1. 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 C ORNELL U NIVERSITY ’ S I NTERNATIONAL H EALTH C ARE C ONFERENCE Wednesday, May 12, 2010

2. 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.

3. 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.

4. THE DEMONSTRATION PROJECT: BACKGOUND  The QCOC used a rigorous selection process that resulted in eHealth Solutions (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.

5. 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.

6. Billing System FACILITYDATA CENTERPARTNERS Desktop PC 802.11b Ethernet Scanner Printer Labs/Radiology Payers Pharmacies Personal Digital Assistants (PDAs) Laptop/Tablet PC Remote Users THE NURSING HOME EMR SYSTEM Desktop PC SigmaSafe™ Hospitals SigmaCare Architecture SigmaCare Architecture  128-Bit Security & Availability 128-Bit Security & Availability 128-Bit Security & Availability .NET Framework & SQL Server.NET Framework & SQL Server.NET Framework & SQL Server  24/7/365 System Monitoring 24/7/365 System Monitoring 24/7/365 System Monitoring Laptop/ Tablet PC Smart Phones RHIO SSL 128-Bit Encryption

7. AN EXAMPLE OF FRONTLINE STAFF EMR TECHNOLOGY

8. 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 interviews with 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

9. 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 Managerial strategies for adoption and use Organizational preparedness for adoption Organizational preparedness for adoption Organizational learning Organizational learning Outcomes associated with the technology Outcomes associated with the technology

10. THREE EMR STRATEGIC GOALS AND OBJECTIVES Type AType BType C Strategic EMR Goals and Objectives ControlEfficiencyEmpowerment Top Management’s Application of EMR Surveillance and discipline Monitoring and resource savings Learning and skill development

11. VARIATION IN EMPLOYEE TECHNOLOGY ACCEPTANCE ACROSS ORGANIZATIONS

12. VARIATION IN EMR ADOPTION COSTS AS A FUNCTION OF EXPERIENCE (Avgar, Tambe, and Hitt, 2010)

13. 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 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 employee acceptance of technology The relationship between organizational characteristics and the cost of adopting the technology The relationship between organizational characteristics and the cost of adopting the technology

14. EXPLAINING IMPLEMENTATION COST VARIATION: SERVICE TICKETS AND WORKER DISCRETION (Avgar, Tambe, and Hitt, 2010).05.1.15.2.25 Service Tickets -.4-.20.2.4 Employee Discretion Levels avgticketsFitted values

15. 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

16. DECISION TO LEAVE NURSING HOME DUE TO FEAR OF USING EMR

17. 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

18. 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

19. TIME SPENT DOCUMENTING RESIDENT CARE ONE YEAR AFTER THE INTRODUCTION OF EMR TECHNOLOGY TIME SPENT DOCUMENTING RESIDENT CARE ONE YEAR AFTER THE INTRODUCTION OF EMR TECHNOLOGY

20. AMOUNT OF RESIDENT CARE DOCUMENTATION TIME SAVED USING EMR TECHNOLOGY

21. 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

22. PERCENTAGE OF EMPLOYEES OBSERVING ERRORS AND NEAR MISSES AT TIME 1 AND TIME 2

23. 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

24. 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

25. ControlEfficiencyEmpowerment Managerial Style AuthoritarianProgressiveParticipatory “Culture change”? NoPartialYes Employment Relations AdversarialTraditionalHigh Performance Labor Relations AdversarialCooperative ORGANIZATIONAL CHARACTERISTICS ASSOCIATED WITH EMR ADOPTION STRATEGY

26. USE OF TIME SAVED BY FRONTLINE STAFF