Does the meaningful use of

Electronic Health Records

improve patient outcomes?
-Deepa Wani, Manoj Malhotra
 Table of Contents
Background on
Problem the meaningful Hypothesis Econometric
Statement use of EHRs Development Model Conclusion

02 04 06 08
01 03 05 07 09

Motivation Literature Methods

Review Main Results &
Post-hoc Results
 Problem Statement

Past research on the efficacy of Electronic Health Records (EHR)

have shown in consistent results

Unlike past research focusing on only partial versus full adoption

of EHR, this study aims to examine the impact of meaningful
assimilation of EHRs as mandated by the HITECH
 1

Firms have benefited by using IT throughout their organisation.

Many have started investigating the innovation diffusion
aspect of IT

2
Motivation
Healthcare comprises of 20% of United State’s GDP. EHRs
adoption in US hospitals is less than 10% in 2009

HITECH Act was introduced in 2009 to increase the adoption

of EHR. After this Act the adoption rates of EHR
increased to 80% in 2015
 4

IPT is used to investigate whether the meaningful use of EHR

has improved the effectiveness with which the hospitals
treat patients

5
Motivation
In the previous studies, they used adoption as a metric and
measured the performance in voluntary environment

Now, the extent of adoption and use of EHR is used to

measure the performance in mandated environment
 7

Key challenges for the organisations are managing uncertainty,

providing personalised care on healthcare providers, self
selection bias
Motivation
8

Econometric model is used to help accounting the multiple

factors that might affect the outcome
 1

EHR initiative is rolled out in three stages:

o Promotes the adoption of HER

o Emphasizes care coordination
Background on o Improves healthcare outcomes

the meaningful 2
use of EHRs
To qualify for an incentive payment scheme, hospitals have
to successfully demonstrate meaningful use of EHR

Hospitals that attested meaningful use of EHR in 2011 received

100% of incentive payment, which decreases in the later
years
 Literature Review

1 2 3

Prem kumar et al. Gattiker and Goodhue (2005) found Stratman (2007) explains that
(2005) shows the the extent of interdependence and adopting enterprise resource
correct fit between task differentiation between subunits of planning realize improvement in
and technology an organisation operational performance

4 5 6

Stock and Tatikonda (2008) reports that IT assimilation They believe healthcare
quality of task outcomes improves with focuses on utilizing setting is also important
the interaction between source and built in capabilities of and unique, since IT
technology achieves the right fit IT adoption
 o Studies do not specifically evaluate the impact of EHR’s

Studies
investigating o This study is significant because the motivation, challenges
and barriers are very different
healthcare
Information o Second significance is of task complexity associated with
heterogeneous patient population on relationship between
Technologies meaningful assimilation of EHR’s and length of stay
 o Other studies focus mostly on multi-hospital empirical
studies, and ignore single site and case studies

o Reference technologies are different in different papers

Studies and difficult to interpret and reconcile differences in the
outcomes
investigating
electronic health o Outcomes using readmissions as an outcome measure
records (EHRs) under EMR adoption

o Majority of the studies listed in Thompson provide a

review of studies that look specially at LOS as a outcome
measure
 o Major issues with prior studies

- They capture adoption and not assimilation of IT

- Do not clarify whether adoption has occured in one

clinical unit or hospital wide
Studies - They use self reported measures of use that are highly
investigating susceptible of self reporting bias.

electronic health o Study sets apart focus on assimilation of EHR’s

records (EHRs)
o These studies are very different from their focus paper

o The major drawback of the studies is that they used survey

data to measure EHR utilization
 o They claim that their studies overcome these drawbacks of
prior studies concerning benefits that arise EHR
assimilation

Studies o They created 3 groups of hospitals - partial , full and

meaningful EHR assimilators
investigating
electronic health o Thus the study seeks to bring forth a better understanding
records (EHRs) of how meaningful assimilation of EHR technology

o They are inconsistencies in results as well

 Hypothesis
Development
 Hypothesis Development
Two main hypotheses in the section by discussing choice of dependent variable
and exploring how meaningful use of EHRs can affect patient care

LOS received less attention in terms of outcome variable

Studying about LOS is an important aspect under pressure to reduce this measure
under current fixed pay development

In addition, their studies at Koppel looks at reducing LOS compromises readmission

of patients

This important link has been previously studied

Meaningful use of IT and its impact on patient care
The bundle of technology systems consisting various decision making tools , decision
support systems and evidence based guidelines can not help reduce errors

