Dissertation title: Making IT work: Essays in health IT implementation and integration”

This multi-method dissertation explores organizational factors that impact implementation and advanced use of health information technologies (IT). The main objective of the dissertation is to further our understanding of the factors that hinder or promote adoption and successful integration of health IT in a world where the vast majority of healthcare organizations in the U.S. have electronic health records (EHRs), yet their potential in achieving interoperability, streamlining care delivery, and improving outcomes has not been fully realized.

Chapter 1: Horizontal consolidation improves hospital interoperability and IT capacity (co-authored with A Jay Holmgren and Robert Huckman) is a quantitative, quasi-experimental study that explores the impact of consolidation on the level of integration and advanced use of hospital EHRs. Leveraging longitudinal data and a stacked difference-in-differences approach, we show that hospitals that underwent horizontal consolidation report significantly higher levels of interoperability and adoption of advanced clinical data analytics functions than those that did not consolidate. These critical improvements in IT systems occur with and without a change in the EHR vendor, suggesting other organizational mechanisms beyond vendor concordance – such as managerial practices or data governance approaches – might be employed by consolidated systems to achieve better data sharing and IT capacity. These findings suggest that horizontal consolidation in hospital markets may have previously unrecognized benefits for the functioning of health IT and underscore the deepening relationship between organizational structures and IT capacity.

Chapter 2: Adoption of advanced IT capabilities by critical access hospitals as a function of proximity to a regional extension center (co-authored with Nate Apathy and A Jay Holmgren) is a quantitative, descriptive study that examines the association between availability of workforce support on adoption of advanced EHR functions among critical access hospitals (CAHs). Most CAHs have implemented EHRs, however, they have continued to struggle with adoption of more advanced EHR functions. The Regional Extension Center (REC) program was created as part of the HITECH Act to provide workforce support and IT expertise to CAHs to facilitate EHR implementation. Here we use variation in geographic distance from the closest REC to create a sample of nearby and distant CAHs and find that nearby CAHs report higher adoption of advanced patient engagement functions, but not of advanced clinical data analytics functions. The findings suggest that RECs may have helped with adoption of some but not all advanced EHR functions, stressing the importance of a comprehensive approach to bridging the “digital divide”.

Chapter 3: Implementation of a continuous patient monitoring system in the hospital setting (co-authored with Alice Kim, Darren Scully, Paula Wolski, Ania Syrowatka, David Bates and Patricia Dykes) is a field-based qualitative study that focuses on understanding the factors associated with the integration of a continuous contact-free patient monitoring system (CFCM) in an acute care inpatient setting. CFCM is a contactless tool that collects patient heart and respiratory rate data and alerts nursing staff (primary users) of abnormal trends, thus assisting in early detection of patient deterioration. Using a combination of stakeholder interviews and process observations, we studied the entire implementation continuum of CFCM, before, during, and after deployment. Pre-deployment findings revealed that the biggest perceived barriers to implementation were: (1) concerns about alarm fatigue; (2) questions about accuracy and trust; (3) impact on patient experience; and (4) challenges to the status quo. Stakeholders identified the value of CFCM as preventing deterioration and being beneficial for patients who are not good candidates for telemetry. These insights were used to create educational materials that addressed each specific barrier and emphasized the shared value of CFCM, as identified by stakeholders. Post-deployment data collection revealed immediate and sustained mean alarm response rate below the desired target of two minutes. Interview analysis showed lessened concern for alarm fatigue and improved trust in the technology. Post-deployment challenges included potentially insufficient training for providers (secondary users) and impact on patient experience. In addition to understanding the perceived barriers to implementation and establishing shared value before deployment of new digital technologies, recommendations for future implementations include: (1) studying strategies for optimal tailoring of education to each user group; (2) identifying and reinforcing positive process changes after deployment; and (3) including patient experience as the overarching element in frameworks for digital tool implementation.