Qual-IT - February 2006 | Archived

Two reports recently prepared by the American Hospital Association (AHA) and by the Greater New York Hospital Association (GNYHA) draw on national and regional surveys on hospitals' adoption of HIT to demonstrate great interest—but  wide variation—in the use of clinical HIT in hospitals today. Both surveys show increasing activity and progress in adopting such technology.

Many hospitals—at least 60 percent nationally—use electronic systems to order lab and radiology tests, and can view the results of those tests electronically, the surveys found. Other clinical HIT systems are not as commonly deployed. Nationally, for example, almost half of the hospitals responding to the AHA survey have fully implemented computerized prescription order entry, but only a quarter have systems fully or partially in place to provide real-time or retrospective drug interaction alerts. In the greater New York area (which includes, in this survey, one Rhode Island hospital system), GNYHA found that almost one-third of respondents have fully implemented computerized provider order entry, and another 25 percent have at least partially implemented it. About 40 percent of the New York-area hospitals report that electronic medical record (EMR) systems are operational in some departments or functional areas of their hospitals, with an additional 14 percent reporting fully operational systems. Nationally, use of specific EMR functions varies tremendously, from a mere 2 percent fully capable of patient support through home monitoring, for example, to some 30 percent fully able to access current medical records and medical histories.

Hospitals also have not widely adopted more advanced forms of HIT. The surveys found very few hospitals, nationally or in the New York area, to have adopted bar coding for medication administration and tracking. Although about one-third of hospitals are employing telemedicine, which permits remote facilities to communicate with a hospital via digital imaging or high-speed internet connections, the AHA survey found, very few are currently using radio frequency identification to track patients, equipment, or supplies throughout the hospital.

Even when hospitals implement HIT, its use by staff members is not always consistent. The AHA survey, focusing on physician, nurse, and other clinical staff use of HIT, found physicians to be least likely to use electronic medical records, with two-thirds of the responding hospitals reporting that fewer than half of their physicians utilize these systems. Only 20 percent of hospitals reported that 75 percent to100 percent of their physicians use EMR functions. Almost half reported a comparable percentage of use among nursing staff.

The GNYHA survey assessed the percentage of clinician orders entered via hospitals' computerized order entry systems. About one-fifth of responding hospitals indicated that 76 percent to 100 percent of clinician orders are entered this way, while over 30 percent indicated that no more than 10 percent of provider orders make use of computerized entry. 

More than half the hospitals responding to the AHA survey reported that they currently share electronic health information with other local or regional entities. Among this group, more than two-thirds reported exchanging data with private-practice physicians' offices, and about 40 percent did so with laboratories, payers, and other hospitals. Forty percent of the GNYHA survey's respondents reported that they were undertaking collaborative HIT projects with other providers or entities. 

Both the AHA and GNYHA surveys questioned hospitals on perceived barriers to HIT adoption. Respondents' top concerns fell into three broad categories:

·         Costs, as expected, were cited as the most significant barrier, both nationally and in the New York area. In both surveys, initial and ongoing HIT costs were cited by 95 percent and 87 percent of respondents, respectively. Ongoing HIT costs are of particular concern for smaller hospitals, AHA emphasizes.

·         Interoperability is a common concern as well, cited by 77 percent of the AHA and 70 percent of the GNYHA respondents.

·         Staff training and acceptance is also widely viewed as a barrier. Lack of availability of well-trained IT staff was cited by 65 percent of respondents in both surveys. In the GNYHA survey, 65 percent of responding hospitals cited acceptance of technology by clinical staff as a significant or moderate (“somewhat of a”) barrier.

The implications of hospitals' HIT adoption for the New York City health care workforce is a focus of another study, conducted by the Center for Health Workforce Studies (CHWS) at SUNY Albany School of Public Health, with funding support from the 1199 Hospital League Health Care Industry Planning and Placement Fund. The 2005 study combined a literature review with findings from site visits and interviews conducted at hospitals across the city.

CHWS focused on five health care technology categories: EMRs, telemedicine, clinical technology, distance learning and continuing education, and other technologies. While the technical and functional requirements of these systems vary widely, the study highlights important cross-cutting issues, including the wide variety of health professionals—from physicians to housekeeping staff—who are or will be using these technologies; the broad range of training needed, from basic computer literacy to more sophisticated computer skills; the range of environments in which training will take place, from professional education programs to the workplace itself; and the important role of vendors in the training process.

The report also points out widespread “digital divides”: older health care workers may be less than proficient with today's commonly used technology tools, and not all workers have the tools to connect to hospital e-mail or intranet systems. It also notes the differential impact on workers in various hospital areas and positions. In some cases, technology merely converts current paper-based tasks—such as data entry by nurses monitoring patients—into electronic or web-based forms. In others, however—for pharmacy, laboratory, or radiology technicians, for example—job functions may be fundamentally altered. Hospitals need to anticipate and plan for these changes, and develop strategies for training as well as workflow and process redesign. 

AHA, GNYHA, and CHWS all found that hospitals are actively engaged in procuring and implementing new technology. In the New York area, CHWS found a clear difference between those facilities that view HIT as part of an overall business strategy and those simply reacting to external pressures. The more proactive hospitals, already widely recognized as technology leaders in New York and nationally, anecdotally report financial and clinical benefits from their considerable HIT investments. Moreover, many of these hospitals are also leaders in forging collaborative partnerships for clinical information exchange, which should generate additional cost savings. Several areas of potential benefit have been described in the Center for Information Technology Leadership study commissioned by the United Hospital Fund.

The HIT “value proposition” has also been quantified in a recent study commissioned by the state of Florida (Menachemi 2006), which uses descriptive and quantitative analyses of a hospital survey, as well as financial and case-mix data reported to the state's Agency for Health Care Administration. Assessing hospitals' overall HIT implementation as well as individual clinical, administrative, and strategic business HIT components, the study found a “positive and significant relationship between HIT use and numerous measures of financial performance across Florida hospitals,” even when case mix and bed size are taken into account. While there are methodological limitations, and additional research is needed, this study could help to strengthen the business case for hospitals' HIT implementation efforts.

Much of the HIT policy discussion has focused on technical issues, including the need for data standards and interoperability across HIT systems. The studies summarized above shed light on the strategic nature of HIT implementation. As with any other industry or business sector, health care needs to make aggressive and coordinated investments in new technologies, the implementation of which requires ongoing process redesign and workforce training. Finding and committing the financial resources is a big challenge, but changing the professional and organizational culture of health care to embrace these changes may pose additional challenges. Improving quality and safety, while helping to improve hospitals' financial performance, are compelling incentives, however, for accelerated HIT adoption and use.

American Hospital Association. 2005. Forward momentum: Hospital use of information technology. Available online at http://www.ahapolicyforum.org/ahapolicyforum/resources/content/FINALNonEmbITSurvey105.pdf

Center for Health Workforce Studies. 2005. The role of innovative technologies in improving the quality of patient care: Training implications for the health workforce. Available online at http://chws.albany.edu

Greater New York Hospital Association. 2006. Hospital information technology survey report. For further information, contact Susan Stuard (stuard@gnyha.org).

Menachemi N, J Burkhardt, R Shewchuk, D Burke, and RG Brooks. 2006. Hospital information technology and positive financial performance: A different approach to finding an ROI. Journal of Healthcare Management 51(1):40-59. Available online (subscribers only) at http://www.ache.org/pubs/jhmsub.cfm