The Adoption of Electronic Medical Records by US Hospitals

160 Pages·2016·4.11 MB·English

by  Yinyue Hu

The Adoption of Electronic Medical Records by U.S. Hospitals: An Exploration of
Network Methods and Models
A Dissertation submitted in partial fulfillment of the requirements for the degree of
Doctor of Philosophy at George Mason University
by
Yinyue Hu
Master of Arts
Georgetown University, 2010
Bachelor of Arts
University of Shanghai for Science and Technology, 2008
Director: Laurie Schintler, Associate Professor
School of Policy, Government and International Affairs
Spring Semester 2016
George Mason University
Fairfax, VA
This work is licensed under a creative commons
attribution-noderivs 3.0 unported license.

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DEDICATION
This dissertation is dedicated to my grandfather, YIN Guangqi, who had always
inspired me to never stop learning.
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ACKNOWLEDGEMENTS
First and foremost, I would like to express my deep gratitude and appreciation to
my committee members, without whose persistent help this dissertation would not have
been possible. I owe a debt of gratitude to my committee chair Professor Laurie Schintler
for her guidance and extreme patience from the very early stage of my doctoral study
through the completion of this dissertation. I would like to thank my committee member
Professor Robert Axtell, who introduced me to agent based modeling and complexity
theories, for his friendly guidance and thought-provoking suggestions. My earnest thank
you goes to my committee member and supervisor for nearly six years, Professor Arnauld
Nicogossian, for his mentorship throughout my doctoral study. I am beyond grateful to
have had the opportunity to work with him. His continued direction and support is what
makes me survive the doctoral study. He has taught me what a true researcher should be in
innumerable ways.
Also, I would like to thank my external reader Professor Azhar Rafiq from Virginia
Commonwealth University for offering his help to review my dissertation. I would also
like to recognize Professors Naoru Koizumi, Phil Auerswald and Ray Sommer for their
input during my years of study at George Mason University. I would like to thank my
friends and colleagues at George Mason University for their feedback, support and
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friendship. Also, a thank you to Professor Charles Doarn from University of Cincinnati for
all the constructive discussions throughout the years.
This dissertation would not be possible without the Dissertation Completion Grant
from the Office of the Provost at GMU during my last semester of the study. In a similar
vein, I would like to thank the School of Policy, Government and International Affairs for
the financial support granted at various stages of this dissertation. I would like to
acknowledge the HIMSS Foundation for granting me the access to the research data.
I would like to thank my parents for continuously encouraging me in all my
pursuits. They always put education at the first priority and have faith in me. Finally, I
would like to thank my husband, Kai He, who supported me in every possible way to see
the completion of this work. Thank you for being such a great life and intellectual partner.

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TABLE OF CONTENTS
Page
List of Tables ................................................................................................................... viii
List of Figures .................................................................................................................... ix
List of Abbreviations .......................................................................................................... x
Abstract .............................................................................................................................. xi
Chapter 1 INTRODUCTION .............................................................................................. 1
1.1 ELECTRONIC MEDICAL RECORDS ................................................................... 2
1.2 RESEARCH QUESTIONS ....................................................................................... 5
1.3 RESEARCH DATA AND METHODOLOGY ........................................................ 8
1.4 ROADMAP OF THE DISSERTATION ................................................................ 12
Chapter 2 LITERATURE REVIEW ................................................................................. 13
2.1 EMPIRICAL STUDIES ON EMR ADOPTION .................................................... 13
2.2 NETWORK ANALYSIS ........................................................................................ 16
2.2.1 Network Measures and Models ........................................................................ 16
2.2.2 Network Analysis in Health and Medical Studies ............................................ 24
2.3 DIFFUSION OF INNOVATION ........................................................................... 26
2.4 AGENT BASED MODELING ............................................................................... 31
2.4.1 Agent Based Models of the Diffusion of Innovation ....................................... 31
2.4.2 Implications from Agent Based Models ........................................................... 33
2.5 SUMMARY ............................................................................................................ 39
Chapter 3 NETWORK ANALYSIS ................................................................................. 41
3.1 METHODOLOGY .................................................................................................. 42
3.1.1 Spatial Clustering ............................................................................................. 42
3.1.3 Network Construction....................................................................................... 46
3.1.3 Network Analysis ............................................................................................. 47
3.2 RESULTS................................................................................................................ 48
3.3 SUMMARY ............................................................................................................ 61
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Chapter 4 EVENT HISTORY MODEL ........................................................................... 63
4.1 METHODOLOGY .................................................................................................. 64
4.1.1 Cox Proportional Hazard Model....................................................................... 64
4.1.2 Model and Variable Specification .................................................................... 65
4.2 RESULTS................................................................................................................ 68
4.2.1 Descriptive Statistics ........................................................................................ 68
4.2.2 Preliminary Regression Analysis...................................................................... 75
4.2.3 Cox Proportional Hazard Model....................................................................... 79
4.3 SUMMARY ............................................................................................................ 86
Chapter 5 AGENT BASED MODELING ........................................................................ 87
5.1 METHODOLOGY .................................................................................................. 89
5.1.1 Model ................................................................................................................ 89
5.1.2 Parameter Setting .............................................................................................. 90
5.2 RESULTS................................................................................................................ 92
5.2.1 Baseline Model ................................................................................................. 93
5.2.2 Individual Interventions .................................................................................... 95
5.2.2 Alteration Interventions .................................................................................. 101
5.3 SUMMARY .......................................................................................................... 108
Chapter 6 CONCLUSION .............................................................................................. 110
6.1 SUMMARY OF FINDINGS ................................................................................ 111
6.2 LIMITATIONS OF THIS STUDY ....................................................................... 113
6.3 POLICY IMPLICATIONS ................................................................................... 115
6.4 IMPLICATIONS FOR FUTURE RESEARCH ................................................... 117
Appendix ......................................................................................................................... 119
References ....................................................................................................................... 138

