an integrative review of the literature on technology transformation in healthcare andrew b
TRANSCRIPT
An Integrative Review of the Literature on Technology Transformation in Healthcare
Andrew B. Phillips
Submitted in partial fulfillment of the requirements for the degree of
Doctor of Philosophy under the Executive Committee
of the Graduate School Of Arts And Sciences
COLUMBIA UNIVERSITY
2012
© 2012 Andrew B. Phillips All rights reserved
ABSTRACT
An Integrative Review of the Literature on Technology Transformation in Healthcare
Andrew B. Phillips
Healthcare transformation through technology is a core objective of health reform. It is
important for decision makers to understand the likelihood that reform policies will in fact
transform. This study evaluates evidence of technology transformation in healthcare through an
integrative review of the healthcare and business literature, guided by the theory of punctuated
equilibrium (TPE). TPE describes the process of transformation within organizations, markets,
and groups. The theory explains transformation as a pattern of long periods of incremental
change (equilibrium) punctuated by short periods of dramatic change (revolution). An
underlying deep structure defines the environment of the organization, market, or group.
Radical change in the deep structure of the environment is necessary for transformational
change.
This integrative review covered the period January 2004 through April 2012. The
inclusion criteria required that the article or study address both the implementation of health
information technology in the United States and describe one of the three components of TPE.
Five hundred twenty articles focusing on transformational change were identified through
structured database searches of MedLine/PubMed, Business Source Complete, Social Science
Research Network, and others. The articles were reviewed, and coded using the three elements
of TPE. A directed content analysis of the coded data produced 10 themes describing the three
TPE elements: variations in the environment, market complexity, regulation, flawed risk and
reward, theories of technology acceptance, barriers, ethical considerations, competition and
sustainability, environmental elements of revolution, and internal elements of revolution.
The results describe a healthcare market exhibiting strong equilibrium and substantial
resistance to change from HIT. Minimal descriptions of the revolutionary element of TPE were
evident. The deep structure of healthcare indicates that the historical provider and hospital-
centered market prevails. Conditions that might encourage alteration of this deep structure were:
empowering and engaging patients; updating care delivery models; and reducing market
uncertainty. The revolutionary changes seen in other complex markets from banking to travel to
manufacturing relied heavily on the power of the consumer to alter deep structure. Although the
concept of patient centeredness was present in the literature there was little clarity regarding the
patient as an agent of structural change.
To our knowledge this is the first application of TPE to investigate technology
transformation in healthcare. Others have demonstrated TPE as a viable model for explaining
transformational change in other markets. The study is limited by the study timeframe and the
absence of newer literature reflecting the impact of recent policy changes. Despite this limitation
the findings suggest that TPE presents a potentially valuable framework to guide evaluation of
the progress of policies that encourage transformation from technology.
Some propose that altering the complex deep structure of healthcare may require a
complete destruction of existing processes before new processes, innovations, and technologies
can emerge. The Affordable Care Act (2010) and the meaningful use provisions of the HITECH
Act (2009) are moving healthcare toward new patient centered models of care. Uncertainty
around the future of reform policies from possible repeal or amendment likely contributes to
resistance to transformational change. This may perpetuate the historical rational and
incremental pattern of HIT advancement. Patients as consumers have the potential to influence
change given the appropriate tools. The importance of consumers to the transformation process
suggests that policies fostering technologies that integrate patients into new care delivery models
are likely paramount to realizing technological transformation.
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TABLE OF CONTENTS
TABLE OF CONTENTS ................................................................................................................. i TABLE OF FIGURES ................................................................................................................... iii TABLE OF TABLES ..................................................................................................................... v ACKNOWLEDGEMENTS ........................................................................................................... vi DEDICATION .............................................................................................................................. vii CHAPTER 1: INTRODUCTION/PROBLEM .............................................................................. 1
Problem Statement ...................................................................................................................... 1 Background ................................................................................................................................. 2 Theoretical Framework – Punctuated Equilibrium ..................................................................... 4 Research Aim and Methods ........................................................................................................ 6 Significance ................................................................................................................................ 7
CHAPTER 2: REVIEW OF THE LITERATURE ........................................................................ 8 Status of US Healthcare System ................................................................................................. 8
Causes of Poor Performance ................................................................................................. 10 Theories of Technology Transformation .................................................................................. 11 Punctuated Equilibrium ............................................................................................................ 17
Gersick’s Theory of Punctuated Equilibrium ....................................................................... 17 Deep Structure ............................................................................................................................... 18 Equilibrium Period ......................................................................................................................... 19 Revolutionary Period ..................................................................................................................... 19
Complexities of Healthcare Market/System ............................................................................. 20 CHAPTER 3: METHODOLOGY/RESEARCH DESIGN ......................................................... 23
The Integrative Review ............................................................................................................. 23 Integrative Review Methodology ............................................................................................. 25
Problem Identification .......................................................................................................... 27 Literature Search ................................................................................................................... 27
Data Sources .................................................................................................................................. 27 Search Terms ................................................................................................................................. 28 Title and Abstract Inclusion Criteria .............................................................................................. 29
Data Evaluation/Reduction ................................................................................................... 31 Relevance and Rigor ...................................................................................................................... 31 Evaluative Data .............................................................................................................................. 33
Data Comparison/Synthesis .................................................................................................. 36 CHAPTER 4: RESULTS ............................................................................................................. 38
Search Results ........................................................................................................................... 38 Description of the Identified Literature .................................................................................... 39 Elements of Punctuated Equilibrium in the Identified Literature ............................................. 43
Deep Structure ...................................................................................................................... 46 1. Variations in the Environment ................................................................................................... 46 2. Market Complexity .................................................................................................................... 49 3. Regulatory .................................................................................................................................. 51
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4. Flawed Risks and Rewards ........................................................................................................ 53 5. Theories of Technology Acceptance and Diffusion .................................................................. 55
Equilibrium ........................................................................................................................... 58 1. Barriers to Change ..................................................................................................................... 59 2. Ethical Considerations ............................................................................................................... 61 3. Competition and Sustainability .................................................................................................. 62
Revolution ............................................................................................................................. 63 1. Environmental Elements Necessary for Transformation ........................................................... 63 2. Internal Elements Necessary for Transformation ...................................................................... 65
CHAPTER 5: DISCUSSION ....................................................................................................... 67 The Role of Technological Discontinuities in Transformation ................................................ 69 Resistance from the HIT Environment ..................................................................................... 73 Healthcare Complexity and System Inertia .............................................................................. 74 The Role of the Consumer in Transformation .......................................................................... 75 Implications for Current HIT Policy ......................................................................................... 76 Implications to Nursing in HIT ................................................................................................. 77 Limitations ................................................................................................................................ 78 Areas for Further Study ............................................................................................................ 80
REFERENCES ............................................................................................................................. 81 Appendix A – Specific Search Strategies ..................................................................................... 89 Appendix B – List of Identified Articles ...................................................................................... 91 Appendix C – Sample Coded Table of Identified Articles ......................................................... 130
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TABLE OF FIGURES
Figure 1 - Representation of three components of Gersick's theory of punctuated equilibrium - deep structure, equilibrium period and revolutionary period ............................................ 6
Figure 2 - The IT Transformation Process. Competence enhancing and destroying processes represent alternate pathways for achieving transformation. From Inside the future: Surviving the technology revolution, by H. C. Lucas, 2008, p. 21. Copyright 2008 by ABC-CLIO Inc. Reprinted with permission. .................................................................... 14
Figure 3 – The Technology Cycle. The cycle is defined by eras of ferment and incremental change separated by technological discontinuities and a dominant design. From “Technological discontinuities and dominant designs: A cyclical model of technological change” by P. Anderson and M. L. Tushman, 1990, Administrative Science Quarterly, p. 606. Copyright 1990 by Sage Publications Inc. Journals. Reprinted with permission. .... 16
Figure 4 – Sample screen shot of data coding screen used in Access database. ........................... 36
Figure 5 - Search flow for relevant literature ................................................................................ 39
Figure 6 - Comparison of punctuated equilibrium component by year ........................................ 40
Figure 7 – Distribution of articles by state. Darker color indicates higher number of articles. ... 43
Figure 8 - Rogers technology adoption life cycle. Top graph represents cumulative adoption. Bottom graph represents adoption by diffusion period. From “Modelling and forecasting the diffusion of innovation - A 25-year review,” by N. Meade and T. Islam, 2006, International Journal of Forecasting, 22(3), p. 520. Copyright 2006 by Elsevier Limited. Reprinted with permission. (Meade & Islam, 2006) ......................................................... 57
Figure 9 – Schema for the Technology Acceptance Model (TAM) and TAM2. From “The technology acceptance model: its past and its future in health care,” by R. J. Holden and B. T. Karsh, 2010, Journal of biomedical informatics, 43(1), p. 161. Copyright 2010 by Elsevier Limited. Reprinted with permission. .................................................................. 58
Figure 10 – Pattern of incremental change and transformation described by the theory of Punctuated Equilibrium. Equilibrium (green) is characterized by long periods of incremental change and resistance to transformation. Revolution (red) from a technological discontinuity results in transformation and a radical change in Deep Structure. ........................................................................................................................... 68
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Figure 11 - The Technology Cycle. The cycle is defined by eras of ferment and incremental change separated by technological discontinuities and a dominant design. From “Technological discontinuities and dominant designs: A cyclical model of technological change” by P. Anderson and M. L. Tushman, 1990, Administrative Science Quarterly, p. 606. Copyright 1990 by Sage Publications Inc. Journals. Reprinted with permission. .... 69
Figure 12 – Competence enhancing and competence destroying pathways of technology transformation. .................................................................................................................. 71
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TABLE OF TABLES
Table 1 - Summary of research process, methods and tools used in the integrative review of the literature. ........................................................................................................................... 26
Table 2 - Databases used in literature search ................................................................................ 28
Table 3 - Kappa calculations for literature coding ........................................................................ 30
Table 4 - Definition of rigor used for data coding. ....................................................................... 32
Table 5 - Definition of relevance used for data coding. ............................................................... 32
Table 6 - Definitions of punctuated equilibrium components used in coding data sources. ........ 33
Table 7 - List of data elements captured in the study’s database .................................................. 34
Table 8 - Articles by punctuated equilibrium component ............................................................ 40
Table 9 - Articles by rigor and relevance ...................................................................................... 41
Table 10 - Articles by study design .............................................................................................. 41
Table 11 - Articles by technology type ......................................................................................... 42
Table 12 - Articles by stakeholder ................................................................................................ 42
Table 13 - Summary of the ten (10) themes identified from the directed content analysis of the literature. ........................................................................................................................... 44
Table 14 - Categorization of articles by punctuated equilibrium component theme and rigor score. Articles can address more than one component and not all articles were relevant to a theme. ............................................................................................................................. 45
Table 15 - Frequency of technology acceptance and diffusion models in the study data. ........... 56
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ACKNOWLEDGEMENTS
This dissertation project was supported by T32NR007969 (Center for Evidence-based
Practice in the Underserved), Suzanne Bakken, Principal Investigator.
I thank all that were involved in my grand experiment returning to school. It started
small and grew into the dissertation that is presented here.
My family at school was a continuous source of encouragement over the past five years,
providing advice, information and companionship. My advisors Dr. Jacqueline Merrill and Dr.
Suzanne Bakken and committee members Drs. Patricia Stone, Rainu Kushal and David
Kauffman helped me to transform my thought processes into that of an academic; continuously
challenging me every step of the way.
My children each provided their own individual help during the process -- Grace
convinced me that I was smart and could accomplish anything; Bob provided me with a never-
ending stream of loving accolades and just always seemed happy and confident in me; and Jack
provided many hours of direct labor building the various databases that were used in this project
and made me smile when needed.
My family stood with me each step of the way providing me with moral and financial
support – even a place to sleep. Without them I would not have succeeded.
And lastly, my wife Amy who I met and married during the process, who provided hours
of endless support, comfort, and proofreading services. I can’t begin to thank her enough.
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DEDICATION
To my wife, children and family. I love you all.
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CHAPTER 1: INTRODUCTION/PROBLEM
The United States (US) receives a poor return on its healthcare investment. Healthcare
costs continue to be higher than any other industrialized country while measures of healthcare
quality and efficiency remain comparably poor (Congressional Budget Office, 2007, 2008, 2010,
2011; Davis, Schoen, & Stremikis, 2010; Phelps, 2010; US Department of Labor, 2010). In
addition, 50 million individuals remain without health insurance (Congressional Budget Office,
2011; DeNavas-Walt, Proctor, Smith, & U.S. Census Bureau, 2011). There is significant public
investment in healthcare technology and related research that are expected to improve cost,
quality and access to healthcare. The last three years have seen the adoption of major healthcare
reform legislation and a significant capital investment for this purpose. These policies favor the
use of health information technology (HIT) to improve access, quality and costs yet there is
mixed evidence of the success of HIT in real life settings. To achieve transformation in HIT, and
the cost and quality benefits that are expected from it, policy must move beyond adoption of
technology to the transformation of care. Transformation then can be considered a sequence of
change that begins with adoption and ends when technology has fundamentally changed how
tasks are carried out.