Numerous studies show that the right match between information processing needs
and information processing capabilities lead to better organizational performance 

Unclear returns on investment and physician resistance has been cited as factors
associated with slow adoption

Full adoption of EHRs is itself unlikely to improve performance as measured by LOS 

Meaningful EHRs assimilators strive to improve the overall quality of treatment

processes by streamlining
 Hypothesis 1
Meaningful-EHR assimilators will be associated with a shorter length of stay, on
average, compared to full-EHR adopters and partial-EHR adopters
 Impact of meaningful use of EHRs when task of
treating patients is more complex

The difference between the amount of information required

Task Complexity to perform the task and the amount of information already
possessed by the organization

Complexity and intra-unit dependence of

the core task
Sources of uncertainty
Degree to which the environment is
Task Characteristics dynamic

Degree of interdependence among

various subunits of an organization
 Types of Complexities

DISEASE COMORBIDITY COORDINATION

COMPLEXITY COMPLEXITY COMPLEXITY

Number of pieces of Total number of

information about a procedures done on a
How complex it is to
patient that need to be patient for diagnostic
treat the disease itself
processed in order to or exploratory purposes
complete the task of that are necessary to
treating the patient address a complication
 Hypothesis 2a
For meaningful-EHR assimilators, the magnitude of the reduction in LOS (as
compared to full-EHR adopters and partial-EHR adopters) will be, on average, larger
for high-disease-complexity patients than for low-disease-complexity patients
 Hypothesis 2b
For meaningful-EHR assimilators, the magnitude of the reduction in LOS (as
compared to full-EHR adopters and partial-EHR adopters) will be, on average, larger
for high-comorbidity-complexity patients than for low-disease-complexity patients
 Hypothesis 2c
For meaningful-EHR assimilators, the magnitude of reduction in LOS (as compared to
full-EHR adopters and partial-EHR adopters) will be, on average, larger for high-
coordination-complexity patients than for low-coordination-complexity patients
Methods
GOAL: the impact of EHRs on patient LOS for
three groups of hospitals – partial-EHR
adopters, full-EHR adopters, and meaningful-
EHR assimilators, and magnitude of effect will
be greater for higher-complexity patient
 Description of Datasets
o For meaningful-EHR assimilators: Hospitals successfully attested for meaningful-
use certification using data from the Medicare EHR incentive program

o For full-EHR adopters: Hospitals that adopted the bundle of EHR functionalities that
are required for meaningful use attestation using the HIMSS database

o Although hospitals may have technologies in place,

Two key insights from data of
adoption of the necessary
bundle of technologies
required for meaningful use
in hospitals
they struggle to assimilate them in their work
processes
o Using a continuous measure based on a count value
of technologies does not work, as then there would
not be any distinguish between full-EHR adopters
and meaningful-EHR assimilators
 Description of Datasets
Combine the OSHPD,
To account for self- CMS, and HIMSS
selection, perform our 03 01
datasets using a
analysis using a unique CMS ID number
treatment-effects mode

Consider the top 5

02 major diagnostic codes
04 (MDC), by volume, for
Collect additional data from four our analysis
different sources:
All data sources are joined
05
together with a unique
CMS Medicare identifier
number
 IPPS: information on number of
AFD: Information used to calculate
beds, not-for-profit status, teaching
nurse-patient ratios, operating
and urban hospitals, and case mix
margin, and system membership
index

Dartmouth Atlas: defines the

HIMSS: dataset containing
service area that a hospital is in,
information on various
used to calculate competition in
technologies adopted by hospitals
each service area
 Description of Key Variables
Consider only 99% of the
observations, as the
Delete observations remaining 1% of the Disease complexity: it
with incorrect dates observations have a very arises from how
since these were listed high LOS which can complex it is to treat the
with negative LOS in potentially result in a highly disease itself
the OSHPD database right-skewed distribution

o CMS assigns a relative weight to each DRG code

that reflects the resource consumption by each
DRG. More complex procedures consume more
resources and are assigned higher weight

o Combine the dataset containing patient level data

with the DRG weights dataset using a unique CMS
Medicare identifier number
 Comorbidity Complexity: It refers to the number of pieces of
information about the patient that need to be processed in
order to complete the task of treating the patient

o Calculated using two pieces of information about a patient: (i) information on the Elixhauser
Index (ii) information on the severity score for each comorbidity, ranging from −7 to 12, with
larger weights representing more severe comorbidities

