DISSERTATION PROPOSAL DEFENSE ARGOSY UNIVERSITY COLLEGE OF BUSINESS
August 10th, 2015
Candidate: Joseph C. Makres
Dissertation Chair: Dr. David Hancock
Dissertation Member: Dr. Steve Shao
A HEALTHCARE MANAGEMENT PROBLEM FOR TODAY’S HEALTHCARE EXECUTIVES
Today’s Healthcare Environment Healthcare Consultant Perspective
CIOs looking for guidance on what strategy / approach to take for their particular organization
$100 Million Dollar Investment
Maximum reimbursement with the highest quality care
Data/literature lacking on VBP Program performance and health information technology strategies
Literature and information on EMRs and financial metrics available – only at application level
Healthcare executives looking for answers
PROBLEM
Uncontrolled U.S. Healthcare Expenditures
Poor Quality Performance
Increased financial investment in health information technology (HIT)
Fragmented healthcare system
Disparate HIT applications without integration
Transformational change to reimbursement model
Fee-for-service to value-based care
Failed HIT implementation can cost millions
How to determine HIT return on investment
WHAT IS THE PROBLEM
Real-world Example:
Disparate Systems
Care Coordination
Patient-Centered Care
PURPOSE
Examine whether HIT can improve quality, increase efficiency, and reduce costs
$20 billion allocated to HIT in 2009 ARRA
Hospital reimbursement based on Quality not quantity
Value-Based Purchasing (VBP) Program (1.5% in 2015)
Accountable Care Organization (ACO) contracts
Literature identifies three key HIT management strategies
How do they impact quality outcomes
How do improve efficiency
Does more or less integration improve performance
#2 How have HIT management strategies changes over time?
SIGNIFICANCE
Managerial decision-making Healthcare executives making multi-hundred million dollar decisions What is the best way to organize their IT department, HIT applications,
and overall HIT management strategy to achieve the greatest ROI Improve patient satisfaction Increase overall quality of care How will we meet Meaningful Use and receive Medicare’s financial
incentive Stage 1 Stage 2
Effective HIT management requires: Planning Coordination Work Redesign Change Management
Study will help healthcare executives evaluate and make important decisions on which HIT management strategy provides them with the best quality of care for patients and maximum financial reimbursement!
RESEARCH QUESTIONS
Are there significant differences in VBP Total Performance Scores for acute-care hospitals pursuing single-vendor, best-of-breed, or best-of-suite HIT management strategies?
Null Hypothesis No significant difference in performance between HIT
management strategies
Has the proportion of HIT management strategies within the acute-care hospital population changed over time?
Null Hypothesis HIT management strategy proportions have not
changed over time
THEORETICAL PERSPECTIVE
Value-Based Purchasing Programs
Ability to change provider behavior
Davis & Damberg
Principal-Agent Theory
Environmental Uncertainty
Changes to reimbursement method
Compliance with payer demands/contracts
Interoperability & HIT
Resource Dependency Theory
Pfeffer & Salancik (1978)
Kazley & Ozcan (2007)
Menachemi, Shin, Ford, & Yu (2011)
HOW
Quantitative, non-experimental, cross-sectional analysis with longitudinal component
Data
HIMSS Analytics Database (2009 & 2012)
Value-Based Purchasing – Total Performance Score
Fiscal year 2015
One-way ANOVA with post hoc pairwise comparisons
Chi-square goodness of fit
Simple Regression for each strategy
SIGNIFICANT LITERATURE REVIEW FINDINGS
SIGNIFICANT LITERATURE
Over 130 references
Briggs (2003) Identified and labeled health IT strategies into
separate categories based on other industries Single-Vendor (SV) - enterprise-wide planning software
products are designed to integrate administrative, clinical, and strategic applications across multiple locations and provide hospitals with out-of-the box solutions
Best-of-Breed (BoB) - offer more suitable products for the needs of any department adopting this technology because they offer richer domain-specific functionality, and since they are designed for a specific department result in greater buy-in from staff
Best-of-Suite (BoS) - are a mix between BoB and single-vendor approaches where hospitals use one package of applications as the basis for integrating all other applications within specific functional units