Problem Statement
The many stakeholders, relationships, interactions, data and expertise of healthcare
delivery create a complex system that is resistant to change. Some policy makers see technology
as a solution to this problem and they point to the successful technology transformations that
have been achieved in other complex markets. The finance, manufacturing and travel markets
are examples of successful technology transformations. These transformations have resulted in
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reduced costs, improved quality, increased efficiencies and greater customer
involvement. The healthcare market however does not behave like other markets. The economic
relationships are distorted by the presence of insurance and other payment systems, the
requirement to participate in the system and the significant knowledge gap between patient and
provider (Phelps, 2010). There is a gap in the evidence for evaluating the progress of
transformation and to guide the focus future policy efforts to assure continued progress toward
improved healthcare cost, quality and outcomes. An understanding of how transformation from
technology occurs in healthcare and an evaluation of the success or failure of current strategies is
important for forming future policy.
Background
The 2001 Institute of Medicine report Crossing the Quality Chasm provided a vision of
healthcare that is still largely unrealized today (Institute of Medicine, 2001). Over the last 75
years, the major healthcare policy foci of cost, access and quality have served as a consistent
impetus for policy change. With the exception of expanded access under Medicare, Medicaid
and the Children's Health Insurance Program (CHIP), the outcomes of government health
policies have been poor. Healthcare costs continue to outpace inflation, an increasing number of
individuals are without care, and the quality of care compared to other Organization for Co-
Operation and Development (OECD) countries ranks last in most categories (Congressional
Budget Office, 2010; Davis, et al., 2010; DeNavas-Walt, et al., 2011; US Department of Labor,
2010).
Legislation sets the stage for technology transformation in healthcare. In 2004, a
technology focus was added to this traditional triumvirate of health policy: cost, access and
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quality. President Bush, through executive order, created the Office of the National
Coordinator (ONC) for Health Information Technology (Bush, 2004). HIT became seen as
crucial to improving healthcare. Two recent pieces of national legislation have reinforced the
position of technology at the center of health reform. The Health Information Technology for
Economic and Clinical Health Act (HITECH), part of the American Recovery and Reinvestment
act of 2009, allocated $19 billion toward planning, development, research and implementation of
both a National Health Information Network (NHIN) and the adoption of Electronic Health
Records (EHR) by hospitals and providers (American Recovery and Reinvestment Act of 2009).
In 2010, the Patient Protection and Affordable Care Act (ACA) opened the door for new delivery
models, including incentives for medical homes and affordable care organizations. These new
models of care under ACA encourage clinicians to coordinate patient care in new ways and focus
on sharing patient information to improve quality and efficiency (Patient Protection and
Affordable Care Act, 2010). Both legislative reforms represent significant investment in
healthcare information technology. Whether it is to collect and share patient data, to create new
healthcare delivery models or to develop new treatments and research capabilities, technology is
central to current US federal and state policy.
Current HIT policy is focused on encouraging technology adoption and use through the
meaningful use EHR incentive program. In the most recent peer-reviewed studies, only 17% of
ambulatory care practices had EHR systems (DesRoches et al., 2008) and only 9.1% of hospitals
had implemented at least a basic EHR system (Jha et al., 2009). More recent figures issued by
the Department of Health and Human Services show that these numbers have increased
significantly to 55% for physicians and 48% for hospitals (Jamoom et al., 2012; U.S. Department
of Health & Human Services, 2012). Adoption is only one step in the transformation process
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envisioned by policy makers. Transformation requires a fundamental shift in the way
healthcare is delivered. This gap between adoption and transformation is critical to future policy
discussions. Understanding how to close this gap within healthcare’s complex environment
requires a greater understanding of how transformation occurs.
A model for technology transformation specific to healthcare can help evaluate areas
where transformation is occurring and where it is not. In addition, such a model can provide
guidance for future policies and provide a means for measuring future progress. Much like
economic models that define recessionary and inflationary periods and provide direction for
economic policy, a model for healthcare transformation can support policy makers to facilitate
transformation.
Theoretical Framework – Punctuated Equilibrium
The theory of punctuated equilibrium describes how organizations and systems change
and develop during transformation and the theory is replacing earlier explanations for
transformational change based on gradual and incremental modification. Within this newer
theory, change occurs in short dramatic bursts. Between these bursts of change, organizations
experience lasting relative equilibrium that is often difficult to interrupt. These periods of
equilibrium become lasting and comfortable for organizations and systems. Positive or negative
incremental changes are absorbed by the system with little or no lasting effect. Dramatic, often
disruptive, change is frequently required to break the established equilibrium. Organizations and
systems thus alternate between long periods of calm equilibrium and short periods of dramatic
change. Change is in these systems is often called “revolutionary.”
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Transformational change has been described and studied in organizations
(Tushman & Romanelli, 1985), groups (Gersick, 1988), science (Kuhn, 1996), and biology
(Eldredge & Gould, 1972). In each case, the main elements of punctuated equilibrium are shown
to be present, namely, change occurs in short revolutionary periods separated by relatively long
periods of equilibrium. This study uses the framework proposed by Gersick that combines these
scientific models into a “grand theory” of change guided by punctuated equilibrium (Gersick,
1991).
Gersick divides punctuated equilibrium into three components; deep structure,
equilibrium period and revolutionary period (Figure 1). Deep structure describes the underlying
environment of the system. It is this deep structure that discourages revolutionary change and
reflects a system’s underlying beliefs, choices and organizational design. Deep structure can be
thought of as the “design of the playing field and the rules of the game.” (Gersick, 1991, p. 16)
The elements that make up this deep structure influence what actions or conditions are required
to trigger transformation. The second component, the equilibrium period is defined as a period
where the basic organization and structure of the system remains unchanged. Gersick defines the
equilibrium period as a time of strong inertia that inhibits radical system change. This does not
mean that change does not occur, but rather that change is incremental and related to the goals of
the system or to ameliorate disruptions to the system from the environment. Lastly,
revolutionary periods represent changes that fundamentally alter the deep structure of the
system. These disruptions occur as a result of either internal or environmental changes. Internal
changes represent the inability of the system to meet its own goals and demands based on its
current design. Environmental changes represent pressures on the system from the environment
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in which it operates, for example a shortage of employees and resources or introduction
of a new technology into the system.
Figure 1 - Representation of three components of Gersick's theory of punctuated equilibrium - deep structure, equilibrium period and revolutionary period
This study looks for structural measures or elements of the healthcare market that
describe the three components of punctuated equilibrium enumerated by Gersick. The
application of punctuated equilibrium theory to technology transformation in healthcare provides
a potential method to evaluate or even measure the progress of policies that encourage healthcare
transformation through technology. In the future, such elements can be used to propose a model
of technology transformation in healthcare. Potential elements might include measures of
efficiency, demand, innovation, growth and technology use. Understanding whether
transformational change has occurred, or whether we remain in a period of equilibrium is
important to future policy discussions.
Research Aim and Methods
The aim of this study is to evaluate the evidence for healthcare technology transformation
in the healthcare, science and business literature. Through an integrative review of the literature,
Equilibrium)Period)1)Revolu1onary)
Period) Equilibrium)Period)2)
New)Deep)Structure)Deep)Structure)
Environment,)core)values,)strategy,)power)distribu1on,)structure,)control)systems)))
Iner1a,)momentum,)resistance)Radical)change)in)deep)structure) New)iner1a,)momentum)
Disrup1on/ShiC)
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the study investigates elements of the punctuated equilibrium using data from the period
2004 to 2012.
Significance
The interaction among practitioners, patients and healthcare information remains the core
process of healthcare delivery. While huge advances in knowledge and treatment alternatives
have improved our ability to diagnose, treat and cure, the process of healthcare remains largely
the same. How technology is ultimately incorporated into these relationships and processes will
be key to the successful technological transformation of healthcare desired by policymakers.
Healthcare professionals, including physicians, nurses and other practitioners, and policy makers
need to look at the process of care delivery within technology transformation. Ultimately,
transformation means changes in the way medicine is practiced, coordinated and reimbursed.
The roles of patients and the healthcare system that serves them must be considered as part of
any technology transformation.
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CHAPTER 2: REVIEW OF THE LITERATURE
The cost of healthcare in the US is unsustainable and exacerbated by the 2008 – 2011
economic recession and the growing number of uninsured individuals (Congressional Budget
Office, 2010, 2011; US Department of Labor, 2010). By at least one measure, attempts at
implementing transforming legislation have failed for over a century (Altman & Shactman,
2011). Technology is proposed as a solution to many of these problems. Policies at both the
national and local levels are being considered to promote technology adoption and use and
ultimately the transformation of healthcare.
This chapter begins with a review of the US health system and the potential reasons for
its underperformance. A discussion of technology transformation follows, including a definition
of transformation and the elements and patterns that describe it. The theory of punctuated
equilibrium is examined next and serves as the theoretical framework for this study. This study
uses a “grand theory” of transformation developed by Gersick that merges these various
transformational theories based on punctuated equilibrium (Gersick, 1991). The chapter
concludes with a discussion of the complexities of the US healthcare system and how these
complexities might impact change and ultimately technology transformation.
Status of US Healthcare System
The cost of healthcare in the United States is higher than other industrialized countries,
yet the quality lags behind. Healthcare costs have been rising at more than double the rate of
inflation since 1997 (Centers for Medicare and Medicaid Services, 2010; US Department of
Labor, 2010). Compared to other countries, the average annual cost of healthcare as calculated
by the OECD and as reported in a Center for American Progress Report was $6,700 in 2006,
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more than double the median expenditure of $3,100 for all OECD countries (Furnas,
2009). In 2007 this cost rose 7% to $7,200 (Davis, et al., 2010). Even when measured as a
percent of Gross Domestic Product (GDP), the US still ranks highest, with health expenditures
representing 16% of GDP. Without successful healthcare reform, this figure is expected to grow
to 25% of GDP by the year 2025 (Congressional Budget Office, 2007). Changes from recent
legislation, including the Affordable Care Act do not alter these figures significantly and the
most recent projections for healthcare spending show a rise in spending to 26% by 2035
(Congressional Budget Office, 2011).
Despite significant spending in the US, the quality of healthcare continues to rank poor
globally. In a seminal study by the Institute of Medicine (IOM) “To Err Is Human: Building a
Better Health System”, 44,000 – 98,000 deaths each year were found to be attributable to
preventable causes (2000). This was a severe blow to the perceived quality of healthcare in the
US given the level of spending and medical advances at that time. This report was followed by a
second report in 2001 from the IOM, “Crossing the Quality Chasm: A New Health System for
the 21st Century”. In this second report, the IOM looked for ways to reinvent and improve the
delivery of care and presented a strategy and plan for doing so. The report established aims for
meeting patient needs, guidelines for the redesign of the healthcare delivery system and
suggestions for changing the healthcare environment. The report described a healthcare system
“in need of change” (p. 1) and overly focused on acute and episodic care with a shortage of
clinical programs able to treat chronic conditions in a methodical coordinated way (Institute of
Medicine, 2001).
As a result of this and similar reports, beginning in 2003, the IOM and the Agency for
Healthcare Research and Quality (AHRQ) began issuing annual healthcare quality reports. In its
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most recent report for 2010, the IOM states that “[h]ealth care quality and access are
suboptimal, especially for minority and low-income groups.” (Agency for Healthcare Research
and Quality, 2011, p. 2). In a recent Commonwealth Fund study of how the US healthcare
system compares internationally, the US was last or next to last as measured by quality, access,
efficiency, equity and healthy lives (Davis, et al., 2010). “Despite having the most costly health
system in the world, the United States consistently underperforms on most dimensions of
performance, relative to other countries” the report states. (Davis, et al., 2010, p. Abstract)
Causes of Poor Performance
In a report prepared jointly by the IOM and the National Academy of Engineering, and
building on the two previous IOM reports “To Err is Human” and “Crossing the Quality Chasm,”
the authors reason several causes for the quality/efficiency gaps in the healthcare system
(Institute of Medicine, 2000, 2001). First, health complexity from the rapid advances in medical
science and technology contributes to a growth in specialization and expectation of cure. This
increase in specialization in turn reinforces a continued fragmentation of the healthcare delivery
system. The joint report states that more than 100 clinical specialties are practicing largely
independent of each other with fewer than 24% practicing within a hospital setting (Reid,
Compton, Grossman, & Fanjiang, 2005). This fragmentation creates a gap in knowledge transfer
and an entrepreneurial culture within the clinical community.
