Caregivers with Computers: Key EMR Adoption and Implementation Lessons from the New York State Demonstration Project David B. Lipsky School of Industrial and Labor Relations Cornell University Ariel C. Avgar School of Labor and Employment Relations University of Illinois at Urbana-Champaign Cornell University’s International Health Care Conference Wednesday, May 12, 2010
THE DEMONSTRATION PROJECT: BACKGROUND • Collective bargaining agreements between 1199 SEIU United Health Care Workers East and nursing home operators in downstate New York established the Quality Care Oversight Committee (QCOC). • The agreements called, among other things, for the implementation of electronic medical records and other health information technologies by the QCOC.
THE DEMONSTRATION PROJECT: BACKGOUND • Arbitration award in March of 2006 mandated the parties to adhere to their agreements. • The parties jointly approached the New York State legislature for funds to support the adoption of EMR in about 22 New York City area nursing homes as a demonstration project.
THE DEMONSTRATION PROJECT: BACKGOUND • The QCOC used a rigorous selection process that resulted in eHealthSolutions (EHS) obtaining the contract for the HIT implementation. • The QCOC also mandated the evaluation of the demonstration project. • Cornell University was selected to conduct the evaluation.
THE DEMONSTRATION PROJECT: SIGNIFICANCE • The demonstration project is a unique initiative potentially with national significance for the health care industry. • It introduced cutting edge technology through a labor-management partnership with the objective of improving resident care.
Laptop/Tablet PC Printer THE NURSING HOME EMR SYSTEM Remote Users SigmaCare Architecture • 128-Bit Security & Availability • .NET Framework & SQL Server • 24/7/365 System Monitoring Smart Phones Desktop PC Laptop/ Tablet PC Personal Digital Assistants (PDAs) RHIO 802.11b Payers Hospitals Scanner SigmaSafe™ Labs/Radiology Ethernet Pharmacies Billing System Desktop PC SSL 128-Bit Encryption FACILITY DATA CENTER PARTNERS
RESEARCH BACKGROUND AND DESIGN • Our study of the New York State Demonstration project began in the summer of 2007 • Fifteen homes receiving the technology and five homes not receiving the technology • Sample of staff and employees • Baseline survey and follow-up survey • Baseline and follow-up interviewswith administrators, staff and union representatives in ten treatment homes • Use of archival data • In the course of conducting our research a number of central EMR adoption and implementation themes emerged
LESSON #1: THE ADOPTION AND IMPLEMENTATION OF EMR VARIED GREATLY ACROSS HOMES • All the homes in the study employed essentially the same technology, which was installed and supported by the same vendor • Nevertheless, how they used the technology and benefited from it varied substantially from home to home • EMR adoption and implementation varied across a number of dimensions: • Managerial strategies for adoption and use • Organizational preparedness for adoption • Organizational learning • Outcomes associated with the technology
VARIATION IN EMPLOYEE TECHNOLOGY ACCEPTANCE ACROSS ORGANIZATIONS
VARIATION IN EMR ADOPTION COSTS AS A FUNCTION OF EXPERIENCE(Avgar, Tambe, and Hitt, 2010)
LESSON #2: MANAGEMENT STRATEGY AND THE ORGANIZATION OF WORK REALLY MATTER • The underlying argument made based on our qualitative research is that the quality of EMR adoption rests, to a large extent, on the management adoption strategy and the organization of work • Management strategy and the organization of work affected: • The relationship between an organizational EMR adoption strategy and post adoption use of the technology by management • The relationship between organizational characteristics and employee acceptance of technology • The relationship between organizational characteristics and the cost of adopting the technology
.25 .2 Service Tickets .15 .1 .05 -.4 -.2 0 .2 .4 Employee Discretion Levels avgtickets Fitted values EXPLAINING IMPLEMENTATION COST VARIATION: SERVICE TICKETS AND WORKER DISCRETION(Avgar, Tambe, and Hitt, 2010)
LESSON #3: THE BELIEF THAT THE WORKFORCE IN NURSING HOMES IS A BARRIER TO SUCCESSFUL EMR IMPLEMENTATION IS A MYTH • Prior to implementation we encountered healthy amount of skepticism on the part of administrators and some frontline staff regarding the capacity of the nursing home workforce to adapt to the new technology • One administrator stated: • “We all know that the kind of staff we have in our homes won’t be able to learn to use EMR effectively. We are better off using paper records.” • Both our quantitative and qualitative data do not show any support for these assumptions
LESSON #4: UNION AND EMPLOYEE PARTICIPATION IN EMR ADOPTION IS IMPORTANT • In New York, there was clearly political risk for 1199SEIU’s leaders to engage in a partnership with the nursing home operators in a project designed to support the adoption of EMR • However, union and employee participation in the adoption, implementation, and use of EMR technology was crucial • The union was probably the major vehicle for employee participation in decision making in the homes • Union leaders had a positive and significant effect on employee acceptance of the technology
LESSON #5: EMR CAN FREE UP TIME FOR STAFF TO DEVOTE TO RESIDENTS • One of the anticipated benefits of adopting EMR is the reduction in frontline staff documentation time • Although there was variation across organizations in the amount of time saved, overall, we found considerable support for this effect • We also documented use of saved time to provide resident care
TIME SPENT DOCUMENTING RESIDENT CARE ONE YEAR AFTER THE INTRODUCTION OF EMR TECHNOLOGY
LESSON #6: EMR PROBABLY REDUCES MEDICAL ERRORS • Our survey data documented that the number of respondents reporting that they had observed medical errors declined significantly after the introduction of EMR in the treatment but not in the control homes • Of those respondents reporting errors, the mean number of errors they observed also declined significantly (from 6.3 errors in the three months prior to our Time 1 survey to 4.5 in the three months prior to our Time 2 survey) • This employee based data provides initial support for a positive resident care outcome associated with EMR adoption
PERCENTAGE OF EMPLOYEES OBSERVING ERRORS AND NEAR MISSES AT TIME 1 AND TIME 2
DISCUSSION AND IMPLICATIONS • EMR has the potential to address both workforce and quality of care challenges • Nevertheless, the adoption of EMR is not uniform across all organizations • Some healthcare organizations will benefit more than others from this innovation • Healthcare organizations that pursue a broader efficiency or empowerment strategy for EMR adoption may yield a greater return on public investment • Pre adoption strategies affect post adoption usage
DISCUSSION AND IMPLICATIONS • Healthcare organizations interested in adopting EMR should consider improving specific organizational factors first • The importance of a specific top management strategy and vision for the implementation of the technology • Union and or employee participation in the adoption and implementation processes are crucial