LITERATURE REVIEW
Kazley & Ozcan (2007) Linked hospital use of HIT to securing necessary resources
(i.e. patient demand and financial reimbursement) under a Resource Dependence Theory perspective
Burke, Yu, Au, & Menachemi (2009) First to identify frequency of IT management strategies
pursued by U.S. hospitals SV (61%)
BoS (29%)
BoB (10%)
In-house (<1%)
Hospital characteristics associated with one strategy over another Larger hospitals – BoS or SV Strategy
Small & Medium Hospitals – SV Strategy
LITERATURE REVIEW
Ford, Menachemi, Huerta, & Yu, (2010) Hospitals using BoS approach had fully implemented
HIT systems in significantly greater proportions than did hospitals employing either of the other strategies
Menachemi, Shin, Ford, & Yu, (2011) Number of managed care contracts per hospital (rate
of change or innovation) was negatively associated with SV
Complexity (market competition) was positively associated with BoB
Greater environment munificence negatively associated with SV approaches* When access to resources is high, hospitals tend to choose
BoS strategies
Resource Dependency Perspective
METHODOLOGY – PARTICIPANT SELECTION
U.S. acute-care, non-Veterans Administration hospitals
Both databases
Participants in HIMSS Analytics Survey
Participants in Medicare VBP Program
Burke et al. (2009), Ford et al. (2010), Menachemi et al. (2011)
2008 HIMSS Analytics Database – HIT Management Strategy
METHODOLOGY – RESEARCH INSTRUMENT
Secondary Data Resources
2009 & 2012 HIMSS Analytics Database Survey
2009 Microsoft Access dataset
2012 Microsoft Access dataset
Granted access to HIMSS Analytics + Dorenfest Institute for Health Research Database
Hospital VBP Program Results
Fiscal Year 2015
Over 3,000 acute-care hospitals
Data collected through the Hospital Inpatient Quality Reporting (IQR) Program (CMS, 2013)
Publicly available data
METHODOLOGY – VALIDITY & RELIABILITY
Burke et al. (2009), Ford et al. (2010), & Menachemi et al. (2011) Collected HIT management strategy selection from 2008
HIMSS Analytics Database
One-way ANOVA statistical test Normal distribution verification
Commonly used test to determine if sample populations have equal variances (Lind, Marchal, & Wathen, 2010).
Chi-square goodness-of-fit Normal distribution verification
Commonly used test for expected frequencies (Lind, Marchal, & Wathen, 2010)
Utilized by Menachemi et al., (2011)
METHODOLOGY – DATA ANALYSIS
Data matching
Medicare provider number
Same methodology as Burke et al. (2009), Ford et al. (2010), & Menachemi et al. (2011)
Statistical Procedures
SPSS Premier Grad Pack V22.0
METHODOLOGY – LIMITATIONS/DELIMINATIONS
First study to attempt correlation between HIT management strategies and VBP performance
Participants focus on acute-care U.S. hospitals Not Included: Provider Groups/Networks Home health
facilities, skilled nursing facilities
VBP performance data relatively new and evolving rapidly which will limit ability to generalize about future situations
Dependent on secondary databases not under control of investigator
Control variables, organizational characteristics, and/or environmental characteristics
Scalability Examine individual departments, not entire hospital?
SIGNIFICANCE TO HEALTHCARE COMMUNITY
Healthcare Executives & Management Limited data available linking HIT to VBP performance
Healthcare industry is fragmented (Porter & Tiesberg, 2006), but so is HIT within individual hospitals.
Several studies have already examined relationship between the number of HIT systems and financial performance (FFS not P4P)
First study that looks at performance through pay-for-performance reimbursement instead of traditional DRG-based payments
This study will shed some light on how effective these changes have been at achieving the National Quality Strategy’s strategic objectives and triple aim of better care, better health, and lower costs.
REFERENCES Briggs, B. (2003). The main event: Best-of-breed vs. single-source. Health Data Management,
11(6), 41-4, 46-8. Retrieved from http://search.proquest.com/docview/219533182?accountid=34899
Burke, D. E., Yu F., Au, D., & Menachemi, N. (2009). Best of breed strategies: Hospital characteristics associated with organizational HIT strategy. Journal of Health Information Management, 23(2), 46-51.
Creswell, J. (2009). Research design: Qualitative, quantitative, and mixed methods approaches, (3rd ed.). Thousand Oaks, CA: Sage Publications.
