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Evaluating electronic health record systems: A system dynamics simulation

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 Simulation

Simulation: Transactions of the Society for

Modeling and Simulation International
88(6) 639–648
Evaluating electronic health record Ó The Author(s) 2012
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DOI: 10.1177/0037549711416244
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Narges Kasiri1, Ramesh Sharda2 and Daniel

Adomako Asamoah2

Abstract
Implementing electronic health record (EHR) systems in the next few years is on the agenda for many healthcare
organizations. Before investing in an EHR system, however, decision makers need to identify and measure the benefits
of such systems. We propose using a system dynamics (SD) approach to measuring the benefits of EHR systems. Using an
SD approach, it is possible to map complex relationships among clinical processes in hospitals into a model by which one
can dynamically measure the effect of any changes in the parameters over time. Simulation of EHR implementations using
an SD model produces useful data on the benefits of EHRs that are hard to obtain through empirical data collection
methods. The results of an SD model can then be transformed into economic values to estimate financial performance.
This paper presents an example of an SD model and its application in EHR decision making.

Keywords
electronic health record, electronic health record benefit analysis, simulation, system dynamics

1. Introduction An example of the latter is when an IT investment

Many healthcare organizations will be implementing
electronic health record (EHR) technology in the next
few years. However, before employing information
technology (IT) in the health sector, hospital adminis-
trators need to evaluate such information systems.
Many problems in healthcare systems are due to inac-
cessible data, information, and knowledge. Knowledge
management and information systems are important to
healthcare organizations, but managers have to guar-
antee that such an investment is financially justifiable.
A study by Ford et al.1 shows a positive relationship
between IT adoption and financial performance in hos-
pitals. They employ a macro-level approach to studying
the link between IT and hospital performance. Their
results indicate that the adoption of IT applications in
administrative, clinical, and strategic areas in hospitals
improves financial indices, such as return on assets
(ROA), cash flow ratio, operating margin, and total
margin.
IT benefits usually need to relate to both profitability
and quality in an organization. An example of the
former is when an IT investment leads to efficiencies
in tasks and perhaps to a reduction in the work force.2
decreases the errors in task processing and thus increases
the accuracy of task results.3
Quantifying the tangible (e.g. time efficiency) and
intangible (patients’ satisfaction) benefits of using IT
in clinical and decision-making processes is a difficult
task. We propose using a system dynamics (SD) tech-
nique to estimate EHR benefits through a simulation.
The results of the SD model can then be transformed
into economic values to estimate financial indices.
Use of IT in healthcare organizations lags behind
that in manufacturing and other service sectors. One
of the reasons is the failure of existing systems.4
Failure can be the result of system design. Also a new
1
Management, Marketing and Information Systems, Division of Economics
and Business, State University of New York at Oneonta, USA.
2
Management Science and Information Systems, Spears School of
Business, Oklahoma State University, USA.
Corresponding author:
Narges Kasiri, Management, Marketing and Information Systems, Division
of Economics and Business, State University of New York at Oneonta,
316 Netzer Administration Building, Oneonta, NY 13820, USA
Email: kasirina@oneonta.edu
640 Simulation: Transactions of the Society for Modeling and Simulation International 88(6)
technology might not be appropriate for a specific
setting, or the technology might not be adopted by its
intended users within the organization. The failure of
existing systems might also have financial roots. A
method for valuing an IT asset could help healthcare
managers adjust the financial expectations for IT
investments before new IT projects are designed and
implemented.
Although administrative IT systems that deal with
billing, data processing, and other administrative issues
have been utilized in hospitals for quite some time,5
clinical information systems, such as EHR systems,
have not been used extensively. President Bush, in
April 2004, urged the healthcare industry to adopt
widespread use of EHRs by 2014.6 However, although
electronic healthcare had been a major policy of the
government since 2004, by the summer of 2006, only
about 25% of physicians reported that they were fully
or partially using EHR systems. One of the priorities
