Originl Article Helthc Inform Res. 2014 July;20(3):183-190. pissn 2093-3681 eissn 2093-369X Fctors Affecting Electronic Medicl Record System Adoption in Smll Koren Hospitls Young-Tek Prk, PhD 1, Jinhyung Lee, PhD 2 1 Helth Insurnce Review & Assessment Reserch Institute, Helth Insurnce Review & Assessment Service, Seoul; 2 Deprtment of Economics, Sungkyunkwn University, Seoul, Kore Objectives: The objective of this pper is to investigte the fctors ffecting doption of n Electronic Medicl Record (EMR) system in smll Koren hospitls. Methods: This study used survey dt on doption of EMR systems; dt included tht from vrious hospitl orgniztionl structures. The survey ws conducted from April 10 to August 3, 2009. The response rte ws 33.5% nd the totl number of smll generl hospitls ws 144. Dt were nlyzed using the generlized estimting eqution method to djust for environmentl clustering effects. Results: The doption rte of EMR systems ws 40.2% for ll responding smll hospitls. The study results indicte tht IT infrstructure (OR, 1.48; 95% CI, 1.23 to 1.80) nd orgnic hospitl structure (OR, 1.86; 95% CI, 1.07 to 3.23) rther thn mechnistic hospitl structure or the number of hospitls within county (OR, 1.08; 95% CI, 1.01 to 1.17) were criticl fctors for EMR doption fter controlling for vrious hospitl covrites. Conclusions: This study found tht severl mngeril fetures of hospitls nd one environmentl fctor were relted to the doption of EMR systems in smll Koren hospitls. Considering tht helth informtion technology produces mny positive helth outcomes nd tht n doption gp regrding informtion technology exists in smll clinicl settings, helthcre policy mkers should understnd which orgniztionl nd environmentl fctors ffect doption of EMR systems nd tke ction to finncilly support smll hospitls during this trnsition. Keywords: Medicl Informtics, Helth Informtion Technology, Electronic Medicl Record, Electronic Helth Record I. Introduction Submitted: April 18, 2014 Revised: July 18, 2014 Accepted: July 27, 2014 Corresponding Author Jinhyung Lee, PhD Deprtment of Economics, Sungkyunkwn University, 25-2, Sungkyunkwn-ro, Jongno-gu, Seoul 110-745, Kore. Tel: +82-2-760-0263, Fx: +82-2-760-0946, E-mil: leejinh@skku.edu This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License (http://cretivecommons.org/licenses/bync/3.0/) which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. c 2014 The Koren Society of Medicl Informtics Helthcre orgniztions hve dopted vriety of informtion technologies (IT) in South Kore [1-4]. Among those technologies, the Electronic Medicl Record (EMR) system is core technology tht combines vrious complex informtion technologies, such s computerized physicin order entry (CPOE) system nd picture rchiving nd communiction system (PACS). This system ffects wide selection of clinicl settings in helthcre orgniztions [4]. An EMR system is defined s n electronic record of helth-relted informtion on n individul tht cn be creted, gthered, mnged nd consulted by uthorized clinicins nd stff within one helthcre orgniztion [5]. EMR systems hve vrious benefits nd dvntges in
Young-Tek Prk nd Jinhyung Lee helthcre prctice [6-11]. They sve costs by extrcting lrge number of clinicl documents in timely mnner nd sometimes prevent humn error through techniques, such s lerts, nd by providing dditionl informtion. As result, there is gret potentil for improvement of hospitl prctices. Although there re mny merits to these clinicl nd mngeril systems, their doption rte hs not been very high. The doption rte hs reched 44.9% in Kore [12]. In the United Sttes, the doption rte of EMR systems in hospitls ws pproximtely 12% in 2009 [13]. The question of why some hospitls dopt EMR systems nd others do not is n importnt one. Adoption is defined s the cquisition or implementtion of n EMR system [14]. We need to understnd the mechnism of EMR system doption in order to ccelerte system doption by helthcre orgniztions. Using n understnding of the doption mechnism, helthcre politicins cn contribute to pproprite politicl ctions tht will promote EMR doption by the helthcre industry. There hve been severl studies exmining fctors tht re obstcles to dopting vrious informtion technologies, including EMR nd CPOE systems. However, there hve been no studies trgeting smll hospitls nd the fctors ffecting EMR system doption in Kore. There hve been severl studies on EMR doption in generl nd in tertiry hospitls, s well s in mbultory cre clinics in Kore, but not in smll hospitls [2,4,15]. Outside of Kore, severl studies hve been conducted