o The Elixhauser severity score is the dot product of the Elixhauser Index and the severity score

o Information on comorbidities is provided in the OSHPD database

o Convert the comorbidity description to a 0/1 binary variable and use the severity score to arrive
at the severity score for each patient
 Coordination complexity: it represents the total number of
procedures done on a patient for diagnostic or exploratory
purposes, or which are necessary to address a
complication beyond the definitive treatment itself

o Sum up the procedures done on each patient to arrive at our measure of coordination complexity

o Control for various characteristics, such as patient age (years), gender (female = 1, male = 0), race
(three categories), insurance type (Medicare, Medicaid, Private, Self-pay), admission type
(unscheduled = 1, scheduled = 0), day of admission (weekend = 1, weekday = 0), month of
admission, major diagnostic codes, hospital, and year fixed effect

o Drop observations with missing data on any of the control variables

 1 Data is analyzed over four years (2010-2013)

Analysis Method: Difference-in-difference analysis

2
with multiple groups and multiple years
Econometric
Model
Approach: Studying the impact of EHRs using
3 patient-level data

Reason: Meaningful-use certification at the

organizational level is achieved only if at least 80% 4
of its patients are treated via these systems
 Single Stage Model
1. 2. 3.
Instrument Patient LOS is modeled as a function of EHR Equation:
Variable assimilation and adoption, patient characteristics,
Approach and hospital and time fixed effects

𝐿𝑂𝑆𝑖𝑗𝑡 =𝛼1 𝐸𝐻𝑅 𝑎𝑓h𝑡 +𝛼 2   𝐸𝐻𝑅 𝑓𝑝h𝑡 +𝛼3   𝐸𝐻𝑅 𝑎𝑓h𝑡 ∗𝐶𝑜𝑚𝑝𝑙𝑒𝑥𝑖𝑡𝑦+𝛼
 
4   𝐸𝐻𝑅 𝑓𝑝h𝑡 ∗𝐶𝑜𝑚𝑝𝑙𝑒𝑥𝑖𝑡𝑦+𝛽 1  𝑋 𝑖𝑗𝑡 +𝛽 2  𝑌 𝑗𝑡 +𝛼 𝑗+𝜏 𝑡 + 𝜀 𝑖𝑗𝑡
Variables Meaning
the outcome variable for patient i at hospital j at time t.
the average difference in the LOS between hospitals in the full-EHR adoption and EHR-assimilation state ()
the average difference in the LOS between hospitals in the partial-EHR adoption and full-EHR adoption state () in hospital h at time t
and the average change in the LOS under the moderating impact of varying task complexity for and , respectively
patient specific characteristics, such as age, gender, race, insurance type, admission type, disease type, and complexities
time varying hospital-level characteristics, such as case mix index and number of beds
patient specific characteristics, such as age, gender, race, insurance type, admission type, disease type, and complexities
the hospital fixed effects
time varying
various time hospital-level characteristics,admit
effects (weekday/weekend, suchmonth,
as case mix index and number of beds
year)
the hospital fixed effects
various time effects (weekday/weekend, admit month, year)
 Two Stage Model
1.
Treatment-Effects Model
Previous research indicates
that various organizational,
environmental, and
technological factors affect IT
assimilation
2.
Use of two-stage,
treatment effects model
To account for endogeneity in
the decision to attest promptly
and allows the inclusion of all
variables that have been used in
the estimation of the choice
model to be included in the
outcome equation as well
3.
Assumption
When hospitals choose to
invest in various other
quality-enhancing clinical
technologies, they would
do so in EHRs as well
 First Stage – Choice Model
o
●  First stage explains a hospital's decision to attest for meaningful use in earlier years

o Determined using a Probit model

o The un-observables are captured through their mean effect in the treatment decision on
the treatment outcome

Variables Meaning
Treated as an endogenous binary variable, and is modeled as an indicator function that depends
on a set of exogenous covariates, ,that drive the decision to attest for meaningful use sooner
than later.
Error
Error term
term (normalized
(normalized to
to 1
1 to
to ensure
ensure identification)
identification)
Second Stage – Outcome/Performance Model
o
●  Second stage explains the impact of meaningful-EHR assimilation versus full-EHR
adoption on patient LOS

o Errors are modeled as a bivariate normal random variable with a distribution, N (0, 0, σ2 , 1,
ρ)