outlined by President Obama’s administration is devel-
oping IT, and particularly electronic healthcare. The
Administration considers this priority as one of the
ways to improve the healthcare system. Approximately
US$20 billion of the stimulus package approved in 2009
was assigned to promote IT in healthcare. In particular,
there are some incentives for physicians to implement
EHR systems.
There are many different aspects of EHR implemen-
tation, such as choosing an appropriate technology and
managing the project to ensure quality and return on
investment, all of which should be studied to under-
stand possible barriers that might keep EHR adoption
rates low. One can divide adoption barriers into two
categories: behavioral issues that are related to physi-
cian and medical staff attitudes toward IT acceptance7,8
and financial barriers, which are a major factor in IT
adoption in any organization and, in particular, in
healthcare. In this research, we look into the issues
related to realizing the benefits of EHR systems and
their evaluation.
The Healthcare Information and Management
Systems Society (HIMSS) defines EHR systems as ‘a
longitudinal electronic record of patient health informa-
tion generated by one or more encounters in any care
delivery setting. Included in this information are patient
demographics, progress notes, problems, medications,
vital signs, past medical history, immunizations, labora-
tory data and radiology reports.’ EHR systems auto-
mate clinicians’ workflow and serve as an evidence-
based decision support system. Studies on EHR systems
show that implementation of such systems improves
safety, quality, and efficiency in healthcare systems.9 In
particular, the key impact of EHR systems has been in
reducing the number of adverse drug events (ADEs) and
increasing physicians’ efficiency.2
Adoption of EHR technologies requires considerable
investment in the technology, as well as in training and
changing management. Such investments have to be
evaluated systematically. SD has been extensively used
as a quantitative technique for measuring the changes
made in healthcare processes.10,11 In this paper, we pro-
pose an SD technique to estimate and measure the
benefits of an EHR system. An SD technique helps man-
agers quantify EHR benefits in order to justify their
IT budget.
2. Simulation in healthcare
decision making
There are many applications of simulation techniques in
healthcare. Simulation helps to model the behavior of
processes involved in healthcare and examine different
practical and theoretical scenarios.12,13 Scheduling of
operations is one domain in particular that has
been addressed by simulation modeling.14–16 Creemers
and Lamrecht17 used simulation to validate their new
scheduling model and to assess its accuracy. Some stud-
ies report using simulation to test decision support sys-
tems developed for healthcare operations.18,19 Ahmad
and Alkhamis18 built a capacity-planning support sys-
tem in an emergency department and used simulation to
measure its performance throughout different scenarios.
Economic analysis of operations in healthcare is
another domain that has been addressed by simulation
models. In a recent study, Persson and Persson20 use a
discrete event simulation to measure the economic per-
formance of a patient-scheduling method in a hospital’s
general surgery department. In another study, Pavlovic
et al.21 looked into how, in clinical trials, the cost
and quality of data changed if electronic data collection
replaced the paper-based method. They used Extended
Event-driven Process Chains to build the conceptual
model of clinical trial processes in electronic-based
and paper-based approaches and simulated various sce-
narios to compare the performance of the model in
each scenario in terms of cost and data quality.
SD has also been used extensively in healthcare stud-
ies.22–27 González-Busto and Garcı́a22 simulated the
long-term effects of both existing and newly developed
policies on waiting lists using an SD simulation. Van
Ackere and Smith23 considered a problem similar to
that of González-Busto and Garcı́a,22 but on a macro
level. The waiting list for elective surgery in the UK
National Health Service was the issue of concern.
Using an SD approach, they present a supply and demand
model and look at related econometrics factors and how
they affect both demand and supply. Wolstenholme24
developed a model for patient flow using the SD approach
in the UK National Health Service. He tested different
scenarios (or policies) and concluded that ‘intermediate
Kasiri et al.
care’ and reduced length of stay of patients in commu-
nity care have more impact on patient wait time than
other traditional methods used to cut down wait time.
With real-world data on AIDS cases and using an SD
approach as an optimization tool, Dangerfield and
Roberts25 show that a three-stage distribution with
unequal phases at each stage offers an optimal time
model to use during forecast of future AIDS incidents.
Royston et al.26 demonstrated the importance of SD by