in smll primry cre clinics nd community helth centers in the United Sttes on the doption nd use of EMR or Electronic Helth Record (EHR) systems, the brriers to EMR system doption, nd experiences of helthcre providers with the use of EMR systems [16-21]. Smll hospitls re widely distributed nd ply roles of gte keepers, referring seriously ill ptients to tertiry hospitls in Kore s ntionl helthcre delivery system. Smll hospitls hve severl unique chrcteristics tht re different from those of lrge generl hospitls, such s wek finncil stbility. They usully do not hve the finncil resources to invest lrge sums in informtion technology like expensive EMR systems [19,22]. In ddition, they tend to hve homogenous group fetures like smll bed numbers nd poor orgniztionl structures. An understnding of the current sttus of smll hospitls is needed regrding EMR doption in order to increse hospitls rte of EMR system doption nd use in prctice settings. This study ims to exmine fctors ffecting EMR doption. Compred to lrge hospitls, smll hospitls hve been the subject of few studies on the fctors ffecting EMR doption. In Kore, smll hospitls re defined s hospitls with more 184 www.e-hir.org thn 30 nd fewer thn 100 beds, ccording to Koren Medicl Lw [4]. The objective of this pper is to investigte the fctors ffecting doption of EMR systems in smll Koren hospitls. Knowledge from this type of study will enble helthcre politicins to determine pproprite politicl ctions for IT dvncement in the helthcre industry. II. Methods 1. Study Subjects The present study used dt from survey conducted from April 10 to August 3, 2009. After sending one-time miling contining n ccess code nd cover letter explining the survey purpose nd Web ddress, dt were collected from n online website. Some hospitls IT deprtments were lso directly contcted by phone to solicit their prticiption in order to increse the response rte. In ddition, this study received help in the form of website dvertisement from the Kore Informtion Technology of Hospitl Assocition (KITHA), which is professionl ssocition composed of chief informtion officers nd IT mngers. Respondents to this study were chief informtion officers, but nyone who ws in chrge of hospitl computer system ws ble to respond if the hospitl did not hve n IT deprtment. In hospitls tht did not hve n IT deprtment, most respondents were nurses. There were 1,063 hospitls t the time of the survey nd totl of 356 hospitls prticipted in the survey. The response rte ws 33.5%. This study selected smll hospitls with more thn 30 nd fewer thn 100 beds. A totl of 144 hospitls qulified ccording to the criteri of this study. The survey instrument ws developed bsed on review of the previous literture [23-28]. The min dependent vrible ws EMR doption sttus. In order to confirm whether hospitls hd ctully dopted n EMR system, the survey sked when they hd deployed the EMR system; this ws defined s the yer of EMR doption. The study provided definition of the EMR system nd sked whether hospitls hd fully or prtilly dopted n EMR system, or not t ll. The study lso ctegorized hospitls tht reported full or prtil doption of the nme system s hospitls with EMR systems, in order to simplify the interprettion of the nlysis results. Tble 1 presents brief description of the mjor study vribles. This study defined tsk complexity s the degree of hospitl tsk diversity nd mesured it by counting the number of specilty services the hospitl provides. Decentrliztion of decision-mking type ws defined s the degree of IT stff prticiption level in mngeril decision-mking ; this mesured, on five-point Likert
Fctors Affecting EMR System Adoption Tble 1. Description of mjor independent vribles Vrible nme Mesure Foundtion Privte, including medicl foundtions, versus public hospitls Multihospitl system Hving multiple hospitls within the sme foundtion Contrct Hving ny contrcts with other hospitls for purchsing medicl supplies or ptient referrls City Rurl re s opposed to urbn re Bed Actul bed size Tsk complexity Number of medicl deprtments Decentrliztion of decision-mking Degree of IT stff s prticiption in mngeril decision mking IT infrstructure Count of the number of 8 sub-systems within the hospitl informtion system Orgnic structurl type Orgnic versus mechnistic fetures following Burns nd Stlker [20] Existence of true competitors Binry (1: true competitor, 0: no true competitor) d =(bed i -bed j ) bed i : bed size of hospitl i if d <= 50 then hospitls i, j will be counted s 1; Else both i & j re counted s 0 Herfindhl-Hirschmn index (HHI) Hospitls