Additional reasons cited include increases in the need for coordinated and longitudinal
care for chronic conditions from an aging population and an emphasis within the healthcare
system on insurers bearing the majority of healthcare expenses. The report lastly refers to an
information technology deficit within healthcare and an insufficient use of the many systems
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engineering tools that have been used successfully to improve quality and efficiency in
other industries (Reid, et al., 2005).
Recent studies reinforce these claims and emphasize the fragmented nature of healthcare
delivery, the poor coordination among clinicians, the need for measurements to assess quality,
and the underuse of information technology as reasons for the poor ranking of the US in quality,
efficiency and other measures (Agency for Healthcare Research and Quality, 2010, 2011; Davis,
et al., 2010). The 2010 quality report from the AHRQ emphasizes the need to “empower
providers with HIT and training” and to produce information that is accessible, relevant and
meaningful (Agency for Healthcare Research and Quality, 2010, p. 13). The report emphasizes
the need for new measures to improve quality and that these measures will require better and
more available technologies. The 2009 International Survey of Primary Care Physicians states
“that the U.S. and Canada lag far behind other industrialized countries in information capacity”
(Davis, et al., 2010, p. 17).
Theories of Technology Transformation
Transformation occurs in many contexts such as education, biology, industry and now
healthcare. In each instance, transformation means something different and is related to the
environment being transformed. In biology, transformation includes the change from a caterpillar
to a moth, or growth from an infant to an adult. In industry the introduction of assembly lines,
transformed the way in which products are made. The Internet transformed how we make
purchases, get information, manage our finances and plan for travel. In each instance,
transformation fundamentally changed how a process was carried out within its environment.
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Although transformation is most often associated with progress, it is not always
experienced positively. In the travel industry, the ability to make reservations on-line eliminated
the need for travel agents. The increase in email forced the US post office to change its business
model. The ability of Wal-Mart to manage suppliers on a global scale eliminated many smaller
retailers.
The theories on technology transformation began with models of organizational evolution
and change. Three researchers lead these discussions – Michael Tushman, Elaine Romanelli
and Philip Anderson. In 1985 Tushman and Romenelli proposed a model of organizational
evolution based on the concepts of convergence and reorientation to describe how organizations
change and adapt. Convergent periods were defined as periods of “incremental and
interdependent change activities with a strategic orientation, and which operate to impede radical
or discontinuous change” (Tushman & Romanelli, 1985, p. 178). Organizations during these
periods experience levels of momentum based on the strength of the organization, organizational
leadership, organizational values, the turbulence of the environment, and size among other
factors. The expression and duration of these factors define a level of inertia experienced by the
organization. Inertia propels an organization down a strategic path with increasing levels of
resistance to change.
Between periods of convergence are periods of reorientation that end in a reordering of
the existing organizational environment. These periods of reorientation must overcome the
inertia of the intervening convergent periods. Reorientation periods are characterized by the
emergence of a new “dominant design” often triggered by technological change (Tushman &
Romanelli, 1985, p. 205). Change involves the “radical disruption of convergent patterns” and is
described as “metamorphic change” (Tushman & Romanelli, 1985). The ability of organizations
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to successfully reorient themselves in the face of changing technologies or market
uncertainty defines the effectiveness of the organization. Effective leadership and an ability to
recognize the environmental conditions characterize highly effective organizations. Low
performing organizations will not reorient or will reorient inappropriately and fail. Tushman and
Romenelli’s summarize their model of organizational evolution as follows:
“Patterns of organizational evolution are characterized by periods of convergence
punctuated by reorientations leading to the next convergent period. These cycles are
driven by the emergence of tension between organizational and institutional forces for
intertia and competitive, technological and legal pressures on performance which are
mediated by the perceptions and decisions of executive leadership.” (Tushman &
Romanelli, 1985, p. 181)
This pattern of convergence and reorientation described by Tushman and Romenelli
represents a punctuated equilibrium model of organizational evolution.
The environment is a significant component of Tushman and Romenelli’s model of
organizational evolution and the cycle of convergence and reorientation proposed in the model.
The authors specifically mention technology as an element of this environment and a major
contributor to the dynamics of the evolutionary cycle. Shortly after publication of this model,
Tushman and Anderson demonstrated that the impact of technology on the environment followed
this pattern of incremental change punctuated by significant rapid breakthroughs (Tushman &
Anderson, 1986). Their study hypothesized that technological change within a market would
share this pattern and could be categorized as either competence enhancing or competence
destroying.
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Competence enhancing change involves the new use of technology to reduce
costs, improve processes, create new products or services, or change organizational structure.
Competence destroying change occurs when organizations are not able to react to new
technologies resulting in business loss, new competition, or bankruptcy. In all cases, successful
transformation results from a process of change in both the organization and the environment and
provides a significant benefit to customers (Dehning, Richardson, & Zmud, 2003; Lucas, 2008;
Tushman & Anderson, 1986). Figure 2 outlines the two IT transformation pathways of
competence destroying and enhancing.
Figure 2 - The IT Transformation Process. Competence enhancing and destroying processes represent alternate pathways for achieving transformation. From Inside the future: Surviving the technology
revolution, by H. C. Lucas, 2008, p. 21. Copyright 2008 by ABC-CLIO Inc. Reprinted with permission.
To test their hypotheses the authors evaluated three industries (cement manufacture,
airline transport, and minicomputer manufacture) from their historical beginnings to 1980
covering a combined period of 190 years. Each industry displayed a pattern of long periods of
TransformationImpact.on.Organization
Impact.on.Others
Use$knowledge$&$skills$of$prior$technology$in$new$ways
New$BusinessNew$competitive$position,$market$share
Dramatically$higher$customer$benefits
Skills$to$operate$core$technology$different;$current$people$and$processes$no$longer$appropriate
New$business$models$(forced)New$entrantsDisintermediationUnbundling
New$strategies
Loss$of$competitive$position
CompetenceEnhancing
Competence.Destroying
Average$costs$reducedBusiness$processesStructure$of$workNature$of$work$productNew$Business$Models$(voluntary)Organization$Structure
or$
15
incremental technological progress punctuated by rare innovations that result in a new
dominant design. The patterns of transformation were found to be similar across all three
industries.
Environmental conditions changed significantly following the emergence of a new
dominant design and were noted to be “sharply different from those that prevailed before the
technical breakthrough” (Tushman & Anderson, 1986, p. 460). Differences in the environment
were also noted after transformation based on whether the change was competence enhancing or
destroying. Competence enhancing transformations were found to favor existing organizations
as the technological advance builds on the existing technological environment. Existing
organizations were able to leverage their existing expertise and adapt successfully to the new
environment. Competence destroying transformations result from a new technological paradigm
and require new skills. In these instances, barriers to entry are lowered and the environment
favors new entrants. Tushman and Anderson were able to show that the features of competence
enhancing and destroying transformations occurred in these patterns. These findings supported
the pattern of transformational change suggested by punctuated equilibrium (Tushman &
Anderson, 1986).
In a subsequent study, Anderson and Tushman refine the understanding of these patterns
and define a cyclical model of technological change defined by eras of ferment and incremental
change separated by technological discontinuities and the emergence of a dominant design
(Anderson & Tushman, 1990). The model is appropriately called the Technology Cycle (Figure
3).
16
Figure 3 – The Technology Cycle. The cycle is defined by eras of ferment and incremental change separated by technological discontinuities and a dominant design. From “Technological discontinuities and dominant designs: A cyclical model of technological change” by P. Anderson and M. L. Tushman,
1990, Administrative Science Quarterly, p. 606. Copyright 1990 by Sage Publications Inc. Journals. Reprinted with permission.
The Technology Cycle begins with a technological discontinuity. The discontinuity can
be characterized as either competence enhancing or competence destroying. In either case the
technological discontinuity represents a “dramatic departure from the norm of continuous
incremental innovation” (Anderson & Tushman, 1990, p. 606). This new innovation begins an
era of ferment during which rival designs compete for dominance. Eventually a dominant design
emerges. The emergence of a dominant design permits standardization, increases industry wide
cooperation, reduces environmental uncertainty and diminishes consumer confusion. Dominant
designs develop from the actions and influences of individuals, organizations, networks of
organizations and government. Dominant designs do not necessarily represent the best
technology, but represent the best environmental fit. Dominant designs can emerge from the
weight of a dominant player (the IBM personal computer), a dominant user (the defense
department), or government regulation (television standards). The authors emphasize that the
appearance of a dominant design “is not an engineering issue as much as a sociological one” and
reflects the dynamics of the agents within the market (Anderson & Tushman, 1990, p. 627).
TIME%
Era%of%Ferment%• Design%Compe55on%• Subs5tu5on%
Era%of%incremental%Change%• Elabora5on%of%Dominant%
Design%
Technological%Discon5nuity%1%
Technological%Discon5nuity%2%
Dominant%Design%1%
17
Government often intervenes to reduce uncertainty in the environment (Anderson &
Tushman, 1990).
Once a dominant design emerges, the market becomes established and it is increasingly
hard to launch new dominant designs. Incremental change becomes the order of the day.
Organizations compete based on incremental improvements to the established technology until
the next technological discontinuity occurs. The Intel/Windows PC environment is an example
of the strength and pervasiveness of an established technological standard (Anderson &
Tushman, 1990).
Punctuated Equilibrium
Punctuated equilibrium was first posited by Eldridge and Gould who suggested that
evolution was not the slow, gradual and incremental change first described by Darwin. Rather
evolution involved long static periods of “equilibria” and short revolutionary “punctuations” of
change (Eldredge & Gould, 1972). In addition to the examples of this pattern just described in
organizational theory, elements of this theory can be seen in scientific progress where there are
long periods of calm followed by short burst of scientific discovery (Kuhn, 1996). The theory
of individual human development follows a similar pattern (Levinson & Darrow, 1978) as does
the dynamics of teams (Gersick, 1988). This study uses a melded theory of punctuated
equilibrium that consolidates the findings from across disciplines developed by Gersick (1991).
Gersick’s Theory of Punctuated Equilibrium
In a 1991 paper, Gersick proposed a theory of punctuated equilibrium defined by three
distinct components: deep structure, equilibrium periods and revolutionary periods (Gersick,
18
1991). Each of these components define an element of the punctuated equilibrium
model and are in agreement with the technological transformation concepts discussed previously.
Deep Structure
Deep structure represents a set of “choices” a system has made (Gersick, 1991, p. 14).
These choices reflect the units and organization of the system and the patterns of activity that
define and maintain it. Deep structures are very stable in that the choices and patterns often
reinforce themselves as part of “mutual feedback loops” (Gersick, 1991, p. 16). The choices
made by systems vary by the environment in which they operate. Within organizations,
Tushman and Romenelli describe these choices in terms of the political and economic
framework of the environment and propose 5 elements that impact this framework; core values
and beliefs, strategy, power distribution, structure, and control systems (1985). Gersick refers to
these elements collectively as the “design of the playing field and the rules of the game”
(Gersick, 1991, p. 16).
Core values describe the core beliefs and values of the organization and its environment.
Strategy defines the markets and services provided by the organization as well as any time and
technology constraints. Power distribution explains the allocation of resources. Structure
formalizes the hierarchy, roles and relationships of the organization. Control systems refer to the
self-limitations placed on the organization and often reflect the organization’s emphasis on
efficiency. These descriptive elements will be used within the methods as a framework for
evaluating and identifying deep structure elements of punctuated equilibrium within the
healthcare system (Gersick, 1991).
19
Equilibrium Period
Within the framework of deep structure, systems make incremental adjustments based on the
rules and limitations of the environment. Systems during this period maintain a level of inertia
that is resistant to major changes. This inertia occurs for several reasons. One is blindness to
new ideas that do not fit within the existing paradigm or deep structure. Another reason posited
by the research is a fear of change or loss of market dominance. In economic terms there is a
tremendous sunk cost incurred by organizations and systems during periods of equilibrium.
Environmental factors may prevent any change even if the need is recognized. And finally, the
system benefits from the increasing skills gained within a known and consistent environment.
All of these factors contribute to the inertia of systems and extended periods of equilibrium.
Inertia prevents the generation of alternatives that do not fit the deep structure of the
environment or alternatively to pull deviations back in line (Gersick, 1991).