using it to model a spectrum of healthcare problems.
They looked at both the development and implementa-
tion of policies through the lens of SD. In particular,
they developed policies to minimize the spread of
Chlamydia through the use of SD modeling. They
also discussed some areas in which SD could potentially
be of use in the future. Cavana et al.27 focused their
research on the New Zealand Ministry of Health. They
looked at a way of closing the gap between policy
makers and clinicians in terms of their outlook on
health services delivery so as to promote the provision
of affordable and quality healthcare within the con-
straints of limited resources. A qualitative SD method
is used to achieve this goal.
SD has been used extensively in the area of IT, which
usually changes an organization’s business processes
and behavior. Through the application of SD, possible
changes in organizations can be projected and analyzed
through conceptual models and simulations.28–30 An
SD model can capture IT benefits that are sometimes
non-linear and achieved over years.31 Feedback loops
and non-linearity effects exist when an EHR system is
integrated into the workflow processes in healthcare
settings.32
In this study our question is: how do tangible and
intangible benefits of EHRs improve the healthcare
processes? Decision makers in healthcare settings need
to identify the impact of EHR systems on their clinical
processes and ensure that the benefits are significant
enough to the extent that spending on such investments
is strategic to the organization. We next introduce the
SD approach and apply it to our problem.
3. The electronic health record system
dynamics model
As noted above, the objective of this SD model is to
analyze the impact of an EHR system in a healthcare
setting after its implementation. The SD model allows
us to map the impact of the new investment on all busi-
ness processes and to identify and quantify the benefits
of such an investment to an organization. In this sim-
ulation, the SD model leads to producing the data
needed to estimate the variability of the benefits/payoffs
of investing in an EHR system. Such a system brings
significant changes to healthcare organizations. The
641
rate of change of different parameters, such as ADEs
and the amount of benefit, can vary in different con-
texts. For example, the availability of resources in
healthcare organizations is a factor that influences the
rate of change and the benefits received from an EHR
system. The variability in the context of an EHR system
can be captured in an SD approach through mapping
complex relationships among the healthcare processes
into a model by which one can dynamically measure the
effect of any changes in the parameters over time.
We chose an SD simulation to identify and measure
EHR benefits for two reasons. Firstly, it is difficult to
collect financial data from hospitals, such as the extra
revenue generated by EHR systems. Therefore, simula-
tion is one way to produce the data needed when the
lack of existing and historical data on the performance
of an IT system is an issue. Secondly, an EHR system,
similar to many other IT systems, influences other pro-
cesses in a healthcare setting. SD has been introduced
to map out the integration of IT systems into the orga-
nizations. Our SD model analyzes the impact of EHR
systems in a healthcare setting during and after its
implementation and estimates the financial perfor-
mance through simulation. For example, the SD
model can capture some of the tangible benefits of
EHR systems in ‘online patient charts,’ ‘electronic pre-
scribing,’ ‘laboratory order entry,’ ‘radiology order
entry,’ and ‘electronic charge capture.’33
To create an SD model, we need to draw causal loop
diagrams for all processes that lead to some benefits.
This is a qualitative step in which the processes, vari-
ables, and relationships within the conceptual model
are identified. These causal loop diagrams are then
transformed into mathematical equations that repre-
sent the relations among variables. The equations and
stock and flow diagrams are then used to simulate dif-
ferent practical and theoretical scenarios.
3.1. Causal loops
In this section, we look into some of the factors that
impact healthcare delivery in the hospital as a result of
the implementation of an EHR system. The causal loop
diagram in Figure 1 shows how different processes and
variables interrelate in an EHR system to offer signifi-
cant benefits to healthcare delivery. The sign on each
arrow indicates the direction of change between each
pair of elements. A positive relationship means both
elements change in the same direction, while a negative
relationship means the elements change in opposite
directions.
Electronic notes (E-notes) and electronic prescribing
(E-Rx) are shown as two common processes in EHR
systems that contribute to an increase in the amount of
staff time saved.34 They also contribute to a decrease in
642 Simulation: Transactions of the Society for Modeling and Simulation International 88(6)

