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The American Journal of Managed Care January 2019
The Gamification of Healthcare: Emergence of the Digital Practitioner?
Eli G. Phillips Jr, PharmD, JD; Chadi Nabhan, MD, MBA; and Bruce A. Feinberg, DO
From the Editorial Board: Rajesh Balkrishnan, PhD
Rajesh Balkrishnan, PhD
The Health Information Technology Special Issue: New Real-World Evidence and Practical Lessons
Mary E. Reed, DrPH
Inpatient Electronic Health Record Maintenance From 2010 to 2015
Vincent X. Liu, MD, MS; Nimah Haq, MPH; Ignatius C. Chan, MD; and Brian Hoberman, MD, MBA
Impact of Primary and Specialty Care Integration via Asynchronous Communication
Eric D. Newman, MD; Paul F. Simonelli, MD, PhD; Shelly M. Vezendy, BS; Chelsea M. Cedeno, BS; and Daniel D. Maeng, PhD
Mind the Gap: The Potential of Alternative Health Information Exchange
Jordan Everson, PhD; and Dori A. Cross, PhD
Patient and Clinician Experiences With Telehealth for Patient Follow-up Care
Karen Donelan, ScD, EdM; Esteban A. Barreto, MA; Sarah Sossong, MPH; Carie Michael, SM; Juan J. Estrada, MSc, MBA; Adam B. Cohen, MD; Janet Wozniak, MD; and Lee H. Schwamm, MD
Understanding the Relationship Between Data Breaches and Hospital Advertising Expenditures
Sung J. Choi, PhD; and M. Eric Johnson, PhD
Currently Reading
Organizational Influences on Healthcare System Adoption and Use of Advanced Health Information Technology Capabilities
Paul T. Norton, MPH, MBA; Hector P. Rodriguez, PhD, MPH; Stephen M. Shortell, PhD, MPH, MBA; and Valerie A. Lewis, PhD, MA
Drivers of Health Information Exchange Use During Postacute Care Transitions
Dori A. Cross, PhD; Jeffrey S. McCullough, PhD; and Julia Adler-Milstein, PhD

Organizational Influences on Healthcare System Adoption and Use of Advanced Health Information Technology Capabilities

Paul T. Norton, MPH, MBA; Hector P. Rodriguez, PhD, MPH; Stephen M. Shortell, PhD, MPH, MBA; and Valerie A. Lewis, PhD, MA
This is the first national study to examine the relationship between healthcare system organizational characteristics and adoption of advanced health information technology capabilities.


Data used were from the system version of the 2017/2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative sample of healthcare systems that took place from June 2017 to August 2018. The survey was based on previous surveys developed involving the National Study of Physician Organizations9,14 along with additional questions focusing on the use of biomedical innovations, patient engagement strategies, evidence-based care management, and performance-based incentives. Respondents were the individuals most knowledgeable about the survey questions, who most commonly were system presidents, chief executive officers, or chief medical officers. Survey responses were matched with data obtained from IQVIA information services to provide additional context on systems’ organizational characteristics. Of the 732 randomly sampled healthcare systems, 446 responded (60.9% completion), 425 of which were included after data cleaning was completed. Given the strong financial incentives that the Meaningful Use program created for basic EHR adoption, we eliminated systems that had not fully adopted basic EHRs (n = 36). The final analytic sample included 389 healthcare systems, 22.6% (n = 88) of which were subsidiaries of corporate parents.


Outcome: advanced HIT adoption. Survey respondents were asked about the adoption and use of 5 advanced HIT capabilities across their health systems. Four of these capabilities—patients’ access to their electronic medical records, patients’ ability to electronically comment on their medical records, physicians’ and patients’ ability to communicate with each other via secure email, and physicians’ ability to know whether patients have filled prescriptions—are required capabilities for Certified Electronic Health Record Technology (CEHRT) designation.15 The fifth, advanced analytic systems, has been identified in previous research as a key ingredient to successful care management for complex patients.16

For each of these capabilities, respondents were asked how many hospitals or medical groups in their systems had the following features, with possible answers being “none,” “some,” “most,” or “all.” To construct a measure of successful advanced HIT adoption, we assigned 1 point to answers of “most” or “all” and 0 points to answers of “none” or “some.” Overall adoption was then measured on a scale of 0 to 5, with a score of 0 indicating no capabilities had been adopted successfully and a score of 5 indicating all capabilities were adopted successfully.

Predictor variables. Health system ownership and management was measured via 2 survey questions that asked survey respondents about whether the system owned or managed hospitals and medical groups. Respondents had the option of answering “no,” “own only,” “manage only,” and “own and manage.” Because we were sampling health systems, which, by nature, had a high level of medical group and hospital ownership and management (nearly 50% of the systems in our sample reported both owning and managing hospitals and medical groups), a categorical variable was created, assigning a value of 1 to systems that owned and managed hospitals and medical groups and 0 to all other systems.

The degree to which a health system centrally allocated resources was measured using answers to 3 questions in the survey based on their ability to serve as potential proxies for resources that could be dedicated to new HIT systems. The questions were “What level of financial planning and revenue sharing best describes your healthcare system?” “At what level [is capital budgeting] primarily conducted?” and “At what level [is IT vendor selection] primarily conducted?” We assigned a point value of 1 for each activity conducted at the system level (and 0 for those conducted locally or regionally) and took an unweighted average of the point values across the 3 questions to develop an index of how much resource allocation was centralized (0 being none of these activities conducted at the system level, 1 being all activities conducted at the system level).

EHR standardization was measured using answers to 2 questions: “How many EHR systems do you have in place across your hospitals’ primary care groups?” and “To what extent are EHR data elements standardized?” Fully standardized EHR data elements and a single EHR system were each assigned a point value of 1, and we took an unweighted average of the point values across the 2 questions to develop an index of how much their EHR systems were standardized.

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