Revolutionary Period
Revolutionary periods represent a departure from the incremental changes that occur
during equilibrium. Changes during revolution alter the deep structure, often leaving no part of
it intact. These periods are usually shorter than the periods of equilibrium as they represent a
rapid breakdown of the deep structure. Revolutionary changes in deep structure result from two
basic causes; (1) internal changes that push the alignment of relationships, values and/or controls
that define deep structure and/or (2) environmental changes that limit the ability of the system to
maintain its current structure. These changes might include limitations on resources, new
demands from customers, shifts in the social or political climate, or new innovations from
technology. Gersick emphasizes that revolutionary change does not necessarily result from a
20
failure of the existing system, but rather requires a shift in the deep structure of the
system (Gersick, 1991).
Complexities of Healthcare Market/System
Viewing healthcare as a complex system is not new (Begun, Dooley, & Zimmerman,
2003; Hawe, Webster, & Shiell, 2004; Paina & Peters, 2011; Paley, 2007; Resnicow & Page,
2008; Tan, Wen, & Awad, 2005). In each case the authors describe healthcare as a complex
system comprised of many agents interacting within an extremely complex environment.
Outcomes are difficult to predict and the market as a whole does not behave in linear ways. This
complexity comes from several sources both human and environmental with differing goals and
behaviors. These differences can be seen in the many layers that make up the entirety of the
healthcare system.
The healthcare system or environment is comprised at a high level of at least three
interacting markets, healthcare delivery (patient-provider), health insurance (patient-provider-
payor), and healthcare research (education-provider-funder) (Phelps, 2010). Each market
maintains its own goals and is comprised of different sets of agents that interact in their own
unique ways. These agent interactions are non-linear and often uncertain. If we examine the
basic patient-provider relationship, we can see many of these complexities and uncertainties.
Illness itself is uncertain. Who becomes ill, the illnesses effect on any single individual and the
individual treatment prescribed appear random and uncertain. Not everyone becomes sick and
not everyone reacts in the same way to treatment. Providers vary in their recommendations and
the cost of care is often not considered when seeking treatment. Patients desire the “best” care,
not the cheapest or most efficient care. Decisions on where to seek care are frequently based on
21
word of mouth or appearance of the provider’s office. High cost is regularly
associated with high quality where this is frequently not the case (Phelps, 2010).
Treatments themselves are becoming complex. New technologies are generating better
diagnostic tools, improving treatment options, and increasing the expectation of cure. Decisions
about whether to pay for these treatments and what to pay for these treatments are complicating
the insurance and payor portion of the market. The complexities of treatment and high price of
care often result in attempts to manage treatment decisions. The goal of insurers to control costs
and the goal of the providers to increase revenue and maintain control over treatment decisions
regularly conflict, creating a complex relationship between providers and insurers. The normal
economic patterns of supply and demand do not seem to apply within the healthcare system.
These uncertainties and conflicting goals contribute to the complexity of the healthcare
system and healthcare policy decisions. The current goals of healthcare policy to increase
access, control costs and improve quality do not easily complement each other. Attempts to
control cost directly impact treatment decisions and employment levels (jobs). Attempts to
increase access to care increase healthcare costs to others. Attempts to improve quality often
increase costs and/or limit treatment options.
Because of these complexities and the non-traditional economic behaviors of the
healthcare market, policies must be designed to promote value from both a provider and patient
perspective (Rouse, 2008). Rouse states, “Traditional systems are managed to minimize costs.
Health care must be managed to maximize value” (Rouse, 2008, p. 22). Many of the current
policies do not address value, but rather focus on the lowest acceptable costs for a particular
service. Medicare and Medicaid are prime examples of this cost control focus (Phelps, 2010).
22
Examining the value added of policies to each agent in healthcare and other markets
will be important to future healthcare policy discussions.
23
CHAPTER 3: METHODOLOGY/RESEARCH DESIGN
An integrative review methodology combined with the theoretical framework of
punctuated equilibrium described fully in Chapter 2 were used to structure and evaluate the data
gathered in the study. The application of an integrative review methodology ensured a structured
process for gathering and processing data. The punctuated equilibrium model, specified by
Gersick provided a framework for evaluating transformation within healthcare and the market’s
fit with this transformational model. The findings from this review will evaluate evidence of
technology transformation in healthcare and inform future models of technology transformation.
This chapter details the activities and methods used to accomplish this aims. Table 1 provides a
summary of the research process, methods and tools used for this study. The research involved
no human subjects’ participation. No Institutional Review Board (IRB) approval was sought for
this study.
The Integrative Review
The integrative review represents a broad review methodology that considers the
inclusion of multiple data sources with varying designs to more completely understand the topic
of study. The goal of an integrative review is to “develop a more comprehensive account of a
specific phenomenon or relationship than each of the related basic research reports [do]
separately” (Cooper, 1989, p. 13). In other words, a more complete understanding of a topic can
be achieved by integrating data from many sources, methods and disciplines.
A broad and inclusive literature search is a core feature of the integrative review. The
strength of the method is the ability to include data from a diverse set of research domains
offering many perspectives to the topic of interest. Unlike a meta-analysis that draws strength
24
from applying statistical methods to a set of similar studies, the integrative review
attempts to build on a broad range of primary data to inform the topic of interest. The integrative
review method can therefore be used to examine more complex theories or concepts
(Whittemore & Knafl, 2005). Integrative reviews often start with a theoretical framework as a
basis for interpretation of new data (Kirkevold, 1997). This is important as a theoretical
framework helps to structure the large volume of data typically gathered in such a review.
The greater diversity of data sources within an integrative review requires qualitative
methods for evaluation. Methods such as directed content analysis, grounded theory,
phenomenology, case study, meta-synthesis, ethnography and others are often used to synthesize
findings. These methods share common features to ensure rigor including prolonged
engagement, triangulation, constant comparison, peer review, negative case analysis, bracketing
and member checking (Corbin & Strauss, 2008; Creswell, 2007; Hsieh & Shannon, 2005; Morse,
Barrett, Mayan, Olson, & Spiers, 2002). Increasing the number and types of primary sources has
the potential to reduce error by expanding the knowledge on the topic of study (Pawson,
Greenhalgh, Harvey, & Walshe, 2005). The broader inclusion criteria of the integrative review,
however, increase the complexity of the study. The integrative review attempts to balance the
benefits from the broader base of primary data sources with the methodological rigor of a
systematic review. Greater rigor is required in documenting and synthesizing the potentially
diverse data sources. Ultimately, the quality and completeness of the data sources included, the
evaluative skills and experience of the researcher and the comprehensiveness of the evaluation
impact the validity of the findings (Whittemore & Knafl, 2005).
Key tenets of the integrative review are a well-defined, documented and transparent
process to reduce bias, a broad and complete search of the literature utilizing multiple search
25
strategies, the inclusion of multiple study designs, methods and types to build a
complete picture of the topic of interest, a meaningful evaluation of the quality of data included
in the study, a systematic method for analyzing and synthesizing data such as directed content
analysis and the logical presentation of results with demonstrated evidence threads, clearly stated
limitations and conclusions that do not exceed the evidence provided (Pawson, et al., 2005;
Whittemore & Knafl, 2005).
This study follows the integrative review methodology suggested by Whittemore and
Knafl summarized below (2005). This study also takes into consideration the checklist items
suggested by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
for the reporting of systematic reviews (Liberati et al., 2009).
Integrative Review Methodology
The five (5) steps in an integrative review of the literature outlined by Whittemore and
Knafl are problem identification, literature search, data evaluation, data analysis and presentation
(2005). Each step is discussed fully below and outlined in Table 1. In combination these steps
form a structured and transparent methodology to ensure a repeatable and rigorous review of the
literature.
26
Table 1 - Summary of research process, methods and tools used in the integrative review of the literature.
Research Process Method Tool Product Problem Identification
Evaluative thinking and gap analysis
Review of current literature.
Identified aims for the integrative review.
Literature Search Search of databases and references using search terms depicting technology transformation Limitations – English language only, full text availability and published data on or after 2004 Inclusion criteria: Deals with implementation and/or adoption of technology (Diagnostic and therapeutic technologies such as CT scanning techniques, DNA sequencing, radiation therapies, and others were excluded.) Focus on change, adoption, transformation, implementation, resistance or outcomes Describes component of punctuated equilibrium Set in the United States Focus on healthcare delivery
4 electronic databases (MedLine/PubMed, Business Source Complete, Social Science Research Network, Web of Knowledge and Factiva) Ancestry search of references to improve completeness.
Comprehensive list of relevant articles for evaluation.
Data Evaluation/Reduction
Directed content analysis (Hsieh & Shannon, 2005)
Coding sheet and entry into SQL database Analysis matrix of punctuated equilibrium elements using customized database
Coded database of literature Coded text of the three components of punctuated equilibrium
Data Comparison/Synthesis
Directed content analysis (Hsieh & Shannon, 2005)
Counts, patterns, constant comparison, negative case analysis, bracketing
List of components and findings specific to healthcare that reflect (or not) the punctuated equilibrium model of transformation
Presentation Integrative review method (Whittemore & Knafl, 2005)
Visual representation(s) Articulation of findings and conclusions
27
Problem Identification
Problem identification requires a clear enumeration of the problem addressed by the
review, the sampling time frame and intended data sources. A clear problem and purpose ensure
appropriate and pertinent literature is identified and facilitates the construction of pertinent
variables for the extraction of relevant data from identified sources. The integrative review
method often encourages the use of a theoretical perspective to advance the understanding of
theory to a potentially new domain.
Literature Search
The search strategy was designed to obtain the largest number of eligible primary sources
using multiple search methods (Whittemore & Knafl, 2005). The search terms used reflect the
definition of technology transformation and emphasize change within organizations. Multiple
data sources and strategies were used to ensure a wide inclusion of potential articles. In all, five
electronic databases were included in the literature search. Ancestry and bibliography searches
of included citations were performed on included articles.
Data Sources
Five electronic databases were searched during March and April 2012 (Table 2). Each
database was selected for its potential to inform a model of healthcare technology
transformation. MedLine/PubMed provides a complete source of health, life sciences and
biomedical research. Business Source Compete is the main electronic database for business
related journals covering disciplines in marketing, management, management information
systems, operations management, accounting, finance and economics. The Social Science
28
Research Network (SSRN) is a leading database of social science literature covering
topics from cognitive science to organizational theory.
Table 2 - Databases used in literature search
Database Description MedLine/PubMed Database of life sciences articles maintained by the
National Library of Medicine. Business Source Complete Database of full-text journals in this disciplines of
business, marketing, management, MIS, POM, accounting, finance and economics. Database is maintained by EBSCO
Social Science Research Network Database of abstracts and electronic articles covering social sciences and the humanities. Database maintained by Social Science Electronic Publishing, Inc
Web of Knowledge An academic citation indexing and search service which covers the sciences, social sciences, arts and humanities. Maintained by Thomson Reuters
Factiva Provides access to more than 28,500 sources such as newspapers, journals, magazines, television and radio transcripts, photos, news wires etc. Maintained by Dow Jones and Company.
An ancestry search was performed using the Web of Knowledge database and the three
foundational articles describing punctuated equilibrium and technology transformation: Gersick
(1991); Anderson and Tushman (1990) and Tushman and Romanelli (1985). Lastly the
FACTIVA electronic database was searched to identify potential news articles relating to
healthcare technology transformation. FACTIVA is a database containing articles and news
releases from major news wires such as Associated Press, Dow Jones and others.
Search Terms
Separate search strategies were tailored for each database to adjust for the structure,
content, and available search tools within each data source. The specific search terms reflected a
combination of terminologies and meanings for “technology” and “transformation” and used a
combination of MESH terms, key words and free text searches. Additional search limitations
29
included English language and a publication date on or after 2004. The 2004 date
represents the creation date of the Office of the National Coordinator for Health Information
Technology by President Bush. The specific search criteria for each database are in Appendix A.
Title and Abstract Inclusion Criteria
All search results were subjected to two rounds of eligibility. The first round examined
titles and abstracts only. Two reviewers with healthcare domain expertise examined a random
sample of 50 abstracts and reached consensus on the definitions and application of the inclusion
criteria to the search results. An initial Kappa of 0.7326 was calculated prior to consensus
discussions. This score falls within the range of “substantial agreement” and indicates a
significant level of consensus between the two raters (Viera & Garrett, 2005). All abstracts were
then reviewed by the author based on the agreed upon criteria. The inclusion criteria required
that each data source:
1. Deal with the implementation and/or adoption of health information technology.
(Diagnostic and therapeutic technologies such as CT scanning techniques, DNA
sequencing and radiation therapies, and others were excluded.)
2. Focus on change, adoption, acquisition, transformation, implementation, resistance or
outcomes of new technology.
3. Describe at least one of the three components of punctuated equilibrium (deep structure,
equilibrium or revolution).