medical records
- - storage

radiology -- +
+
patient
performance
- treatment time -
+ -
+

-
-
- adverse drug
event (ADE)
- staff training
-
-

E-Note +
+ E-Rx

- -
+
- + Staff time saved -
+ compliance via
+
laboratory + EHR
performance
-

+
ADE correction
cost

Figure 1. Causal loop diagram. EHR: electronic health record.

patient treatment time, which is the time it takes for a
patient to receive medical assistance starting from ini-
tial contact with the receptionist to the time he or she
leaves the hospital after receiving medical care from the
physician and other hospital staff. The average increase
in patient treatment time as a result of ADEs is 1.74 per
occurrence.35 According to Anderson,5 entering records
directly entered into computer-based medical informa-
tion systems contributes to increased quality of care
and reduces costs related to ADEs. Hence, instead of
paper notes and paper prescriptions, doctors can reduce
costs when notes on patients and prescriptions are
entered directly into the EHR system. Quality of care
is directly affected by the amount of time a patient
spends at the hospital. Based on the diagram in
Figure 1, there is a positive link between E-note and
staff time saved, as well as E-Rx and staff time saved.
This indicates that the more physicians use the EHR
system, the less time nurses and other staff need to
manually retrieve records and files on patients in
order to offer medical support to them; in fact, there
is no need to transfer files and paper documents from
one department to another physically. Staff can there-
fore transfer the time saved on dealing with documen-
tation to having direct contact with the patients, and
hence improve the quality of healthcare given to
patients and subsequently decrease ADEs.
E-notes and E-Rx also impacts the occurrence of
ADEs.34,36 The more the system is utilized to record
notes on patients and write prescriptions, the fewer mis-
takes in the administration of drugs that stem directly
from inefficiencies in manual drug administration pro-
cesses. Hence, patients spend less time at the hospital as
a result of not having to deal with delays related to
complications that could occur with paper notes and
paper prescriptions. In addition, ‘staff time saved’ is
increased, since the time needed to correct the mistakes
related to ADEs is eliminated. The occurrence of ADEs
in hospitals is estimated to be an average of 6.5 events
per 100 hospitals.37,38 Subsequently, when the ADE
Kasiri et al.
rate decreases through the use of E-note and E-Rx,
ADE correction costs also decrease.
The electronic records storage (E-Storage) variable
refers to the capability to store records in the hospital
that otherwise would have been stored in paper format.
E-Storage is important because it helps in easy retrieval
of medical records of patients even after many years.
For instance, EHR systems enable the use of E-notes
and E-Rx, electronic forms of paper notes and paper
prescriptions respectively. These are easier to store and
retrieve than data in hard copy formats. Hence, EHR
systems help facilitate the storage and retrieval of
health records. Access to the patient’s EHRs helps phy-
sicians easily make decisions and diagnoses based on
past records. The delay link from E-Storage to patient
treatment time indicates that patients can be taken care
of much faster if electronic data, which offer quicker
retrieval, are available. Uncertainty in clinical decision
making on the part of physicians is greatly reduced as a
result of E-Storage capability.36 Of course, electronic
storage of this data is enhanced by greater use of E-
Rx and E-notes.
Hospitals are required to comply with certain stan-
dards regarding the administration of medication and
other related healthcare administration processes.39
Certain drugs may be restricted and the amount given
to a particular patient must be closely watched at any
period in time by staff. With an EHR system, physi-
cians can easily track patient’s records to know how
much has been given and what amount is yet to be
given. If an attempt is made to prescribe an amount
that is more than the requisite amount for that partic-
ular patient, a ‘red flag message’ can be generated to
warn the physician of the imminent breach in compli-
ance. In this way, it is easier to comply with regulations
regarding the dispensing of a particular drug and
ensure that the maximum amount that is supposed
to be given to the patient is not exceeded. In addi-
tion, rules can be set in the EHR system to prevent
physicians from prescribing certain combinations
of drugs because of negative reactions such combina-
tions may cause. If a particular rule is violated during
E-Rx, a warning message can be immediately gener-
ated to warn the physician of the imminent danger.
ADEs that may occur as a result of incorrect amounts
and combinations of drugs given can hence be
minimized.
The likelihood that any information system in an
organization will be used is closely related to how
well the users are trained in using the system. Hence,
when staff, including nurses, physicians, and lab assis-
tants, are given adequate periodic training, the use and
acceptance of E-Rx, E-notes and the EHR system in
general increase. Training also leads to greater compli-
ance with standards.
643
In addition, when the EHR system is integrated with
other healthcare delivery departments, such as the radi-
ology and laboratory departments, their performance