within county Numeric number HHI¹= n: the number of hospitls in locl re bed i : bed size of hospitl i tbed: totl bed in locl re Number of hospitls in given re Rurl re is governmentl dministrtive district hving fewer thn 100,000 residents in locl re nd urbn re is district hving more thn 100,000 residents. scle, the verge prticiption levels of IT deprtment stff in n orgniztion s hiring, promotion, progrm, nd policy chnges. A higher number mens tht hospitls hd decentrlized decision-mking process, in which IT deprtment stff ctively prticiptes in the decision-mking process. This study lso defined IT infrstructure s the physicl nd institutionl structures relted to informtion technology ; this ws mesured by counting the number of 8 res of hospitl informtion systems: outptient CPOE, inptient CPOE, phrmcy drug mngement nd dispensing system, ptient chrging processing, clinicl lbortory work, rdiology work mngement, intensive cre unit mngement, nd dministrtive procedures systems. Orgnic versus mechnistic fetures of hospitls were scled following mesurement tool from Burns nd Stlker [23]. They were mesured using five-point Likert scle, with higher number indicting tht hospitls hd orgnic mngeril structures. According to Burns nd Stlker s conceptuliztion, orgnic orgniztions hve chrcteristics, such s flexible rules, decentrliztion of decision-mking, nd frequent mutul relince mong employees, while mechnistic orgniztions hve the opposite sides of these chrcteristics [29]. Two different vribles to mesure mrket competition were used: the Herfindhl-Hirschmn index (HHI) [30] nd the existence of true competitors. The HHI ws clculted using two vribles: the totl number of beds in given re nd the ctul bed size of the hospitls. With respect to the existence of true competitors, true competitor sttus ws determined bsed on the difference of the number of beds between ny two hospitls within the sme locl re. This study designted both hospitls s true competitors if the difference in the number of beds between ny two hospitls ws fewer thn 50. 2. Dt Anlysis The dt ws nlyzed using the generlized estimting eqution (GEE) method with logic function nd binomil distribution. Also, we dopted n exchngeble vrincecovrince structure to djust for environmentl clustering effects [31,32]. Specificlly, this cn be modeled using logistic regression pproch with logic function nd binomil distribution. The dependent vrible ws EMR doption; Vol. 20 No. 3 July 2014 www.e-hir.org 185
Young-Tek Prk nd Jinhyung Lee independent vribles were the covrites mentioned bove. The GEE model ws pplied becuse severl environmentl fctors within the sme re eqully ffected hospitl covrites. This study used SAS ver. 9.1 (SAS Institute Inc., Cry, NC, USA) for dt nlysis. III. Results 1. Generl Chrcteristics of Study Hospitls Tble 2 shows the bsic chrcteristics of the study hospitls ccording to EMR doption sttus. The overll doption rte of EMR systems ws 40.3% for ll responding smll hospitls. There ws no difference in EMR system doption between smll public nd privte hospitls. Hospitl sttus s multihospitl system (yes vs. no) nd hving contrcts with other hospitls (e.g., group purchsing contrcts) were not relted to EMR doption. However, hospitls locted in urbn res hd significntly higher EMR doption rtes thn did hospitls in rurl res. 2. Internl Fetures of Hospitls nd EMR Adoption Tble 3 shows the reltionship between hospitl s internl Tble 2. Bsic chrcteristics of study hospitls ccording to EMR doption sttus Bsic chrcteristic Totl EMR doption sttus c 2 -test p-vlue Yes (%) No (%) No. of respondents 144 58 (40.3) 86 (59.7) - - Foundtion Public Privte Multihospitl systems Yes No Contrcts with other hospitls Yes No Loction of hospitls Rurl re Urbn re EMR: Electronic Medicl Record. 45 99 49 95 63 81 33 111 17 (37.8) 41 (41.4) 18 (36.7) 40 (42.1) 28 (44.4) 30 (37.0) 8 (24.2) 50 (45.0) Vlues in the prentheses re the percentges (%) of the row totls. 28 (62.2) 58 (58.6) 31 (63.3) 55 (57.9) 35 (55.6) 51 (63.0) 25 (75.8) 61 (55.0) 0.170 0.680 0.388 0.534 0.808 0.369 4.576 0.032 Tble 3. Internl fetures of study hospitls ccording to EMR doption sttus Internl feture Totl EMR doption sttus Yes No c 2 -test p-vlue No. of respondents 144 58 86 - - Bed size 144 122.2 127.8 0.39 0.694 Tsk complexity (no. of medicl specilties ) 144 6.4 6.0 0.94 0.351 Structure Decentrlized decision-mking IT infrstructure Orgnic structure 144 144 144 2.8 8.4 2.8 2.9 6.1 2.5 0.21 5.34 2.21 0.837 <0.001 0.029 EMR: Electronic Medicl Record. Mesured it by counting the number of 27 medicl specilties: internl medicine, peditrics, neuroscience, neuropsychitry, dermtology, surgery, thorcic surgery, orthopedics, neurosurgery, plstic surgery, obstetrics, ophthlmology, ENT (er nose nd throt), urology, tuberculosis, rehbilittion medicine, nesthesiology, dignostic rdiology, tretment rdiology, clinicl pthology, ntomicl pthology, fmily medicine, nucler medicine, Emergency medicine, occuptionl nd environmentl medicine, dentistry, nd preventive medicine. 186 www.e-hir.org
