Hospital adoption of information technologies and improved patient safety: a study of 98 hospitals in Florida.

EXECUTIVE SUMMARY

Most of the studies linking the use of information technology (IT) to improved patient safety have been conducted in academic medical centers or have focused on a single institution or IT application. Our study explored the relationship between overall IT adoption and patient safety performance across hospitals in Florida. Primary data on hospital IT adoption were combined with secondary hospital discharge data. Regression analyses were used to examine the relationship between measures of IT adoption and the Patient Safety Indicators (PSIs) of the Agency for Healthcare Research and Quality.

We found that eight PSIs were related to at least one measure of IT adoption. Compared with administrative IT adoption, clinical IT adoption was related to more patient safety outcome measures. Hospitals with the most sophisticated and mature IT infrastructures performed significantly better on the largest number of PSIs. Adoption of IT is associated with desirable performance on many important measures of hospital patient safety. Hospital leaders and other decision makers who are examining IT systems should consider the impact of IT on patient safety.

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Preventing medical errors and improving patient safety are among the most important potential advantages of adopting information technology (IT) in healthcare. For decades, the Institute of Medicine and other experts have been discussing the theoretical and anecdotal benefits of using computers to improve the quality of care (Bates et al. 2001; Dick, Steen, and Detmer 1991; Institute of Medicine 2001; McDonald 1976). Hospital researchers have demonstrated that the use of individual IT applications (e.g., computerized order entry and clinical decision support systems) is associated with desirable outcomes, including reduction of errors (Bates et al. 1998; Kaushal, Shojania, and Bates 2003), improved compliance with published guidelines (Dexter et al. 2001; Teich et al. 2000), and more efficient delivery of care (Bates et al. 1999a; Tierney et al. 1993).

Despite the growing body of literature that links IT to improved outcomes, the generalizability of existing studies has been questioned because many of the studies have been conducted in select academic medical centers, which have advanced resources and a decades-long commitment to IT that are not typical of other U.S. hospitals (Chaudhry et al. 2006). Furthermore, many studies have focused on individual homegrown IT applications and were not designed to measure the collective IT capabilities of a given hospital. Thus, it is not known whether hospitals that adopt a relatively higher number of commercially available information systems truly provide superior care.

This article explores the relationship between IT adoption and patient safety performance among hospitals in Florida. We combined primary IT survey data and secondary administrative discharge data from hospitals in the state, and then we measured overall hospital IT sophistication using a previously derived and validated method (Burke and Menachemi 2004). Patient outcomes were measured using the Patient Safety Indicators (PSIs) developed by the Agency for Healthcare Research and Quality (AHRQ).

CONCEPTUAL FRAMEWORK

The presence of IT does not in itself improve the quality of care. In fact, when improperly implemented, IT may inadvertently increase errors (Koppel et al. 2005). However, when properly designed and implemented, IT systems can ultimately produce better outcomes by improving various aspects of care delivery. For example, Bates and colleagues (1998; 1999b) found that the use of a computerized physician order entry system resulted in a 55 percent reduction in serious medication errors and, when used with a clinical decision support system, an 83 percent reduction in overall medication errors. Overhage and colleagues (1997) showed that automated computer reminders can significantly increase adherence to evidence-based protocols and can significantly decrease the number of pharmacy interventions for inappropriate medication orders in the hospital setting. Kuperman and colleagues (1999) found that computer-generated alerts to physicians from a laboratory information system resulted in significant decreases in both the time until treatment was ordered and the time until orders were implemented. Wong and colleagues (2003), who studied the effect of computerized documentation on the use of time by nurses in the critical care unit, suggested that an information system can decrease time spent on administrative duties and can increase time spent on direct patient care.

Other patient safety benefits have been identified with the use of various technologies, including bar-coded medication management (Johnson et al. 2002; Meyer et al. 1991), pharmacy information systems (Grams, Zhang, and Yue 1996; Troiano 1999), pharmacy dispensing systems (Kaushal, Barker, and Bates 2001), and clinical decision support systems (Berner et al. 2006). Collectively, these studies show that IT can be used to improve efficiency and timely access to clinical information, enhance the clinical decision-making process, and improve communication between providers. Ultimately, greater efficiency can translate into improved outcomes because it enables clinicians to spend more time with patients.

Although each of these studies examined only one IT application used in only one hospital, we extrapolated from the literature and hypothesized that hospitals that have adopted a greater number of information systems will provide safer care. We also projected that hospitals with more robust IT infrastructures would perform better on patient safety measures.

METHODS

We used both primary and secondary data. The primary data were collected in 2003 with a survey that targeted all chief information officers (CIOs) of Florida hospitals. The survey included a variety of questions regarding priorities, barriers, and current IT adoption. Secondary data included hospital discharge data for 2003, which were obtained from the Florida Agency for Health Care Administration, the agency responsible for regulating hospitals in Florida. Using the hospital discharge data and software from AHRQ, we calculated outcomes using the PSIs of AHRQ.

Hospital IT Data

The primary survey data were collected as part of a larger study on IT adoption practices among acute care hospitals in Florida (Menachemi et al. 2005a; Menachemi et al. 2005b; Menachemi et al. 2006; Menachemi et al. 2007a; Menachemi et al. 2007b). To identify eligible hospitals, we obtained a list of all hospitals in the state from the Florida Hospital Association. In the original study, the focus was on acute care facilities; thus, Veterans Affairs hospitals, psychiatric facilities, and other specialty facilities (e.g., pediatric hospitals) were excluded.

The mailed questionnaire asked CIOs to indicate which clinical, administrative, and strategic information systems were already implemented at their hospital at the time of the survey (for a complete list of these IT applications, see the appendix at the end of this article). Before administering the survey, we tested the survey instrument for clarity, readability, and content validity with a panel of IT experts and local hospital CIOs. The survey also included questions regarding facility characteristics and other hospital-level metrics. The survey protocol was approved by the institutional review board at Florida State University.

Of the 198 hospitals targeted in the study, 98 provided usable responses, for an overall response rate of 49.5 percent. Based on a previously validated method (Burke and Menachemi 2004) that has been used frequently by researchers (Bhattacherjee et al. 2006; Burke et al. 2002; Menachemi et al. 2007a; Menachemi et al. 2007b; Wang et al. 2005), we divided measures of IT adoption into three functional categories: clinical, administrative, and strategic. Each of these three measures was composed of a summated scale that represents the total number of individual IT applications adopted by a given hospital for each functional category. For example, the clinical IT summated scale for a given hospital could range from 0 (if that hospital had adopted none of the clinical IT applications examined) to 25 (if that hospital had adopted all clinical IT applications). The administrative IT summated scale ranged from 0 to 21, and the strategic IT summated scale ranged from 0 to 10.

Overall, each hospital received three scores--one for the count of IT applications the hospital adopted in each of the three categories. Higher scores on any scale indicated that relatively more IT applications were adopted. Because strategic applications are designed to make use of and to integrate readily available administrative and clinical information, such applications are typically adopted only after a significant number of administrative and clinical IT systems are present (Burke et al. 2002). Thus, higher scores on the strategic IT scale indicate a higher degree of information system integration and a higher level of overall robustness of a hospital's IT infrastructure. The strategic IT scale is, therefore, a proxy measure for overall information system maturity, as described by the Institute of Medicine (2000; 2001).

Patient Safety Indicators