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LIST OF TABLES
Table Page
Table 1-1 HIMSS EMR Adoption Model ........................................................................... 3
Table 1-2 Summary of Data .............................................................................................. 10
Table 2-1 Network Measures and Methods ...................................................................... 18
Table 3-1 Number of Hospitals Which Underwent Management or Structural Changes 42
Table 3-2 Sample Result of DBSCAN Sensitivity Test (2005 data) ................................ 45
Table 3-3 Summary of Network Data ............................................................................... 52
Table 3-4 Summary Statistics of Simulated Random Network and Real Network .......... 61
Table 4-1 Basic EMR........................................................................................................ 69
Table 4-2 Summary Statistics of Number of Beds ........................................................... 73
Table 4-3 Multicollinearity Test ....................................................................................... 76
Table 4-4 Logistic Regression Results for Hospital EMR Adoption ............................... 78
Table 4-5 Cox Model for Hospital EMR Adoption .......................................................... 81
Table 4-6 Cox Model for Hospital EMR Adoption, Reduced Dummies ......................... 85
Table 5-1 Parameter Setting.............................................................................................. 92
Table 5-2 Network Properties, Real vs. Ideal ................................................................. 106

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LIST OF FIGURES
Figure Page
Figure 1-1 Summary of EMR Adoption Score of U.S. hospitals, 2008-2015. ................... 4
Figure 1-2 Flowchart of Methodology .............................................................................. 12
Figure 3-1 Illustration of DBSCAN (Ester et al. 1996) .................................................... 44
Figure 3-2 Illustration of Network Construction .............................................................. 47
Figure 3-3 Illustration of Levels of Adjacent Vertices ..................................................... 48
Figure 3-4 Sample Node Subgraphs, 1.5 Levels of Adjacent Vertices ............................ 50
Figure 3-5 Sample Node Subgraphs, 2 Levels of Adjacent Vertices ............................... 51
Figure 3-6 Network Visualization, 2005 .......................................................................... 53
Figure 3-7 Network Visualization, 2013 .......................................................................... 54
Figure 3-8 Distribution of Top 200 Hospitals by Degree Centrality, 2005 ...................... 55
Figure 3-9 Distribution of Top 200 Hospitals by Degree Centrality, 2013 ...................... 56
Figure 3-10 Histogram of Degree Centrality .................................................................... 58
Figure 3-11 Degree Distribution ....................................................................................... 59
Figure 3-12 Degree Distribution with Power Law Fit, 2013 ............................................ 60
Figure 4-1 Summary of EMR Adoption, 2005-2013 ........................................................ 70
Figure 4-2 Distribution of Hospital by Specialty and Category ....................................... 71
Figure 4-3 Hospital Ownership Status .............................................................................. 72
Figure 4-4 Number of Beds, Boxplot ............................................................................... 73
Figure 4-5 Degree Centrality, Boxplot ............................................................................. 74
Figure 4-6 Direct Network Exposure, Barplot .................................................................. 75
Figure 4-7 Estimated Survival Function ........................................................................... 83
Figure 5-1 HIT Legislations and Policy Interventions ..................................................... 88
Figure 5-2 Baseline Model, Scale Free Network .............................................................. 94
Figure 5-3 Baseline Model, Real Network ....................................................................... 94
Figure 5-4 Individual Intervention, Real Network ........................................................... 97
Figure 5-5 Individual Intervention, Scale Free Network .................................................. 98
Figure 5-6 Final Uptake of Individual Interventions, Real Network ................................ 99
Figure 5-7 Final Uptake of Individual Interventions, Scale Free Network .................... 100
Figure 5-8 Uptake Comparison, Individual Interventions .............................................. 101
Figure 5-9 Alteration Interventions, Real Network ........................................................ 103
Figure 5-10 Alteration Interventions, Scale Free Network ............................................. 104
Figure 5-11 Final Uptake of Alteration Interventions, Real Network ............................ 105
Figure 5-12 Final Uptake of Alteration Interventions, Scale Free Network................... 105
Figure 5-13 Uptake Comparison, Alteration Interventions ............................................ 107

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LIST OF ABBREVIATIONS
Electronic Medical Records .......................................................................................... EMR
Agent Based Modeling ................................................................................................ ABM
Health Information Technology ...................................................................................... HIT
Healthcare Information and Management Systems Society ..................................... HIMSS
American Recovery and Reinvestment Act ............................................................... ARRA
Health Information Technology for Economic and Clinical Health ....................... HITECH
Clinical Data Repository ............................................................................................... CDR
Nursing Documentation ................................................................................................ DOC
Electronic Medication Administration Records......................................................... EMAR
Clinical Decision Support .............................................................................................. CDS
Computerized Physician Order Entry ......................................................................... CPOE
Full-time Equivalent ...................................................................................................... FTE
American Hospital Association .................................................................................... AHA
Distance-based Spatial Clustering of Application with Noise .............................. DBSCAN

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