3.01, 95% CI [1.49, 6.05], another measure of dynamism, was positively associated with EMR adoption. Physicians practicing in areas with a malpractice crisis, OR = 0.82, 95% CI [0.71, 0.94], representing environmental complexity, had lower EMR adoption rates. Practice Implications: Understanding how market factors relate to practice-based physicians’ EMR adoption can assist policymakers to better target limited resources as they work to realize the national goal of universal EMR adoption and meaningful use.

Hospital Characteristics Associated With Achievement of Meaningful Use

EXECUTIVE SUMMARY The objective of this study was to identify factors associated with hospitals that achieved the Medicare meaningful use incentive thresholds for payment under the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009. We employed a cross‐sectional design using data from the 2011 American Hospital Association Annual Survey, including the Information Technology Supplement; the Centers for Medicare & Medicaid Services report of hospitals receiving meaningful use payments; and the Health Resources and Services Administrations Area Resource File. We used a lagged value from 2010 to determine electronic health record (EHR) adoption. Our methods were a descriptive analysis and logistic regression to examine how various hospital characteristics are associated with the achievement of Medicare meaningful use incentives. Overall, 1,769 (38%) of 4,683 potentially eligible hospitals achieved meaningful use incentive thresholds by the end of 2012. Characteristics associated with organizations that received incentive payments were having an EHR in place in 2010, having a larger bed size, having a single health information technology vendor, obtaining Joint Commission accreditation, operating under for‐profit status, having Medicare share of inpatient days in the middle two quartiles, being eligible for Medicaid incentives, and being located in the Middle Atlantic or South Atlantic census region. Characteristics associated with not receiving incentive payments were being a member of a hospital system and being located in the Mountain or Pacific census region. Thus far, little evidence suggests that the HITECH incentive program has enticed hospitals without an EHR system to adopt meaningful use criteria. Policy makers should consider modifying the incentive program to accelerate the adoption of and meaningful use in hospitals without EHRs.

Assessing the performance of freestanding hospitals.

Freestanding hospitals are becoming less common as more hospitals are joining or establishing relationships with multihospital systems. These associations are driven by factors, such as unrelenting competition in local markets, aging physical plants, increasing labor costs, and higher physician fees, that place a high demand on financial assets. Despite these factors, many freestanding hospitals continue to do well financially, showing increases in total profit margins and total cash flow margins. This article examines which market, management, financial, and mission factors are associated with freestanding hospitals with consistently positive cash flows, relative to those without consistently positive cash flows. The study sample consisted of freestanding, nonfederal, short-term, acute care general hospitals with more than 50 beds and three years of annual cash flow data. Data were taken from the annual surveys of the American Hospital Association, the cost reports of the Centers for Medicare and Medicaid Services, and the Area Resource File of the Health Resources and Services Administration. The data were analyzed using logistic regression to identify those factors associated with a consistently positive cash flow. Freestanding hospitals with positive cash flows were found to have a greater market share and to be located in markets with a higher number of physicians and fewer acute care beds; to have fewer unoccupied beds, higher net revenues, greater liquidity, and less debt on hand; and to treat fewer Medicare patients than those without a positive cash flow. The findings suggest that these hospitals are located in resource-rich environments and that they have strong management teams.

Assessing the process of designing and implementing electronic health records in a statewide public health system: the case of Colima, Mexico

The findings of a case study assessing the design and implementation of an electronic health record (EHR) in the public health system of Colima, Mexico, its perceived benefits and limitations, and recommendations for improving the implementation process are presented. In-depth interviews and focus group discussions were used to examine the experience of the actors and stakeholders participating in the design and implementation of EHRs. Results indicate that the main driving force behind the use of EHRs was to improve reporting to the two of the main government health and social development programs. Significant challenges to the success of the EHR include resistance by physicians to use the ICD-10 to code diagnoses, insufficient attention to recurrent resources needed to maintain the system, and pressure from federal programs to establish parallel information systems. Operating funds and more importantly political commitment are required to ensure sustainability of the EHRs in Colimaima.

The agreement and internal consistency of national hospital EMR measures

There has been national focus on increasing the use of electronic medical records (EMR) in hospitals because of their potential to improve care. Previous research has examined EMR use and reported an inconsistent relationship between EMR use and performance. This study examines the agreement between and the internal consistency of two national datasets that measure hospital EMR use. Data include the Health Information Management Systems Society (HIMSS) and the American Hospital Association (AHA). This analysis is essential to determine the strength and challenges of the nationally available EMR measures that are used in research, which informs national policy and practice. The results show very poor agreement between the two national datasets on hospital EMR use. The datasets demonstrate some internal consistency. In the absence of a gold standard measure of EMR use, researchers must be aware of the limitations of national EMR measures, and future research may validate the datasets.

Measuring Patient Satisfaction's Relationship to Hospital Cost Efficiency: Can Administrators Make a Difference?

Objective: The aim of this study was to assess the ability and means by which hospital administrators can influence patient satisfaction and its impact on costs. Data Sources: Data are drawn from the American Hospital Association’s Annual Survey of Hospitals, federally collected Hospital Cost Reports, and Medicare’s Hospital Compare. Study Design: Stochastic frontier analyses (SFA) are used to test the hypothesis that the patient satisfaction–hospital cost relationship is primarily a latent “management effect.” The null hypothesis is that patient satisfaction measures are main effects under the control of care providers rather than administrators. Principle Findings: Both SFA models were superior to the standard regression analysis when measuring patient satisfaction’s relationship to hospitals’ cost efficiency. The SFA model with patient satisfaction measures treated as main effects, rather than “latent, management effects,” was significantly better comparing the log-likelihood statistics. Higher patient satisfaction scores on the environmental quality and provider communication dimensions were related to lower facility costs. Higher facility costs were positively associated with patients’ overall impressions (willingness to recommend and overall satisfaction), assessments of medication and discharge instructions, and ratings of caregiver responsiveness (pain control and help when called). Conclusions: In the short term, managers have a limited ability to influence patient satisfaction scores, and it appears that working through frontline providers (doctors and nurses) is critical to success. In addition, results indicate that not all patient satisfaction gains are cost neutral and there may be added costs to some forms of quality. Therefore, quality is not costless as is often argued.