level is increased. Greater efficiency in the radiology
and laboratory departments leads to fewer ADEs and
shorter patient treatment times. In addition, using the
EHR system reduces the rate of duplication in radiol-
ogy work and provides quicker access to radiology
records and, hence, directly increases the savings in
staff time. With the EHR system, a functional depart-
ment, such as the radiology department, can directly
access the patient’s x-ray order through the E-note
functionality. Hence, mistakes related to incorrect
interpretation of physician’s hand-written orders can
be avoided, leading to a decrease in patient treatment
time at the hospital.
The causal loop diagram shows various benefits of
EHR systems, such as a lower rate of ADEs, higher
amounts of staff time saved, and lower patient treat-
ment times. In the next section, we develop a stock and
flow diagram with loops that reflect some of the most
important factors that impact the flows. These relation-
ships and effects can be translated into mathematical
equations for simulation purposes. Based on estimated
parameters and initial values, we simulate the model
and discuss the results.
3.2. Example case
In this section we focus on the E-note process in the
causal loop diagram (Figure 1) and build a stock and
flow diagram (Figure 2) to simulate the effects of imple-
menting E-notes on outcome variables, such as patient
treatment time and staff time. Staff time saved is basi-
cally due to two main effects: quicker processing of
electronic orders and fewer occurrences of ADEs. In
a model built by Anderson,5 processing of medical
orders decreases from 36.9 minutes to 33.9 minutes,
which saves staff time by about 5%–10%. However,
the major factor in saving staff time is the reduction
in the rate of ADEs when EHR systems are imple-
mented. In this section, we simulate our model to
show how extra staff time needed as a result of the
occurrence of an ADE is affected by different variables,
such as ‘rate of ADEs per paper note’ and ‘rate of
ADEs per patient.’ As shown in the stock and flow
diagram (Figure 2), ‘staff days’, which is a stock,
increases when the flow, ‘ADE caused by paper notes’
increases. The same stock decreases when the ‘ADE
caused by E-notes’ flow increases, because when more
ADEs occur, staff has to spend extra time taking care of
patients and monitoring them in order to ensure that
the ADE occurrence does not degenerate into some-
thing fatal. The patient may even have to spend extra
days at the hospital in order to be effectively attended
644
staff hour required to fix
ADE caused by paper
notes
daily number of
paper notes
rate of ADE per
paper note
rate of ADEs per
patient
rate of increase in patient
treatment time by ADE
Figure 2. Stock and flow diagram. ADE: adverse drug event.
to by medical staff. On the opposite end, it is expected
that the use of E-notes decreases the occurrence of
ADEs. Hence, the increased use of E-notes, as com-
pared with paper notes, means fewer occurrences of
ADEs. Consequently, the staff time required to respond
to ADEs is reduced.
Initial parameters were chosen for the variables
based on experts’ opinions in the field. For instance,
in a research by Anderson,5 4060 medication orders
were written each week in 14 hospitals. In this same
research, of 195,392 orders written by doctors, it
was predicted that 2115 would result in an ADE. This
is equivalent to 1% of all the orders written, which is
the same as the rate of ADEs per paper note. In addi-
tion, the rate of ADEs per patient was estimated as
6.5 events per 100 hospital admissions.5 Devine
et al.40 compared the effect of an electronic order entry
system with a situation where there was no electronic
order system. They found a 20% decrease in the occur-
rence of errors from the baseline rate of 25%.
Gozdan41 found that by using technology in admin-
istering medication to patients, nurses were more suc-
cessful in following ‘the five rights’ principle: right drug,
right dose, right patient, right time, and right route.
Simulation: Transactions of the Society for Modeling and Simulation International 88(6)
staff hour required to fix
ADE caused by E-notes
daily number of
staff time E-note
saved
ADE caused by ADE by E-Note
paper-note
rate of ADE caused
by E-note
error improvment
saved patient rate by e-note
treatment time
This eases up the time nurses would otherwise use to
manually ensure that the five rights principles are fol-
lowed. Zielski42 reports that 35% of nurses’ time is
spent working on documentation. Hence, when staff
time is freed up as a result of the EHR system, staff
can, for instance, pay more attention to correctly
administering medication and hence reduce ADEs.
Subsequently, when ADEs decrease, more staff time
can be redirected to other areas to improve both patient
and staff satisfaction.
3.3. Simulation
The SD model was used to simulate the increase or
decrease in staff days based on the occurrence of
ADEs at the hospital. It is expected that the use of
E-notes eventually replaces the use of paper notes by
staff. The ‘ADE caused by paper notes’ flow is influ-
enced by the rate of ADEs per paper note, daily
number of paper notes, and staff time required to fix
ADEs caused by paper notes. In the simulation, the
time spent fixing an ADE was chosen to be the same
for both ‘ADEs caused paper note’ and ‘ADEs caused
by E-note’. In addition, the daily number of paper
Kasiri et al. 645