Fctors Affecting EMR System Adoption Tble 4. Environmentl fetures ccording to EMR doption sttus Internl feture Totl EMR doption sttus c 2 -test b p-vlue Yes (%) No (%) No. of respondents 144 58 86 - - Hving true competitors Yes No 111 33 47 (42.3) 11 (33.3) 64 (57.7) 22 (66.7) 0.86 0.354 HHI score (men) 144 0.303 0.374 1.56 0.121 No. of hospitls within the re (men) 144 9.448 7.151 2.23 0.027 EMR: Electronic Medicl Record, HHI: Herfindhl-Hirschmn index. Vlues in the prentheses re the percentges (%) of the row totls. b Chi-squred test for hving true competitors nd t-test for the rest of the vribles. fetures nd its EMR doption sttus. There ws no difference in bed size between the two groups. Hospitls dopting EMR systems hd higher tsk complexity thn tht of hospitls not dopting EMR systems, s mesured by the number of medicl specilties, but this ws not sttisticlly significnt. Hospitls dopting EMR systems hd significntly higher IT infrstructure (p < 0.001) nd orgnic structurl chrcteristics thn did hospitls not dopting EMR systems (p < 0.05). Hospitls dopting EMR systems hd higher number of hospitls within their locl re thn did hospitls not dopting EMR systems; this ws sttisticlly significnt (Tble 4). This indictes tht high competition within the locl re might ccelerte EMR system doption by hospitls. 3. Fctors Affecting EMR Adoption by Smll Koren Hospitls Smll hospitls equipped with high levels of IT infrstructure nd with orgnic mngeril structures were more likely to dopt EMR systems thn were other types of hospitls (Tble 5). EMR doption ws positively ssocited with the number of hospitls within given re. A one-unit increse in IT system ws ssocited with 48.5% higher odds of dopting n EMR system, which ws sttisticlly significnt (95% CI, 1.23 to 1.80; p < 0.005). For one-unit increse in the score of structurl fetures towrd n orgnic form, the odds of EMR doption were estimted to increse by multiplictive fctor of 1.857 fter controlling for hospitl covrites (95% CI, 1.07 to 3.23; p < 0.05). A one-unit increse in the number of hospitls within given re ws ssocited with 8.2% higher odds of dopting n EMR system (95% CI, 1.01 to 1.17; p < 0.05), which ws sttisticlly significnt. Tble 5. Fctors ffecting EMR doption by smll Koren hospitls Independent vrible OR 95% CI p-vlue Foundtion type (privte) (ref=public) Multihospitl system (yes) (ref=no) Contrcts with other hospitls (ref=none) Loction (urbn) (ref=rurl re) IV. Discussion 0.913 0.29 2.81 0.873 0.691 0.21 2.23 0.537 1.381 0.60 3.16 0.445 1.857 0.52 6.66 0.342 No. of beds 0.996 0.99 1.00 0.133 Tsk complexity No. of medicl specilties 1.077 0.91 1.28 0.393 Structurl fetures Prticiption IT infrstructure Orgnic structure Environmentl fctors True competitor HHI All hospitls within re 0.824 1.485 b 1.857 0.918 1.528 1.082 0.59 1.15 1.23 1.80 1.07 3.23 0.27 3.15 0.12 19.6 1.01 1.17 0.259 <0.001 0.029 0.892 0.745 0.035 EMR: Electronic Medicl Record, HHI: Herfindhl-Hirschmn index, OR: odds rtio, CI: confidence intervl. p < 0.05, b p < 0.005. The present study primrily investigted the fctors ffecting EMR doption in smll Koren hospitls. Although severl studies hve investigted EMR doption in Kore, there hve been few studies trgeting smll hospitls nd the internl fetures relted to EMR doption. Policy mkers need to Vol. 20 No. 3 July 2014 www.e-hir.org 187
Young-Tek Prk nd Jinhyung Lee determine how to motivte smll hospitls to invest finncil nd humn resources in EMR system doption in order to ddress the doption gp in smll clinicl prctice settings with regrd to helth informtion technologies [19]. Becuse smll hospitls lck lrge finncil investment resources for their hospitl fcilities nd helthcre IT, the present study results could provide meningful informtion to ssist governments in supporting smll hospitls with regrd to EMR doption. This study found tht the EMR doption rte of smll hospitls ws 40.3%, which is slightly higher thn tht found in previous studies. According to previous study investigting EMR doption, the overll doption rte of generl hospitls ws 38.0% [2], which ws n lmost identicl doption