4. Be set in the United States, due to the unique features and characteristics of the US health
system.
5. Focus on healthcare delivery.
30
Those data sources (articles, books, presentations, news, etc.) satisfying the
initial inclusion criteria were subjected to a second full text review. The full text of each article
was obtained and the same inclusion criteria were applied to the full text of each article. Data
sources meeting the inclusion criteria after the second review were subsequently coded based on
the data evaluation methods described below. A second sample of the included data sources was
examined and coded by two reviewers and consensus reached on the appropriate coding
interpretation for each artifact. Separate Kappa values were calculated for each coding factor
(rigor, relevance and punctuated equilibrium (PE) component). Table 3 shows the Kappa values
calculated for each factor. A weighted Kappa was used for rigor and relevance to reflect the
ordinal nature of the scales used. Weighting places a greater error value when scores between
raters are farther apart, i.e. 5 and 2 versus 5 and 4 (Viera & Garrett, 2005).
Table 3 - Kappa calculations for literature coding
Category Kappa Inclusion-Exclusion 0.7326 Rigor 0.8047* Relevance 0.6563* PE Component 0.5541 *Weighted
The scores for rigor and relevance fall within the range of “substantial agreement” and
indicate a significant level of consensus between the two raters (Viera & Garrett, 2005). The PE
Component score showed only moderate agreement and reflects the variation in knowledge
between raters and the domain of punctuated equilibrium and transformation. The author then
reviewed and coded all remaining articles based on the coding definitions and criteria. During
coding, relevant articles from bibliographies were identified, retrieved and coded.
31
Data Evaluation/Reduction
Relevance and Rigor
All data sources were coded based on a subjective analysis of the data source’s relevance
to the study aim and rigor of the data methodology, setting and size. Such a methodology has
been proposed by Pawson, et al (2005) who suggest this type of analysis because of the
variability in method, design, quality and relevance of the data sources in an integrative review
and the difficulty developing a common scoring methodology for all included literature (Pawson,
et al., 2005; Whittemore & Knafl, 2005). Under this methodology, relevance reflects the data
source’s applicability to one of the three concepts of punctuated equilibrium in the study’s
theoretical framework. High relevance reflects a direct discussion of one of the three
components of punctuated equilibrium or the discussion of a model of transformational change.
Low relevance reflects data sources that do not directly discuss either a model or a component of
the theoretical framework, but add knowledge to other components or features of technology
change such as relationships, process, culture, cost, etc. Relevance was scored on a 5-point
Likert scale (0-5) with a score of 5 representing the highest relevance.
Rigor is a subjective judgment of confidence in the findings of the data source based on
study methodology and other factors. In this case, the methods, setting, population and purpose
was considered in evaluating rigor. Greater emphasis was placed on those articles showing
greater strength in size and setting and relevance to the study aim. Again a 5-point Likert scale
(0-5) was used with a score of 5 representing the highest rigor. The specific definitions of
relevance and rigor applied can be found in Table 4 and Table 5.
32
Table 4 - Definition of rigor used for data coding.
Rigor Value Quantitative Qualitative 0 Newspaper, magazine or other similar publication, opinion piece without citations for
facts. 1 Opinion in peer reviewed journal
Quantitative study with literature or expert analysis as data inputs
Opinion in peer reviewed journal
2 Case studies/Focus Groups 3 Observational studies with historical
controls. Cross sectional surveys Comparative case study
4 Observational studies with concurrent control groups.
Systematic or integrative reviews. Less formal qualitative studies, but well documented repeatable methods.
5 Experimental study such as RCT Formal qualitative method applied such as grounded theory, ethnography or other. Requires detailed repeatable description of methods.
Table 5 - Definition of relevance used for data coding.
Relevance Value 0 Does not address any component of Punctuated equilibrium. (Note: This category is
rare/unlikely in that most articles that have made it through the inclusion criteria speak to at least a minimal component of equilibrium)
1 Speaks to a component of punctuated equilibrium, but the finding is not a direct outcome of the study, and only stated as part of the discussion or introduction to the study. Poorly developed news or opinion piece where punctuated equilibrium is a secondary element of the article and not sufficiently supported – often not in a peer reviewed journal.
2 Identifies as part of the study findings a component of punctuated equilibrium, but the finding(s) are not the principle finding or aim of the study. News or opinion piece where punctuated equilibrium is not the primary aim of the article.
3 A principle aim and finding of the study relates to a component of equilibrium. News or opinion article that directly address a component of punctuated equilibrium. Example, a study or article evaluating the characteristics of medical practices that influence the adoption of health information technology.
4 A study or well-cited opinion piece that directly addresses a component of punctuated equilibrium. Article is well document and cited, makes a compelling and clear argument and is in a peer-reviewed journal. A model of technology adoption or transformation is often discussed or a unique perspective is offered.
5 The article meets more than one of the criteria for a score of ‘4’. For example, the article not only directly addresses a component of punctuated equilibrium, but links these components together or defines relationships and influences among components of punctuated equilibrium.
33
Evaluative Data
Descriptive and evaluative information were extracted from each eligible article and
entered into a Microsoft Access database. The descriptive information allowed for the
reevaluation, sorting and analysis of the data. Descriptive information included basic
information such as publication date, type of study, technology addressed, etc. The specific
punctuated equilibrium component(s) was included as part of this descriptive data. During
consensus discussions between raters, the definitions for each of the three components of
punctuated equilibrium were refined. Table 6 provides the final definitions of deep structure,
equilibrium and revolution utilized for coding each of the data sources.
Table 6 - Definitions of punctuated equilibrium components used in coding data sources.
Punctuated Equilibrium Component Definition and Example Deep Structure Rules and Characteristics of the current environment
either nationally or within a hospital or practice. Implementation studies that discuss structure or culture of organization including organizational priories and competitive environment. Barriers to change from the external environment of healthcare.
Equilibrium Internal obstacles to change. Elements that create inertia for the organization or system, i.e. large investment needed for IT. Implementation studies that describe process of implementation
Revolution Studies that describe deep structure altering changes within an organization. Policies that encourage such change. Definitions of revolutionary change or transformation
Evaluative information was more subjective and included the details about the punctuated
equilibrium component described by the data source. A template to capture this information was
developed by the author based on the principles of change suggested in the theoretical
34
framework proposed by Tushman and Romanelli (1985). Figure 4 shows a screen shot
of the database template used for coding and entering both the descriptive and evaluative data.
The final list of 39 elements captured for each data source is shown in Table 7 below.
Table 7 - List of data elements captured in the study’s database
Data Element Description 1. Publication Date Year of publication or dissemination 2. Data Source Source of the data. One of the five databases used or
bibliography search 3. Title Title of the article or news story 4. Author Author(s) of the article or news story 5. Journal Journal, magazine, paper or other publication source 6. Article Included Article meets inclusion criteria (Y/N) 7. Excluded Article does NOT meet inclusion criteria (Y/N) 8. Excluded Reason Details on why article did not meet the criteria 9. Use as background Articles that did not meet inclusion criteria but were
worthy of potential discussion within the study. These articles were often used on providing background or perspective throughout the study.
10. Article not found Full text could not be obtained 11. Notes General comments about article 12. Population size Size of population addressed by study. Blank if not a
study 13. Population Unit Population unit, i.e. physician, patient, hospital. Blank if
not a study. 14. Industry setting Setting of study, physicians in a hospital, hospitals
within a national system. 15. Study Design Type Study design, i.e. survey, focus group, RCT, etc.
“Opinion” or “News” if not a study 16. Location Location within the US if provided, “National” if
concerning a national topic or national survey. 17. Technology Description of technology covered by study 18. Model/Component Article describes a “Component” of Punctuated
Equilibrium or a “Model” of punctuated equilibrium 19. Deep Structure Y/N Article describes this component of punctuated
equilibrium 20. Equilibrium Y/N Article describes this component of punctuated
equilibrium 21. Revolution Y/N Article describes this component of punctuated
equilibrium 22. Quality Rigor 0-5 score on the rigor of the study or article 23. Quality Relevance 0-5 score on the relevance of the study or article 24. Quote or Thought Key quote(s) or thoughts on the article as they relate to
punctuated equilibrium 25. Linkages What does article say about linkages between
Punctuated equilibrium components 26. Influencers What does article say about influencers of punctuated
equilibrium component
35
Table 7 – (continued)
Data Element Description 27. Cost What does article say about costs and punctuated
equilibrium component 28. Culture What does article say about culture and punctuated
equilibrium component 29. Time What does article say about time and punctuated
equilibrium component 30. Precipitators What does article say about precipitators of punctuated
equilibrium component 31. Followers What does article say about followers of punctuated
equilibrium component 32. Punctuated Equilibrium component Specific component addressed in study or article 33. Deep Structure detail Detail with regard to deep structure element. 34. Patient Does study or article address patients 35. Practitioner Does study or article address practitioners 36. Hospital or Group Does study or article address a hospital(s) or hospital
group 37. National System Does study or article address the national system of
healthcare 38. Vendor Does study or article address HIT vendors 39. Strength Weakness Describes the strengths and weaknesses of the study or
article
36
Figure 4 – Sample screen shot of data coding screen used in Access database.
Data Comparison/Synthesis
Data comparison and synthesis is the methodical and structured synthesis of data into a
justifiable and cohesive conclusion about the topic of interest (Whittemore & Knafl, 2005).
Strategies for developing conclusions and synthesizing data within integrative reviews are “one
of the least developed aspects of the process” (Whittemore & Knafl, 2005, p. 550). This study
applied a directed content analysis methodology as suggested by Hsieh and Shannon (2005).
Directed content analysis is compatible with the integrative review process in that the method is
37
frequently used to “validate or extend conceptually a theoretical framework or theory”
(Hsieh & Shannon, 2005, p. 1281). Because analysis is based on an existing framework, it is
more guided and structured than other qualitative approaches. In this case, the coding of the
literature was based on the theoretical framework of punctuated equilibrium.
Coded data were reviewed using a variety of qualitative methods. The database structure
allowed for the sorting of data in a variety of ways. For example, literature addressing only the
component of equilibrium could be pulled from the data based on stakeholder type, or timeframe,
or type of study, or even a specific key word. Several data reports were pulled from the coding
database using this capability and evaluated to identify unique themes within the database.
Qualitative methods including constant comparison, data immersion, repeated questioning of the
literature, probing and sorting, and negative case analysis were applied to the coded data.
Themes emerged as the researcher became immersed in the data. The literature was categorized
and sorted into the emerging themes to produce the study findings.
38
CHAPTER 4: RESULTS
Search Results
The search strategy resulted in a total of 4,166 candidate articles for inclusion in the study
(Figure 5). Of these, 153 were duplicates, leaving 4,013 abstracts for initial review. Three
thousand forty six (3,046) abstracts were excluded for not meeting the inclusion criteria based on
the abstract alone. Articles were excluded primarily for non-US setting, not addressing HIT, or
evaluating a new clinical therapy or diagnostic technique rather than a clinical information
system(s). Of the 967 articles eligible for full review, 447 were excluded: 92 for non-US setting,
144 for not addressing HIT and/or not relevant to punctuated equilibrium framework, 20 for
addressing diagnostic or therapeutic measures and 20 for other reasons. A further 171 articles
could not be located after searching both local academic libraries and requesting the resource
through inter-library loan. In some cases, the specific resource was missing from the library
stacks, cataloged incorrectly, or not readily available without a significant cost (e.g. proprietary
documents such as industry white papers or embargoed articles based on publisher restrictions).
Five hundred twenty (520) articles are included in this integrative review and are referred
to throughout the remainder of this document as the identified literature. The term article(s)
where it appears in this document is a general term meaning a single article or collection of
articles within the identified literature. Any article(s) that describe surveys, case studies,
systematic reviews, randomized control trials or other experimental design are referred to as
studies or study.
39
Figure 5 - Search flow for relevant literature
Description of the Identified Literature
The analysis and coding of all the identified literature produced between 2004 -2011
found a relatively even distribution within the three elements of punctuated equilibrium theory.
About 35% of the articles described deep structure, 38% described equilibrium and 26%
described revolution (Table 8). When examined by year, the focus of the studies varied.
Articles produced earlier in the study period (circa 2004 -2006) more likely addressed
equilibrium. Deep structure was consistently identified in literature produced throughout the
study period. Articles addressing revolution became more prevalent during the end of the study
period (circa 2008 – 2011) versus the beginning (Figure 6).
Electronic*databases*searched*!
MedLine! !3,208!Business!Source!Complete! !261!Social!Science!Research!Network!!!(SSRN)! !18!FacDva!(Grey!Literature) !627!
!Bibliography*Search*
!!16!ArDcles!