notes is assumed to be the same as the daily number of
E-notes written by the physician. Table 1 shows the
simulation values for different instances where the
‘rate of ADE caused by paper note’ values were altered.
We simulated a trend of decreasing values for ADEs
caused by paper notes. Whenever the ‘rate of ADE per
paper note’ decreased, the ‘ADEs caused by paper
notes’ and ‘ADEs caused by E-notes’ variables also
decreased. This is shown in Table 1. The ‘ADEs
caused by paper notes’ rate decreases sequentially as
the ‘rate of ADEs per paper note’ decreases. In addi-
tion, the corresponding ADEs caused by E-notes
decreases as the rate of ADEs by E-notes decreases.
Overall, the staff time saved is increased.
We generated the staff time saved for a total of 365
days and calculated the corresponding revenue saved
for each time period. Part of the values is shown in
Table 2. It is assumed that one hour costs an average
of US$20, and a day costs US$480.
In Table 2, the third column, ‘Extra revenue for time
saved’, lists the cost savings for each corresponding
‘staff time saved.’ The savings are computed as the
staff time saved multiplied by US$480. In a year
(365 days), the total staff time saved is about 28 days,
given a rate of ADEs per paper note of 0.01 (baseline
parameter). This means extra staff time needed as a
result of the occurrence of ADEs decreases from 41
days to 13 days annually, which is equivalent to 68%
improvement. The values for staff days and the corre-
sponding extra revenue for time saved in Table 2 show
that the revenue per time period increases as the time
period increases. The simulation data in the table is
represented in Figure 3, which depicts two plots
Table 2. Staff time saved and extra revenue generated.
Staff time saved Extra revenue
Days (rate of ADE ¼ 0.01) from time saved