rte. Tht study ws conducted in 2004 nd the study subject ws generl hospitls. Regrding the four fctors of generl hospitl chrcteristics, only hospitl loction ws significntly relted with high doption rte. Hospitls locted in urbn res hd higher doption rtes thn did hospitls in rurl res. However, when we looked t the reltionship between generl nd internl fetures of smll hospitls nd EMR doption, none of the generl chrcteristics were significnt fctors in EMR doption. Loction of hospitls might be confounding vrible ffecting EMR doption. Further study is necessry to determine how this vrible is relted to other internl fetures of smll hospitls. Among hospitl internl fetures, IT infrstructure nd orgnic structurl form were fctors criticlly ffecting EMR doption. These findings were lso found in previous study [12]. Severl theoreticl rguments support this finding. Hospitls with greter IT infrstructure cn more esily invest in EMR systems becuse they hve n environment tht is ccepting of new nd highly complex EMR technologies. Orgnic orgniztionl structures with chrcteristics emphsizing horizontl communiction re ccepting of new ides from employees, which might crete n environment in which EMR systems could be esily instlled. Regrding externl environmentl fctors, HHI nd the existence of true competitors were not relted to EMR doption. Only the number of hospitls within n re ws significntly relted to EMR doption. This finding ws lso observed fter controlling for hospitl s generl chrcteristics. A similr finding ws lso found in previous study [12]. The present study hs two limittions. First, this study hd smll smple size. Given tht there re 778 smll hospitls in Kore, the number of responding hospitls, 144, represents only 19.0% of the totl study popultion. Second, interprettion of the study results should be confined to smll Koren 188 www.e-hir.org hospitls. This study suggests severl policy implictions. First, s mentioned bove, csh investment in EMR systems presents bigger chllenge to smll hospitls thn it does to lrge hospitls, which generlly hve lrger resources. It my therefore be necessry for governments to provide finncil support to smll hospitls. Smll hospitls re widely distributed in the mrket nd n doption gp for helthcre IT exists in smll prctice settings [19]. Second, s cn be seen in the present study results, the doption rte of smll hospitls is reltively low compred to tht of lrger hospitls [2], such s teching hospitls. In the mrket, EMR doption rtes might increse with government finncil support. This is prticulrly importnt for helthcre informtion exchnges (HIE) with regrd to the shring of results of lb or imging tests. Prcticl impcts of HIE could be chieved if lrge nd smll hospitls hd their own EMR systems. Governments should crete politicl inititives to support the doption of EMR systems by smll hospitls. Third, this study only included severl hospitl structurl fctors. Thus, dditionl studies including more vried structurl covrites re necessry. In ddition, further studies re needed to investigte how smll hospitls EMR doption fctors differ from those of lrge hospitls. In conclusion, IT infrstructure, orgnic mngeril structure, nd environmentl complexity were criticl fctors ffecting EMR doption. This study empiriclly verified tht decision mking structure nd number of hospitls, rther thn mrket competition bsed on bed size in given re, were importnt EMR doption fctors. Conflict of Interest No potentil conflict of interest relevnt to this rticle ws reported. Acknowledgments The uthors express their deep thnks to Dr. Sturt M. Speedie, member of the fculty t the Helth Informtics Grdute Progrm of the University of Minnesot, for his comments, dvice, nd support. References 1. Lee Y, Chng H. Ubiquitous helth in Kore: progress, brriers, nd prospects. Helthc Inform Res 2012;18(4):242-51. 2. Prk RW, Shin SS, Choi YI, Ahn JO, Hwng SC. Computerized physicin order entry nd electronic medicl
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Young-Tek Prk nd Jinhyung Lee [cited t 2014 Jul 1]. Avilble from: http://en.wikipedi. org/wiki/herfindhl_index. 31. Smith T, Smith B. PROC GENMOD with GEE to nlyze correlted outcomes dt using SAS. Sn Diego (CA): Deprtment of Defense Center for Deployment Helth Reserch, Nvl Helth Reserch Center; 2006. 32. SAS Institute Inc. SAS/STAT(R) 9.2 user's guide, second edition [Internet]. Cry (NC): SAS Institute Inc.; c2014 [cited t 2014 Jul 1]. Avilble from: http://support.ss. com/documenttion/cdl/en/sttug/63033/html/defult/viewer.htm#sttug_genmod_sect057.htm. 190 www.e-hir.org