Variables Meaning
error term
Variables Included
Significant differences in the characteristics of the three groups of hospitals
o EHR Maturity
are calculated by conducting t-tests using the above-mentioned variables for
o Teaching Intensity the year 2011 (the first year of attestation)
o Profit Status
o Location
o Size
o Case Mix Index
o IT Investments
o System Membership
o Competition
o Operating Margin
o Nurse/Patient Days
Ratio
 Two Stage Model
o
●  Selectivity term is calculated from the results of the choice model

○ ;

o This is substituted as a regressor in Outcome Model to consistently estimate the impact of

meaningful use on patient LOS, while also accounting for the endogeneity in the choice
process
o This approach allows the inclusion of all variables that have been used in the estimation of
the choice model to be included in the outcome equation as well
o The treatment-effects model makes this possible, primarily due to the use of the nonlinear
selectivity term as a control in the outcome equation, which, in turn, allows us to obtain
consistent estimates for the coefficients of interest
 1

EHR assimilators have, on average, lower LOS,

compared to full-EHR adopters

Main Results
2

No significant differences in LOS between full-EHR

and partial-EHR adopters

Hence, Hypothesis H1 is accepted

 EHR assimilation does not have a differential
3
impact on patients with greater disease complexity

EHR assimilation has a greater impact on reducing

4
LOS for patients with higher comorbidity complexities

Main Results EHR assimilation has a greater impact on reducing

5 LOS for patients with higher coordination complexities
as compared to full-EHR adopters

No statistical difference seen between full and partial 6

EHR adopters

Hence, Hypothesis H2a is rejected, H2b and H2C

are accepted
Other Significant Results
Meaningful-EHR assimilators reduce the length of stay by approximately 3% on average

Hospitals with meaningful Hospitals with meaningful

Annual savings of $900,000 use of EHRs see a slight use of EHRs see a slight
for each hospital reduction of 0.2% in LOS for reduction of 0.5% in LOS for
comorbidity complexities coordination complexities

o Hospitals located in urban areas

Type of Hospitals more likely to o Hospitals that belong to a system
pursue meaningful use sooner o Hospitals with greater investments in
other clinical technologies
 1

Meaningful-EHR assimilators experience a reduction in

readmission rate by about 6.5% on average

Post-hoc
Analysis 2
Impact on Readmissions
No additional benefits of meaningful-EHR assimilation on
patients with a greater disease, comorbidity, or
coordination complexity with respect to readmission
 Improving quality, safety,
CORE OBJECTIVES and efficiency for patients

o Improving quality, safety, efficiency

o Engaging patients and families MENU OBJECTIVES
o Improving care coordination
Post-hoc
Menu items focusing on quality, safety, and
Analysis efficiency has an impact on LOS, while patient
1
engagement and care coordination do not have an
Impact of core and menu objectives impact

No impact of these menu items was found on

readmission. Also, no insights were obtained by
2
interacting each of these categories with various
complexity measures
Conclusion
 Contributions to theory

Highlights the
Discarded the The true value of Assimilation rather
shortcomings of
assumption of information systems than full or partial
past healthcare
adoption of complex can only be unlocked adoption, is necessary
literature that
IT systems is by its assimilation to achieve improved
uses proxies for
sufficient to achieve into work processes resource efficiency, as
meaningful use
better outcomes measured by LOS
 Conceptualize the task of Contribute to the
The true value of
treating a patient into three literature on task
information systems
types of complexity complexity objective,
can only be unlocked by
profiles, based on the secondary data can be
its assimilation into
degree of difficulty in used to construct
work processes
accomplishing the task of complexity measures
treating a patient
 Highlight that the
Highlights the decision to attest
importance of including for meaningful
these task complexities, use is
New insights that the endogenous
as they significantly
benefits are enhanced
increase patient
when the degree of
LOS Using detailed
patient complexity is
patient-level data, we
higher
can show that a
reduction in LOS
does not come at the
expense of increased
readmission
 Implications for Practice

Meaningful-EHR Hospitals have Post hoc tests reveal, Meaningful use of EHRs can
assimilation really helps actually reported hospitals that assimilate facilitate more-effective bed
in reducing the overall cost savings from EHRs also experience management and efficient
length of stay as well as the use of EHRs overall reduced operations by freeing up
readmission rates cold place readmission rates capacity through faster
patient turnaround times
THANK YOU!