Table 1. Table showing different values for the rate of adverse 0 1 420.000
drug events (ADEs) and corresponding values for ADEs caused 1 1.077 452.189
by both paper notes and E-notes. 2 1.153 484.373
3 1.230 516.562
Rate of ADE caused ADE caused ADE caused
Instance by paper note by paper note by E-note 4 1.307 548.751
5 1.383 580.936
1 0.9 82.046 4.923 360 28.589 12,007.550
2 0.8 72.930 4.376 361 28.666 12,039.720
3 0.7 63.817 3.829 362 28.743 12,071.930
4 0.6 54.698 3.282 363 28.819 12,104.110
5 0.5 45.851 2.735 364 28.896 12,136.280
6 0.4 36.465 2.188 365 28.973 12,168.490
7 0.3 27.349 1.641
ADE: adverse drug event

800

600

400
Cumulative
staff time
saved (days) 200

0
0 10 20 30 40 50 60 70 80 90 100
Time (days)
Staff time saved: Rate of ADE = 0.5
Staff time saved: Rate of ADE = 0.01

Figure 3. Staff time saved in days. ADE: adverse drug event.

646 Simulation: Transactions of the Society for Modeling and Simulation International 88(6)
superimposed onto the same graph for a period of 100
days. The upper dashed line is for staff time saved when
the rate of ADEs is 0.5. The lower continuous line is for
staff time saved when the rate of ADEs is 0.01.
4. Discussion and limitations
The conceptual model discussed in this study looks
into the effects of EHR system implementation, such
as E-notes and E-Rx, in clinical processes, such as han-
dling ADEs, in hospitals. The simulation model devel-
oped in this study discusses the detail of changes caused
by E-notes on staff time, patient treat time, and the rate
of improvements in ADEs.
After a year (365 days), the total staff time saved due
to the use of E-notes instead of paper notes is about
28 days. This means extra staff time needed as a result
of the occurrence of ADEs decreases from 41 days to 13
days annually, which is, a 68% improvement.
Assuming a mid-term range of 365 days, the corre-
sponding revenue saved is US$12,168, which is in part
due to the fewer occurrences of ADEs caused by paper
notes.39 The example shows that the use of E-notes
causes more staff time to be saved. This subsequently
offers economic benefits to the hospital. In addition,
when staff time is saved, more time is created for staff
to use for other activities that would benefit patients.
There will be more patient–staff contact as nurses and
physician would not be weighed down with extensive
paper documentation, filing, and organization. Overall,
this may also lead to high customer satisfaction on the
part of patients and other hospital patrons.
The simulation in this study was limited to measur-
ing the impact of an EHR system on staff reduction
through E-notes. However, an EHR system impacts
processes in every department and SD modeling can
also be used to simulate those effects. In future
research, we will propose a comprehensive SD model
that maps all tangible and intangible benefits of EHR
technology throughout a hospital. In addition, the
parameters of this model are based on the relevant
studies in the literature. However, similar to any
other simulation model, our model is robust and can
analyze the changes in the outcome variables for any
given set of parameters.
The simulation was run over short-term and mid-
term periods with a maximum of 365 days. In particu-
lar, we did not explore the impact of the use of E-notes
on required amount of staff time in the long term. Such
an analysis may present results that indicate different
economic benefits over different periods of time. This
may inform the making of cost-effective policies and
guidelines during the implementation of EHR systems
in hospitals.
5. Conclusion
Healthcare IT has to be developed more extensively in
practices. IT benefits are complex, hard to measure, and
usually achieved over time. Our study, by using an SD
model as a technique for analyzing the benefits of IT,
proposes a robust approach for a healthcare IT benefit
analysis in a non-traditional way.
The study shows that SD is an effective tool that
helps project the potential impact of an EHR system
in a health institution. The SD technique has not yet
been used in EHR benefits assessments. This model can
simulate and predict performance in various practical
scenarios. The results of such a simulation can then be
transformed into economic values in a cost-benefit
analysis. The example case in this research suggests
that over a mid-term period of one year, the EHR
system could actually positively impact the delivery
of healthcare and make it more efficient in an
ever-increasing population.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Conflict of interest statement
None declared.
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Author Biographies
Narges Kasiri is an Assistant Professor of Management
at the State University of New York Oneonta. She
received her PhD in Management Science and
Information Systems from Oklahoma State
University. Her current research interest is analytical
modeling of problems in information systems and oper-
ations management areas.
Ramesh Sharda is Director of the Institute for Research
in Information Systems (IRIS), ConocoPhillips Chair
of Management of Technology, and a Regents
Professor of Management Science and Information
Systems in the Spears School of Business at
Oklahoma State University. His research has been pub-
lished in major journals in management science and
information systems, including Management Science,
Information Systems Research, Decision Support
Systems, Interfaces, INFORMS Journal on Computing,
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Computers and Operations Research, and many others.
He serves on the editorial boards of journals such as the
INFORMS Journal on Computing, Decision Support
Systems, ACM Transactions on Management
Information Systems, and Information Systems
Frontiers. His research interests are in decision support
systems, especially neural network applications, and
technologies for managing information overload. His
team’s work on forecasting box office revenue of
movies has received a lot of press. The Defense
Ammunitions Center, National Science Foundation
(NSF), US Department of Education, Marketing
Science Institute, and other organizations have funded
his research. He is also a cofounder of a company that
produces virtual trade fairs, iTradeFair.com.
Daniel Adomako Asamoah is doing a PhD in the
Management Science and Information Systems
Department in the Spears School of Business at
Oklahoma State University. He received his MS
degree in Telecommunications Management from the
same university. Before his graduate studies, he com-
pleted a BSc degree in Electrical and Electronic
Engineering at the Kwame Nkrumah University of
Science and Technology, Ghana. His current research
interests are in the areas of decisions support systems
and healthcare information systems.