4,166*Ar:cles* 153*Duplicates*
4,013*Titles*and*Abstracts*Screened*
967*Ar:cles*assessed*for*eligibility**
447*fullDtext*ar:cles*excluded:*
• Unable!to!retrieve!!! !171!• Did!not!involve!technology!!!!!!!ImplementaDon !144!• Non!US !92!• DiagnosDc/TherapeuDc !20!• Other !20!
3,046*records*excluded*• 2,433!MedLine!• 180!Business!Source!Complete!• 10!SSRN!• 392!FacDva!• 20!Ancestry!• 11!Bibliography!!
520*Ar:cles*included*in*study*
Ancestry*Search*!
36!ArDcles!
40
Table 8 - Articles by punctuated equilibrium component
Deep Structure Equilibrium Revolution
MedLine/PubMed 182 180 123 Business Source Complete 3 27 18 SSRI 3 1 - Factiva (Grey Literature) 19 15 9 Ancestry Search (Web of Knowledge) - - 1 Bibliography Search - - 3
Percent of Total 35% 38% 26% Articles may address more than one category
Figure 6 - Comparison of punctuated equilibrium component by year
Table 9 - Articles by rigor and relevance
Rigor (0-5) Relevance (0-5) 5 4 or 3 2 or 1 0 5 4 3 2 or 1 0
MedLine/PubMed 5 123 251 45 43 57 175 149 - Business Source Complete - 1 14 30 4 8 10 23 -
SSRI - 2 2 - - 1 2 1 - Factiva (Grey Literature) - - 2 41 5 - 10 28 - Ancestry Search (Web of Knowledge) - 1 - - 1 - - - -
Bibliography Search - 1 2 - 1 2 - - - Percent of Total 1% 25% 52% 22% 10% 13% 38% 39% 0%
The majority of articles (74%) had a rigor score of 2 or less, a reflection of the many
opinion and news pieces represented in the identified literature (Table 9). Among all identified
0"
5"
10"
15"
20"
25"
30"
35"
40"
2004" 2005" 2006" 2007" 2008" 2009" 2010" 2011"
Deep"Structure"
Equilibrium"
Revolu=on"
Linear"(Deep"Structure)"
Linear"(Equilibrium)"
Linear"(Revolu=on)"
41
literature, case studies represented the main study design type (21%) followed by cross
sectional surveys (15%) (Table 10). Only one randomized control trial was present in the
identified literature.
Articles within the identified literature typically did not specify a type of technology.
Half of the literature examined HIT in general terms or in terms of a larger HIT implementation
effort involving multiple integrated technologies (Table 11). Articles that did address a specific
technology included electronic health records (EHR) (21%), computerized physician order entry
(CPOE) (5%) and other technologies (23%) such as tele-health, ePrescribing, HIT, clinical
decision support systems (CDSS), and person health records (PHR). None of these other
technologies individually represented more than 3% of the total articles included in the study.
Table 9 - Articles by rigor and relevance
Rigor (0-5) Relevance (0-5) 5 4 or 3 2 or 1 0 5 4 3 2 or 1 0
MedLine/PubMed 5 123 251 45 43 57 175 149 - Business Source Complete - 1 14 30 4 8 10 23 -
SSRI - 2 2 - - 1 2 1 - Factiva (Grey Literature) - - 2 41 5 - 10 28 - Ancestry Search (Web of Knowledge) - 1 - - 1 - - - -
Bibliography Search - 1 2 - 1 2 - - - Percent of Total 1% 25% 52% 22% 10% 13% 38% 39% 0%
Table 10 - Articles by study design
Study Design Count (%) New/Opinion 284 (55%) Case Studies 108 (21%) Cross Sectional Surveys 80 (15%) Other 18 (3%) Literature Review 14 (3%) Observational 8 (2%) Focus Group 6 (1%) RCT 1 (<1%) Policy Analysis 1 (<1%) Total 520 (100%)
42
Table 11 - Articles by technology type
Technology Type (Articles may address more than one category)
EHR CPOE CDSS HIE ePrescribing Telehealth PHR General/ HIT not
specified Other
MedLine/PubMed 101 25 15 13 14 14 7 193 53 Business Source Complete 3 2 - - 3 - 1 34 2
SSRI 1 - - - - 1 1 1 - Factiva (Grey Literature) 7 - - - - - - 36 -
Ancestry Search (Web of Science) - - - - - - - 1 -
Bibliography Search 1 - - 1 - - - 1 -
Percent of Total 21% 5% 3% 3% 3% 3% 2% 50% 10%
Hospitals were the most frequent stakeholder addressed in the identified literature (41%),
followed by practitioners (27%) and national viewpoints (20%) (Table 12). A low proportion of
articles addressed patients (8%) and vendors (3%). The geographical focus of the identified
literature was distributed unevenly across the US. Massachusetts and Florida were the two states
with the most representation, followed by New York and Pennsylvania (Figure 7). No location
was provided for 20% of the identified literature and 50% of the identified literature addressed
HIT from a national perspective.
Table 12 - Articles by stakeholder
Stakeholder (Articles may address more than one category) Patients Practitioner Hospital National Vendor
MedLine/PubMed 42 171 238 86 15 Business Source Complete 6 6 24 21 3 SSRI 2 2 1 1 - Factiva (Grey Literature) 3 1 12 25 2 Ancestry Search (Web of Knowledge) - - - 1 -
Bibliography Search - 1 - 2 - Percent of Total 8% 27% 41% 20% 3%
43
Figure 7 – Distribution of articles by state. Darker color indicates higher number of articles.
Elements of Punctuated Equilibrium in the Identified Literature
The directed content analysis of the identified literature yielded several themes across
each of the three punctuated equilibrium components that form the framework for this study:
deep structure, equilibrium periods and revolutionary periods. The themes represent descriptive
categories or elements of punctuated equilibrium as they were observed within the identified
literature. Deep structure themes describe the underlying environment of the health system.
Equilibrium defines the period of inertia that results in only incremental change to the deep
structure. Revolutionary periods fundamentally alter the deep structure of the system. The
themes are organized by each punctuated equilibrium component below.
44
Directed content analysis of the identified literature produced several themes
for each punctuated equilibrium component. The main themes that emerged during analysis are
summarized in Table 13 and discussed in more detail in the remainder of this chapter.
Table 13 - Summary of the ten (10) themes identified from the directed content analysis of the literature.
Identified Theme Description Deep Structure 1. Variations in the
environment The environment of healthcare is defined by several factors that influence the adoption and use of HIT. These factors include location, size, race and the maturity of the vendor market.
2. Market Complexity Healthcare is a complex environment described in the identified literature by patient confusion, multiple social interactions, data complexity and complex reimbursement systems.
3. Regulatory Regulations guide privacy and security, reporting, reimbursement, liability and standards.
4. Flawed Risk and Reward The incentives to adopt HIT are flawed and generally inure more to payers and patients than to the providers adopting the systems. The current fee-for-service model of reimbursement creates a further disincentive.
5. Theories of Acceptance and Diffusion
Several models help explain the patterns of adoption and diffusion within healthcare. These models include the Technology Acceptance Model and the Diffusion of Innovation theory among others.
Equilibrium 6. Barriers The cost of HIT, the lack of human and capital resources, and the
resistance to change from practitioners are barriers highlighted within the identified literature.
7. Ethical Considerations Ethical considerations include an obligation for technology to do no harm, benefit everyone and not limit the ability to practice autonomously.
8. Competition and Sustainability
The market economy of the US demands a value driven business case for HIT adoption.
Revolution 9. Environmental Elements Patient engagement and new models of care represent significant
influencers of revolution within healthcare. 10. Internal Elements Successful organizational change requires effective management,
practitioner champions, a shared vision, and a favorable culture.
Table 14 lists these same themes and shows the allocation of articles by punctuated
equilibrium component, theme and rigor score. The totals shown in Table 14 reflect the coding
conducted for each article based on the methods discussed in Chapter 3. A representative coded
list of all articles analyzed in this study is contained in Appendix C. In the following sections,
45
references are limited to particularly relevant quotes from selected articles or to give
credit to contradictory evidence.
Table 14 - Categorization of articles by punctuated equilibrium component theme and rigor score. Articles can address more than one component and not all articles were relevant to a theme.
Punctuated)Equilibrium)Theme) Rigor)Score:Case%Studys,%Surveys Systematic%Rev,%RCT
DEEP)STRUCTURE 0 1 2 3 4 5 Total1.#Variations#in#the#Environment
a.#Location#(urban/rural) 2############# 1############# 1############# 5############# ;########## ;########## 9#############b.#Size ;########## 2############# ;########## 8############# 1############# ;########## 11############c.#Race ;########## 1############# 1############# 3############# 1############# ;########## 6#############d.#Vendor#maturity 1############# 11############ 7############# 4############# 2############# 1############# 26############
2.#Market#Complexity 3############# 19############ 4############# 8############# 2############# 1############# 37############3.#Regulatory
a.#Privacy/security 1############# 7############# 3############# 4############# 1############# ;########## 16############b.#Stark#laws ;########## 4############# ;########## 1############# ;########## ;########## 5#############c.#ICD;10 ;########## 1############# ;########## 1############# 1############# ;########## 3#############d.#Meaningful#Use ;########## 1############# 4############# 11############ ;########## 5############# 21############
4.#Flawed#Risk#and#Rewarda.#Incentives 1############# 4############# 2############# 4############# ;########## ;########## 11############b.#Delayed#reward ;########## 2############# 2############# 1############# ;########## 1############# 6#############c.#Payments#encourage#inefficiencies ;########## 13############ 1############# 1############# ;########## ;########## 15############
5.#Theories#(TAM#etc.) ;########## 9############# 3############# 10############ 3############# ;########## 25############EQUILIBRIUM6.#Barriers
a.#Cost 9############# 41############ 12############ 18############ 4############# 2############# 86############b.#Resistance 5############# 12############ 4############# 4############# ;########## 2############# 27############c.#HIT#Resources 3############# 5############# 3############# 9############# 1############# ;########## 21############
7.#Ethical#Considerations ;########## 4############# 1############# 1############# ;########## ;########## 6#############8.#Competition#and#Sustainability 2############# 5############# 6############# 10############ 1############# 1############# 25############REVOLUTION9.#Environmental#Elements
a.#Patient#Engagement 2############# 21############ 3############# 5############# 2############# ;########## 33############b.#Policy 1############# 13############ 1############# 5############# 1############# 1############# 22############
10.#Internal#Elements 14############ 40############ 42############ 27############ 7############# 3############# 133##########
Darker%color%=%higher%frequency%of%theme%in%the%identified%literature
News/mag,%Opinion
46
Deep Structure
A set of repeating elements defining deep structure was found within the identified
literature. These elements were grouped into five (5) overarching themes – variations in the
environment, structure and complexity of the environment, regulatory effects, risks and rewards
and models of transformation and diffusion.
1. Variations in the Environment
Environmental factors such as location and size were discussed as factors affecting the
acceptance and use of technology in the healthcare market. Eleven (11) studies addressed the
relationship between practice size and HIT adoption (Table 14 – Item 1c) with one author
stating, “Practice size appears to be one of the most important correlates of EHR adoption.
…larger practices with financial and technological resources and the ability to achieve
economies of scale are generally the only segment of the population that has been able to invest
in EHR systems” (Simon et al., 2008, p. 45). The impact of practice size on adoption rates was
found to be changing over time, but in different directions for hospitals and physicians. Two (2)
studies addressed practice size impact on HIT adoption over time. In a national survey of
physicians, the gap in EHR adoption rates between large and small practices tripled between
2000 and 2004 (Grossman & Reed, 2006). A 2008 national study of hospitals using AHA and
HIMSS data found that the HIT adoption gap between large and small hospitals was diminishing
over time (McCullough, 2008).
Nine (9) studies addressed urban versus rural differences in HIT adoption rates (Table 14
– Item 1b). Urban hospitals were found to have a higher likelihood of HIT adoption than rural
hospitals. In a 2006 survey of hospitals in Iowa, “greater than 90% of urban hospitals, but only
47
30 and 40% of the rural hospitals, [were] using information technology to collect basic
clinical information” (Ward, Jaana, Bahensky, Vartak, & Wakefield, 2006, p. 436). A national
survey of 4,493 hospitals found a widening digital divide between urban and rural hospitals:
“While adoption rates increased modestly [in 2009] smaller, rural and public hospitals fell
further behind their counterparts” (Jha, DesRoches, Kralovec, & Joshi, 2010, p. 1957).
