Publication Date

2014-11-17

Availability

Embargoed

Embargo Period

2016-11-16

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PHD)

Department

Nursing (Nursing)

Date of Defense

2014-11-06

First Committee Member

Martin M. Zdanowicz

Second Committee Member

Brian E. McCabe

Third Committee Member

Todd F. Ambrosia

Fourth Committee Member

Anne L. Felteau

Fifth Committee Member

Cynthia L. Foronda

Abstract

The United States government has invested over a billion dollars to support the nationwide implementation, adoption, and “meaningful use” (MU) of electronic health record (EHR) technology. The American Reinvestment and Recovery Act of 2009 represents just one example of how the delivery of healthcare services is evolving from a fee-for-service to a pay-for-performance model that is data-driven. Under the Centers for Medicare and Medicaid Services (CMS) Meaningful Use (MU) Program, hospitals that fail to demonstrate how their use of electronic health record systems improves patient outcomes will not only lose EHR incentive payments, but could face financial penalties beginning as early as 2015. The transition from paper to electronic records is challenging and end-user resistance is a commonly cited reason for EHR implementation failures. Nurses are the largest group of hospital clinicians and the largest group of EHR end-users, yet there is minimal research on the relationship between the level of nursing care and the successful adoption of EHRs in U.S. hospitals. The aims of this non-experimental quantitative study were to: (a) examine the relationship between nursing excellence and EHR adoption, and (b) examine the relationship between the tenure of nursing excellence and EHR adoption. The predictor variable of nursing excellence was operationalized by Magnet recognition by the American Nurses Credentialing Center (ANCC) as of December 2013. The predictor variable of tenure of Magnet status was represented by two groups, Early-designation (initial designation occurring from 1994-2009) and Recent-designation (initial designation occurring from 2010-2013). The outcome variable of EHR adoption was operationalized by positive receipt of at least one payment from the CMS for the Medicare EHR Incentive Program or the achievement of Level 6 or 7 on the Health Information and Management Systems Society (HIMSS) Analytics Electronic Medical Record Adoption Model (EMRAM) as of December 2013. This study utilized two distinct target populations and two distinct samples. The MU analyses only included hospitals that were eligible for the Medicare EHR Incentive Program based on their CMS facility category. Out of a possible 393 United States (U.S.) Magnet hospitals, 330 represented the target population for the MU hypotheses. Out of a possible 6,582 U.S. hospitals, 4,929 were included in the study sample for the MU analyses. The HIMSS Analytics EMRAM analyses did not exclude hospitals that were ineligible for the Medicare EHR Incentive Program, and they also were independent of healthcare organizations’ CMS reporting structures. Out of a possible 393 U.S. Magnet hospitals, all 393 represented the target population for the HIMSS Analytics hypotheses. Out of a possible 6,582 U.S. hospitals, 6,419 were included in the study sample for the HIMSS Analytics analyses. Data were analyzed using binary logistic regression. Magnet-designated hospitals had 3.58 times greater likelihood than non-Magnet hospitals of receiving Medicare EHR incentive payments for MU attestation (p < .001). Magnet hospitals also had 3.68 times greater likelihood than non-Magnet hospitals of achieving Level 6 on the HIMSS Analytics EMRAM (p < .001), and 4.02 times greater likelihood than non-Magnet hospitals of achieving Level 6 or 7 (p < .001) when Levels 6 and 7 were combined together as one outcome variable. No significant relationships were found between Magnet status and the achievement of HIMSS Analytics EMRAM Level 7 when it was analyzed as an individual dependent variable (p = .802). No significant relationships were found between the tenure of Magnet status and any of the measures of EHR adoption. Further study implications include the examination of multiple hospital characteristics that may contribute to EHR adoption and the qualitative exploration of nursing leaders’ perspectives at Magnet organizations that have successfully adopted EHR technology.

Keywords

Electronic health record adoption; Electronic medical record adoption; Nursing excellence; Magnet Hospitals; Meaningful Use attestation; HIMSS Analytics EMRAM Levels 6 and 7

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