EHR application portfolio and hospital performance: Effects across hospitals with varying administrative scale and clinical complexity

Abstract

Electronic Health Record (EHR) has the potential to transform the work required to create and deliver healthcare services. This has triggered large-scale adoption across hospitals. However, whether all hospitals obtain a similar effect from their EHR implementations remains an important question because there are significant differences differences in characteristics of hospitals adopting these systems. To examine differences in effects across hospitals, we examine whether the impacts of EHR applications are contingent on work domains, by assessing performance effects across hospitals with varying administrative scale and clinical complexity. Because EHRs constitute a suite of applications with different functionalities, examining the effects of different sets of applications is challenging due to nonlinear interdependencies between applications. Therefore, we use an archetype approach, identifying synergistic EHR (EHRSYN) archetype as an ideal portfolio—a conceptual anchor for a hospital’s EHR portfolio. We test contingencies by combining this technology archetype with the work domains—administrative scale and clinical complexity. We test our hypotheses using empirical data from 137 hospitals in California, hypothesizing the differences in effects of EHRs on financial, operational, and clinical performances across hospitals with different administrative scales (size) and clinical complexities (case-mix) of work. While hospitals gain the most by implementing a portfolio close to the EHRSYN archetype, our nuanced models reveal that the benefits of such portfolios increase for large hospitals and are greater for hospitals treating less complex cases. These findings underscore how variations in applications used and work domains demarcate boundaries related to the performance effects of EHRs. We present a detailed discussion of the theoretical contributions and practical implications of our findings.

Introduction

Public investments have increased the usage of electronic health records (EHRs) within hospitals [1]. Governmental interventions have been led by various acts, such as the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and the Federal Health IT Strategic Plan. Large federal government support under the American Recovery and Reinvestment Act (ARRA) included nearly $30 billion for adopting EHRs. As a result, there is now wide-scale adoption of EHRs. For example, within the non-federal acute care hospitals, the adoption of a basic EHR system has gone up to 84 % by 2015 [1]. While adoption is the first step, public funding to enhance EHR adoption across hospitals was based on the reports that the adoption of EHRs will enhance the healthcare performance [2,3]. However, research on the topic is in nascent stages.

Contemporary research reveals that there are differences in how EHRs influence performance across different hospitals, regardless of public funding levels. Social determinants of health play an important role, and researchers are calling for more research examining how contextual factors influence EHR impacts [2,4]. Within hospitals, important contingencies arise due to differences in EHR impacts and differences in organizational work domains—administrative or clinical. Contingencies may influence how much technology impacts vary across work domains. Because investments in EHRs were premised on their greater potential to enhance quality and efficiency in care, it is imperative to study these contingency effects to unravel the efficacy of EHRs across hospitals. Systematic variations in effects may have huge implications for the future adoption and management of EHRs, and the ability of hospitals to serve and save lives. This research highlights and addresses the following research gap: are there systematic differences in the ways EHRs influence performance across hospitals that differ in clinical and administrative characteristics?

Besides being an important question for public accountability and continued support, the question is academically important because realizing the performance effects of information technologies (IT) has been a complex question. Arguments have been made to emphasize that information systems (IS) researchers must focus on unraveling how EHRs reduce costs (financial), enhance operational efficiency and reach, and improve quality of care [5,6]. However, unraveling these effects is challenging due to nonlinear interdependencies between work domains and different EHR applications. There has been a little systematic examination of the complex nonlinearities, and a large body of previous research focuses on single EHR applications, such as computerized physician order entry (CPOE [7,8]). The landscape of EHR applications is complex,¹ as some EHR applications are used to create data and others are used to harness that data² . Previous research highlights that different types of EHR applications have differential effects and are also adopted at different times [2]. Besides complexity in the EHRs’ applications landscape, underlying work domains influence a hospital’s ability to leverage the potential of EHRs, and recent research suggests the need to adapt work processes [89]. We unravel these complex nonlinear interdependencies between and work domains.

To unravel these contingencies influencing EHR impacts, we examine different pathways associated with different outcomes—financial, operational, and quality of care. We examine these pathways, based on three value logics—the (financial) cost logic, the coordination (operational) logic, and the decentralization (quality of care) logic. To examine these effects, we model nonlinear contingencies using the archetype approach, assessing how the portfolio of EHR applications and work domains together influence performance. The archetype perspective helps conceptualize an ideal portfolio of applications with nonlinear interdependencies accommodated across the entire portfolio of EHR applications (synergistic EHR (EHRSYN) archetype³) and work domains^{4 5} . Together, the EHRs and work domains—administrative or clinical—represent organizational–technology archetypes that represent contingencies between EHRs and these domains. We use this formulation to examine how EHRs implementation influence hospital performance—costs, length of stay (LOS), and readmissions—differently across hospitals with varying administrative scale (assessed as the number of beds) and complexity of clinical work activities (assessed as case-mix index (CMI)).⁶

To test the hypotheses, we analyze empirical data from 137 general medical and surgical hospitals in the state of California (CA). Our results establish that there is value in moving toward an EHRSYN archetype, as cost, LOS, and readmission rate reduce with the closeness of an EHR portfolio to this archetype. Our findings unravel contingencies in the effects of EHRs. We find that the reduction in costs, LOS, and readmissions with the closeness of a portfolio to the EHRSYN archetype are stronger for larger hospitals. However, the effect of the closeness of a portfolio to EHRSYN does not vary across smaller hospitals. The benefits that accrue from closeness to the EHRSYN archetype differ across hospitals by complexity in clinical work activities, with greater benefits for hospitals with low clinical complexity.

To broader literature studying impacts of IT within organizations, our study contributes by unraveling three logics—the cost logic, the coordination logic, and the decentralization logic—that underscore how IT systems contribute to service creation and delivery [9,10]. Specifically, we extend previous findings of IT impacts within healthcare organizations [[11], [12], [13]]. By focusing on EHR portfolio implementations, we heed the calls for ways to transcend the focus on IT investments to accurately assess healthcare IT impacts [11]. Our focus on EHR implementations is timely and pertinent because there is an increased focus on unraveling the variance in EHR post-adoption effects across hospitals. For example, research analyzing safety reports indicates that a difference in EHR usability may lead to patient-harming events [105]. Our study extends the research by examining how actual EHR implementations have differential impacts due to differences in work domains.

Differentiating EHR effects across two work domains—clinical and administrative—we contribute by unraveling important contingencies. Within healthcare, administrative and clinical work domains are uniquely distinct, as administrative healthcare workers have to coordinate and manage information flows, and clinical healthcare workers manage the complex clinical operations to deliver effective healthcare services. Contemporaneously, IT have been crucial for creating and providing healthcare services, helping hospitals manage these work activities [13]. Information technologies alleviate uncertainties and help solve complex problems [[14], [15], [16]]. However, traditionally, EHRs have been found to influence work activities differently⁷ . Contingencies unraveled by us underline the role of EHRs as information processing units that help manage uncertainty and solve problems, with effects that change with changes in the hospital’s administrative scale and clinical complexity.

Finally, because EHRs are complex technologies with nonlinear interdependencies among themselves and with organizational context, our use of archetypes presents a new way to assess IT portfolios and organizational implementations. In the healthcare IT domain, previous research using a “portfolio” view examines performance effects due to the sequence of integration of applications [17], types of IT applications, namely, business versus clinical applications [13,18], and clinical, administrative, and strategic IT clusters [19]. Our study extends the scope of these works by modeling interdependencies between EHR applications and organizational work activities—administrative scale and clinical complexity. In doing so, we also address the recent call by scholars for research on advancing the use of EHR to improve patient care [5].