Race was examined in six (6) studies (Table 14 – Item 1d) that found no significant
differences between HIT adoption rates based on race. However, one study found that whites
were more likely than blacks to accept new innovative technologies related to treatment
(Groeneveld, Sonnad, Lee, Asch, & Shea, 2006). This study focused on patient acceptance
rather than solely practitioner acceptance. Other environmental factors addressed by individual
studies were patient mix, Medicare status, personal wealth, and geographic location with
minimal or no impact on adoption and use.
Twenty-six (26) articles addressed the maturity and capabilities of the vendor market
(Table 14 – Item 1e). Variation and uncertainty were described as playing a key role within the
articles reviewed. Uncertainty in both HIT standards as well as future healthcare policies and
their impact on the healthcare market were leading factors mentioned for concerns about the
vendor market. In addition, the variation in standards and capabilities among vendors was cause
for concern as a limiting factor for HIT adoption. One study suggested in relation to current
policy that “[t]he certification process currently in use by the CCHIT [Certification Commission
for Health Information Technology] does not ensure interoperability or future compliance”
(Ford, Menachemi, Peterson, & Huerta, 2009, p. 280). Other authors noted vendor weaknesses
as a barrier to adoption and use -- “Another significant barrier to adoption has been vendor
transience; many early EHR companies are no longer in business or are in precarious financial
48
positions" (Ford, Menachemi, & Phillips, 2006, p. 109). Still others addressed the
variation in how vendor products are used, even the same product at different locations. In a
study of hospital information executives on their experiences with CPOE implementations, poor
design was found to be a major factor in the delay and failure of such systems (Poon et al.,
2004). A recent IOM report noted that “the way in which health IT is designed, implemented
and used can determine whether it is an effective tool for improving patient safety or a hindrance
that threatens patient safety and causes patient harm” (Institute of Medicine, 2012, p. 2-1).
Articles refer to the “considerable variety among applications” within HIT (Davidson &
Heineke, 2007, p. 364), suggesting a level of inconsistency in workflows and application use.
“The old joke is, every vendor has an HL7 (Health Level Seven) implementation, they’re just all
different. (Brailer, 2005, p. 1151)”
The current estimated success rate for HIT implementations is only 28% (Morton &
Wiedenbeck, 2010). The identified literature discusses this failure in terms of vendor immaturity
and the vendor community’s inability to meet the needs of specific organizations. Immaturity
was discussed in terms of stability of the vendor market (Randeree, 2007) and the ability of
hospitals and practitioners to customize and use commercial systems (Poon, et al., 2004; Poon et
al., 2006). In addition, a dichotomy was highlighted between in-house or home-grown systems
and vendor based commercial systems. The Veterans Administration’s VistA system and Kaiser
were frequently mentioned as exemplars of integrated delivery HIT systems and the unique
advantages experienced by such systems. One researcher commented on this dichotomy by
stating:
“Perhaps the most significant advantage that the VHA had in EHR development was the
decision to create an ‘in-house’ product rather than outsourcing the product. Thus, the
49
VHA clinicians did not have to align their clinical processes to ‘off the shelf’
EHR software; a perverse alignment of workflow adaptation to a support system, rather
than the more rational tailoring of such systems to support optimized work flow” (Evans,
Nichol, & Perlin, 2006, p. 168).
2. Market Complexity
Complexity in the structure of the healthcare market, its size, relationships and multiple
interactions was a second major theme identified within the literature. This complexity comes
from several sources both human and environmental with differing goals and behaviors. These
differences can be seen in the multiple layers that make up the entirety of the healthcare system.
The identified literature discusses this environmental complexity in terms of the varying models
of care, the multiple relationships among patients, practitioners, insurers and the government, the
complexities of physician and hospital reimbursement, and the volumes of data involved in
patient care and coordination. The sheer size of the healthcare market only adds to this
complexity.
Thirty-seven (37) articles mentioned complexity in either their findings and/or
conclusions (Table 14 – Item 2). Complexity is discussed in terms of 4 features:
customer/patient linkage –
“The result of all these complicated linkages is that the market forces from patients to
health care providers are far more indirect and blunted than are the market forces from
consumers to producers in most sectors" (Christensen & Remler, 2009, p. 1017);
business failure – “the impact that IM/IT resources had on strategic initiatives was that new,
complex systems often contributed to organizational failure while existing, legacy systems were
50
more likely to yield organizational success and ultimately survival…higher levels of
complexity resulted in higher levels of business failure. (Bewley, 2010, p. 62)”;
human influences –
“However, as a complex sociotechnical system, many parts of healthcare delivery are
messy and non-linear….HIT designs often assume a rationalized model of healthcare
delivery. Templates walk clinicians through a prescribed set of questions even though the
questions and/or their order may not be relevant for a particular patient at that time” (B.
T. Karsh, Weinger, Abbott, & Wears, 2010, p. 619);
and data complexity – “The further information has to be able to circulate (i.e. the more diverse
contexts it has to be usable in), the more work is required to disentangle the information from the
context of its production” (Greenhalgh, Potts, Wong, Bark, & Swinglehurst, 2009, p. 766).
The competing interests of the multiple participants in the healthcare system also
characterized complexities.
“These public health benefits are well beyond the reach of a health care system
characterized by the complexities of medicine and conflicts of multiple parties working at
economic cross-purposes. They are trapped outside the economic equation, positive
externalities of a stubbornly fee-for-service health care system that inadvertently rewards
inefficiency, redundancy, excessive treatment, and rework” (Kleinke, 2005, p. 1248).
The relationships between hospitals and practitioners contribute to complexity in the
market. Physicians are often not employed by the entities they serve resulting in mixed
allegiances. This complexity was described in the literature in terms of system wide
51
functionality and a lack of control over the implementation and change process. For
example an opinion piece states,
“it is not the policy makers who have to make it work, but rather the operational staff of
the health sector. But unlike other service sectors which have harnessed electronic
technology successfully, such as the banking and financing sectors and retail trade, the
employees of the health sector are not line-command employees whose job is to make the
system work” (Rigby, 2006, p. 140).
3. Regulatory
Regulatory issues permeate the deep structure of the healthcare market. Regulations
guide and influence the privacy and security of patient information, direct how hospitals and
practitioners are reimbursed, limit how doctors, hospitals and labs interact, determine liability,
and more recently, guide how HIT is implemented and used. The identified literature discusses
this regulatory environment in terms of its impact on HIT adoption and use.
Sixteen (16) articles address privacy and security issues around HIT adoption (Table 14 –
Item 3a). Privacy and security are cited as potential barriers to HIT interoperability. The
regulatory environment is also described in terms of the limitations imposed on innovation and
sharing of information. “Current legal and financial incentives provide little motivation to share
information, which is critical to improving patient outcomes as well as efficiency” (Diamond &
Shirky, 2008, p. w384)
The Stark Laws and anti-kickback regulations are cited in five articles. These laws and
regulations limit self-referral by physicians and the receipt of services or benefits by physicians
at no cost from hospitals. Due to the relatively high cost of EHR systems for small physician
52
practices, these laws were described as limiting the ability of hospitals to connect
affiliated physicians to the hospital’s existing EHR systems. The Department of Health and
Human Services has since amended its existing policies to permit hospitals and other
organizations to donate technology and services to physicians without violating either the Stark
Law or anti-kickback law. The American Recovery and Reinvestment Act (2009) and the
Affordable Care Act (2010) further clarify the ability of hospitals to provide such services and
technologies to affiliated physicians. Despite the relaxation of these regulations since 2007, they
are still mentioned as a potential barrier to HIT adoption and use by hospitals and affiliated
physicians.
New reporting and data standards represent a last core element of the regulatory
environment. Three (3) articles discussed the new standards required by the new HIPAA 5010
and ICD-10 codes that demand resources and divert attention from other projects (Table 14 –
Item 3c).
The meaningful use provisions of the Medicare and Medicaid EHR Incentive Programs
and/or the provisions of the Affordable Care Act were mentioned in 23 articles (Table 14 – Item
3d). The bulk of the articles discuss suggestions for compliance and/or provide predictions of
future meaningful use objectives under Stage 1 of the program. Issues raised in the articles
included concerns over reporting capabilities of Centers for Medicare and Medicaid Services
(CMS), the ability of vendors to meet the anticipated requirements, the impact on Health
Information Exchange (HIE) success, and the potential impact of meaningful use on the delivery
of healthcare. One author stated “[i]n effect, HITECH has permanently shifted our focus from
adoption of HIT to its use.” (Glaser, 2010, p. 19)
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4. Flawed Risks and Rewards
The identified literature included articles discussing incentives within the healthcare
market for the adoption and use of HIT as flawed and not equally split among practitioners,
hospitals, insurers and patients. This results in an inability to demonstrate value at all levels of
adoption. The goals of each stakeholder vary and the benefits are often disconnected from the
HIT intervention. In most cases value also depends on others using the technology to realize the
full benefit.
Eleven (11) articles (Table 14 – Item 4a) in the literature discuss this flawed return on
investment as “an asymmetrical risk and reward among those who are footing the bill for HIT
and those who reap the lion’s share of the benefit” (Middleton, 2005, p. 1270). This same study
estimated that practitioners received only 11% of the net potential gain from HIT investment
(Middleton, 2005). Returns are noted to inure mainly to insurers, patients, and payers
(employers) in the form of reduced services and improved health. In a 2010 survey of for-profit
and not-for-profit hospitals, the authors found that for-profit hospitals were significantly less
likely to adopt HIE than not-for-profit and public hospitals. The authors concluded that this
“serves to support assertions that HIE is perceived as a financially undesirable proposition.”
Hospitals may perceive that benefits from HIE inure to their competitors rather than themselves.
In a review of the literature by Edwards, et. al. (2010), the authors concluded that the potential
for economic loss as a result of HIE was a significant barrier to adoption. Integrated delivery
systems such as the Veterans Administration and Kaiser reflect an exception to these flawed
incentives. By controlling all aspects of care, both payer and provider, HIT has the ability to
reduce complexities and create efficiencies that are not possible in other delivery models (Javitt,
2004).
54
A second flaw is the time necessary to accrue a benefit. Six (6) articles
discussed the delay in the reward for HIT investment as a barrier to adoption (Table 14 – Item
4b). “The return on investment for an EHR system does not accrue to the provider in the short
run under many reimbursement schemes. Instead the savings from improved care efficiency and
quality typically flow back to health care insurers or payers as a reduction in service use” (Ford,
et al., 2006, p. 109) and “[u]nfortunately, many of the potential benefits of ICT [information and
communications technology], including both reduced costs and improved outcomes, occur far in
the future, when the covered individual will likely have another insurer or provider” (Christensen
& Remler, 2009, p. 1018)
Fifteen (15) articles refer to flawed incentives for HIT adoption (Table 14 – Item 4c). The
more services a practitioner or hospital can provide the more money they can collect. As a
result, there is a disincentive to improve efficiencies – “the less the hospital knows about [the
patient], the more services it can render, the more it can bill his health insurer, and the more it
will collect. In many instances there simply is no business case for improving the effectiveness
or quality of care with or without IT” (Davidson & Heineke, 2007, p. 363). These existing
payment policies, mainly fee-for-service reimbursement plans, result in a disincentive to adopt
HIT – “Providers lose money when they put in health IT, because we have obsolete payment
policies that still reward volume over quality” (Brailer, 2005, p. 1154)
A further flaw is the lower increase in productivity projected by HIT in healthcare versus
other markets. While many markets have experienced tremendous improvements in costs,
efficiencies and quality, the effect of technology in healthcare has not been equal. Bower (2005)
estimates that healthcare experiences a 5% or lower increase in productivity from information
technology versus a more typical 8-17% increase in other markets.
55
5. Theories of Technology Acceptance and Diffusion
Twenty-five (25) articles in the literature test and/or discuss models of technology
acceptance and diffusion to help explain the rate of HIT adoption (Table 14 – Item 5). These
models in order of descending frequency include the Diffusion of Innovation, Technology
Acceptance Model (TAM), an expanded TAM called TAM2, network effect model, Health
Information Technology Factor Model, Absorptive Capacity, least effort model, Learning Chain
Model, and Interactive Sociotechnical Analysis (Table 15). Each model evaluates social and
technical elements associated with new technology and identifies relationships between these
elements that help predict rates of adoption. The diffusion of innovation theory focuses on 5
perceptions of innovation that affect individual behavior. TAM and TAM2 focus on perceptions
of use that affect acceptance and subsequently actual use of technology. The Interactive
Sociotechnical Analysis model looks at the combined environment created by the social network
of organizations and the technology being adopted. The interaction of these two elements
impact actual use of technology – how technology is adopted and used by individuals. The
remaining models share similar components in different orders and weights. All the models
were found to explain significant levels of variance in HIT acceptance and use. In a review of
the literature on technology acceptance models, the authors state that “the relationship between
[perceived usefulness] and intention to use or actual use of health IT is significant in every test,
suggesting that to promote use and acceptance, the health IT must be perceived as useful”
(Holden & Karsh, 2010, p. 166). Summaries of the three most common models in the literature
follow.