CMS. (2013). FY-2013 Frequently Asked Questions About Hospital Value-Based Purchasing Program. Retrieved from http://www.hospitalcompare.hhs.gov
Ford, E. W., Menachemi, N., Huerta, T. R., & Yu, F. (2010). Hospital IT adoption strategies associated with implementation success: Implications for achieving Meaningful Use. Journal of Healthcare Management, 55(3), 175-188.
Helton, J. R. (2011). Assessing the impact of electronic health record technology adoption on hospital labor efficiency. (Order No. 3459837, The University of Texas School of Public Health). ProQuest Dissertations and Theses, 153. Retrieved from http://search.proquest.com/docview/875816135?accountid=34899. (875816135).
Kazley, A. S., & Ozcan, Y. A. (2007). Organizational and environmental determinants of hospital EMR adoption: A national study. Journal of Medical Systems, 31(5), 375-84. doi:http://dx.doi.org/10.1007/s10916-007-9079-7
Lind, D. A., Marcha, W. G., & Wathen, S. A. (2010). Statistical Techniques in Business and Economics (14th e.d.). McGraw-Hill Companies, Inc., New York, NY
Menachemi, N., Shin, D. Y., Ford, E., & Yu, F. (2011). Environmental Factors and Health Information Technology Management Strategy. Health Care Management Review, 36(3), 275-285
Pfeffer, J., & Salancik, G. R. (1978). The External Control of Organizations. Stanford University Press, Stanford, CA.
APPENDIX
Follow Up Question & Answer
SIGNIFICANT / IMPORTANT TERMS
HIT Management Strategies Single-Vendor
Best-of-Breed
Best-of-Suite
Hospital Value-Based Purchasing (VBP) Program Total Performance Scores
Process of Care Measures
Outcomes Measures
Patient Satisfaction
Efficiency Measures (Medicare Spending per Beneficiary)
American Recovery & Reinvestment Act (ARRA)
Patient Protection & Affordable Care Act (PPACA)
Health Information & Management Systems Society (HIMSS)
Health Information Technology for Economic and Clinical Health (HITECH Act)
METHODOLOGY – DATA ANALYSIS
Hypothesis 1
One-way Analysis of Variance
Post hoc pairwise comparisons
Scheffe’s Tests
Hukey’s Test
LSD
Bonferri’s test
Pearson’s Correlation Coefficient
Hypthesis 2
Chi-Square & Simple Regression (Goodness of Fit)
Analyze HIT management strategy proportion over time
PURPOSE & RESEARCH QUESTION
Hospitals & Providers
HIT Investments
IT Resources
Purchasing Strategies
Return on Investment
Payers & Reimbursement Reform
Value-Based Purchasing (VBP) Programs
Pay-for-Performance Contracts
Accountable Care Organizations
Bundled Payment Contracts
Do HIT investments lead to better quality and efficiency outcomes for hospitals and patients?
PROBLEM BACKGROUND
2009 ARRA legislation increased hospital & provider investment in health information technology (HIT) Massive adoption of HIT application and systems through
EHR Incentive Program “Meaningful Use”
2010 Affordable Care Act introduced new reimbursement method – Value-Based Purchasing (VBP) Program Significant departure from traditional fee-for-service
reimbursement to one based on quality, outcomes, & performance
Hospital, Providers, & Payers Improve patient quality & outcomes by restructuring
payment system Reliance on HIT to deliver efficiency and coordination
necessary to achieve quality & performance objective while at the same time lower out-of-control healthcare expenditures
PROBLEM & BACKGROUND INFORMATION
Healthcare Reform Reimbursement Model Experiments
Quality or Value-based Care Concept
Affordable Care Act (2010) Hospital Value-Based Purchasing Program
American Recovery & Reinvestment Act (2009) The Health Information Technology for Economic & Clinical
Health (HITECH) Act The Office of the National Coordinator of Health Information
Technology (ONCD) $20 Billion toward HIT CMS EHR Incentive Program “Meaningful Use”
ACA & ARRA Combined Objective & Outcomes Quality & Efficiency Improvement Care Coordination & Information Sharing Data Analytics: Predictive Modeling Workflow & Process Redesign
PROBLEM & BACKGROUND
Hospitals Costs
Quality of Care
Efficiency
Cost Containment
Health Information Technology (HIT) Investments
Value-Based Purchasing
Care Coordination
Pay-for-Performance
Accountable Care Organizations
Bundled Payment Contracts