56
Table 15 - Frequency of technology acceptance and diffusion models in the study data.
Models of Technology Acceptance and Diffusion # Articles Diffusion of Innovation 7 Technology Acceptance Model (TAM and TAM2) 7 Interactive Sociotechnical Analysis 3 Least Effort Model 1 Network Effect Model 1 Health Information Technology Factor Model 1 Absorptive Capacity 1 Learning Chain model 1
Diffusion of Innovation – Examines how innovations are communicated and adopted
within a social system over time. Since this communication involves a new idea or innovation,
the theory suggests 5 characteristics of innovation perception. These characteristics explain why
different innovations are adopted at different rates. The five characteristics are: relative
advantage, computability, complexity, trialability, and observability. The net effect of these
characteristics is the now familiar stages of innovation – innovators, early adaptors, early
majority, late majority, and laggards. These stages of adoption describe incremental change
following a bell curve pattern (Figure 8) (Rogers, 1995).
57
Figure 8 - Rogers technology adoption life cycle. Top graph represents cumulative adoption. Bottom graph represents adoption by diffusion period. From “Modelling and forecasting the diffusion of
innovation - A 25-year review,” by N. Meade and T. Islam, 2006, International Journal of Forecasting, 22(3), p. 520. Copyright 2006 by Elsevier Limited. Reprinted with permission. (Meade & Islam, 2006)
Interactive Sociotechnical Analysis (ISTA) – Emphasizes HIT as an element of both the
technical and social environments of an organization. These “sociotechnical” interactions are
emergent and dynamic, similar to the behavior of complex adaptive systems. HIT innovations in
the ISTA model impact the sociotechnical framework of the organization, which in turn impacts
how HIT is actually used. This “actual use” produces further changes to the sociotechnical
environment leading to further potential changes in “actual use” (Harrison, Koppel, & Bar-Lev,
2007).
Technology Acceptance Model (TAM) and TAM2 (Figure 9) – TAM describes a series of
the incremental cognitive adjustments individuals make to accept new technology. The model
builds on two factors that influence acceptance – perceived usefulness (level of belief that
technology will help in performing job) and perceived ease of use (level of belief that a
technology will be easy to use). These two factors affect attitude and intention to use or
58
“acceptance” of technology. TAM2 expands on this initial model and adds several
social factors (subjective norm, image, job relevance, output quality, results demonstrability) that
influence perceived usefulness and intention to use or acceptance (Holden & Karsh, 2010).
Figure 9 – Schema for the Technology Acceptance Model (TAM) and TAM2. From “The technology acceptance model: its past and its future in health care,” by R. J. Holden and B. T. Karsh, 2010, Journal of biomedical informatics, 43(1), p. 161. Copyright 2010 by Elsevier Limited. Reprinted with permission.
Equilibrium
Three themes emerged from the analysis of the identified literature relating to the
equilibrium component of punctuated equilibrium. The three themes, barriers to change, ethical
59
consideration, and competition and sustainability, all help to describe those elements of
the healthcare market that reinforce incremental versus revolutionary or transformational change.
Each of the three themes described below have the effect of maintaining the status quo or
limiting change to gradual incremental improvements.
1. Barriers to Change
Barriers identified in the literature include the high cost of HIT, physician resistance to
change, access to resources, complexity, and vendor immaturity. High costs represent the most
frequently identified barrier to change in the literature. The majority of the literature mentions
cost as part of their discussion on HIT adoption and use. Eighty-six (86) articles mentioned cost
as a barrier to HIT adoption (Table 14 – Item 6a).
“In survey after survey (for example, those conducted by the Medical Records Institute,
the Health Information and Management Systems Society, and the Medical Group
Management Association), funding is cited as the most serious impediment to EHR
adoption” (Sprague, 2004, p. 6).
In a national survey of physicians, Gans, et. al. (2005) found the lack of capital resources
to be the highest barrier to EHR adoption, followed closely by the lack of physician support.
Cost was also discussed in absolute terms as an inadequate percentage of total healthcare
spending. Two articles placed healthcare spending between approximately 2 – 7 % of healthcare
budgets versus 10% and higher for other markets (Bewley, 2010; Joch, 2008). Lastly, cost was
discussed in relation to cost overruns, implementation complexity, testing, and automation
efforts.
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Physician resistance was identified in the literature as the next most significant
barrier to HIT adoption and use. Twenty-seven (27) articles discuss this issue (Table 14 – Item
6b). Physician resistance to HIT was described in terms of its threat to autonomy, inefficiency,
poor design, complexity, errors, and depersonalization of the healthcare process. One study noted
that physician resistance is a barrier that persists even when cost issues are overcome (Poon, et
al., 2004).
Resistance was also described in terms of what technologies were ultimately accepted
and used by the market. Innovation is subjected to patient outcomes, liability, and risk of error or
harm to patients and insurers are described as gatekeepers of new technologies in their role as
payer. Soleimani & Zenios discuss this issue in a review of the literature on transformation and
state:
“Stated another way, in most cases it is not acceptable to develop a lower quality health
product and simply accept lower margins to make up for it. Moreover, it is difficult to
challenge nonconsumption and develop a new value chain, as the consumers in health
care (patients, doctors, providers, and insurers) are well-defined and their roles are well
established. Most importantly, existing regulatory and reimbursement systems are
designed to evaluate innovations relative to an established “gold” standard, which again
favors incrementalism over disruptiveness, as defined in non-health care sectors"
(Soleimani & Zenios, 2011, p. 205).
Twenty-one (21) articles address the lack of resources available within the HIT market
(Table 14 – Item 6c). These resources include both the up front capital necessary to purchase
HIT systems and the people needed to build, implement and maintain these systems.
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2. Ethical Considerations
Unique ethical considerations within the healthcare market represent a second significant
element of equilibrium. Traditional ethical issues of justice, autonomy and beneficence have a
strong role in the environment of healthcare technology adoption. The literature discusses a need
to strongly consider ethics when making HIT decisions. Six (6) articles discuss ethics and HIT
(Table 14 – Item 7).
Justice is discussed as the fair distribution of HIT technology and fair treatment as a
result of the implementation of technology. Fair treatment refers to adequate training, inclusion
and consideration for employees during and after implementation. Employees must be equally
empowered to efficiently and effectively use new technology. Fair distribution also refers to the
ability of society to capitalize on the technology adopted.
“For example, only a segment of society may have the mental and/or physical capacity to
take advantage of technologies that provide the opportunity to self-manage an underlying
health condition, thereby yielding distributional effects. These distributional effects are
brought about by the actions of individuals as they segment or stratify themselves into
distinct social groups. This stratification represents a separating equilibrium that may be
considered a form of social exclusion as some members of society may be excluded from
the potential benefits associated with a new technology” (Coyte & Holmes, 2007, p. 48)
Healthcare organizations have an obligation to provide a safe environment with safe
systems – beneficence. Therefore, HIT systems must enhance the capabilities of the practitioners
that work within them. One author states that:
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“In order to practice effectively, clinicians need to draw upon support and
enabling services and technologies in line with their original professional training. If the
organisation chooses to force change upon them, such that they no longer either have the
same technical skill, or feel confident in discharging their professional duties, in effect
the organisation has undermined their professional competence, and thereby has reduced
their ability to practice effectively." (Rigby, 2006, p. 143)
Lastly autonomy must be preserved from both a patient and practitioner perspective.
Systems should not limit the ability of either party to make informed decisions, and with regard
to the patient specifically, maintain their right to make care decisions including refusal of care
(B. Karsh, 2004; Rigby, 2006).
3. Competition and Sustainability
The US remains a market economy and with it come the values of competition and
business sustainability. Twenty-five (25) articles within the literature refer to the additional need
in the United States to ensure that healthcare technologies support the sustainability of US
healthcare organizations (Table 14 – Item 8). HIT has the ability to reshape markets,
relationships and the environment of the healthcare.
“These technologies are reshaping the contours of the health care landscape and
dramatically altering the manner in which health care is sought, organized, delivered, and
received. As a consequence, a comprehensive assessment of the sustainability of
technological innovations needs to consider not just the technology itself but the manner
in which these innovations alter the context in which health care transactions occur"
(Coyte & Holmes, 2007, p. 48).
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The identified literature emphasizes the need for a value driven business case
for HIT and notes how the complexity of the healthcare market complicated these value
decisions. Value arguments in healthcare vary based on which stakeholder group accrues
benefits: insurers, patients, practices, or hospitals? Size, location, goals, and funding also impact
the value calculations of healthcare organizations.
Revolution
The identified literature contained no descriptions of revolutionary change, only potential
conditions that might result in revolutionary change in healthcare. Specific articles discussed
such desired change as transformational. The two themes identified by the analysis and
discussed in the text that follows describe areas where specific authors and researchers believe
future transformation and revolution can be encouraged. The first theme involves environmental
components that may result in revolution and transformation, such as factors or events outside
the control of any single stakeholder or organization. The second theme addresses internal
organizational elements within the control of stakeholders that influence revolution and change.
1. Environmental Elements Necessary for Transformation
External elements that may foster transformation and revolution included new policies to
exert pressure on stakeholders to adopt HIT, increased access to capital, education, standards to
ensure interoperability, empower and improve value to patients, and create new delivery models
for patient care and reimbursement.
Twenty-two (22) articles addressed policy matters relative to healthcare transformation
(Table 14 – Item 9b). Many of the policy recommendation contained within the literature have
been adopted as part of ARRA/HITECH and ACA. These included an increased focus on patient
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safety through the development of new measures, providing financial incentives to
adopt EHR and other HIT, providing direct access to capital, developing national standards for
HIT interoperability, increased funding for education and research on HIT. These proposed
policy recommendations are meant to increase HIT adoption by reducing uncertainty in the
market. In a study on the diffusion of technology in the healthcare market, diffusion was
projected to be slower than desired due to existing uncertainties in the market. National
standards, reliable future healthcare policy and a clear vision of HIT were noted as necessary to
reduce this uncertainty (Ford, et al., 2009).
Updated delivery models were recommended as a means of reducing the disparities in the
risks and rewards present in the current system of reimbursement.
“The recently passed healthcare reform legislation known as the Patient Protection and
Affordable Care Act (PPACA) underscored the federal government’s interest in new care
delivery models such as accountable care organizations (ACOs) and new reimbursement
approaches such as episode and bundle payments that address the cost and quality
imbalance by significantly improving the efficiency, quality, and coordination of care
delivery…These changes may be more significant to the industry and to healthcare
information technology than the meaningful use regulation itself" (Glaser, 2010, pp.
SP20-21).
Engaging and empowering patients was a consistent theme in the literature and was
addressed in thirty-three (33) articles (Table 14 – Item 9a). Transformation was described as
requiring not only an increase in the use of HIT and new models of delivery, but an engagement
of patients in their care. Patients were described as devalued within the current system, “the
65
United States has devalued patient expectations and access to care while over-investing
in processes and technologies that serve the few” (Terry, 2004, p. 225). Transformation of
healthcare is "constrained by the prevailing patient-healthcare paradigm in the US healthcare
sector" (Ciriello & Kulatilaka, 2010, p. 1). Patients are often secondary to other goals with
technology commanding a greater role than patients. “The value to the consumer often is lost in
the desire to have sophisticated and innovative technology” (Cohen, Grote, Pietraszek, &
Laflamme, 2010, p. 5). To increase value from HIT, the role of the patient in the process of care
is essential and merits greater prioritization.
The literature also discusses the engagement of patients as necessary to achieve
transformation within healthcare. This engagement was emphasized continuously through all
years of study data. In a 2005 article, the authors state that “The mere installation of EHRs--
even with comprehensive interoperability--will not sufficiently engage patients in the health
system." (Tang & Lansky, 2005, p. 1290). A 2011 article discusses patient engagement in terms
of patient access to care and rethinking the way in which access is perceived. Access can no
longer be measured as simply a face-to-face encounter and "perceived" access may in fact be
more important, i.e. an ability to email may increase a patients perceived access to their
physician and therefore there perceived quality of care (Fortney, Burgess, Bosworth, Booth, &
Kaboli, 2011). Patient empowerment was described as requiring an effective market that allows
patients to effectively recognize and judge value for services received (Cotter, 2007).
2. Internal Elements Necessary for Transformation
Over 100 articles discussed the changes and conditions needed within an organization to
foster and successfully integrate HIT into their environment (Table 14 – Item 10). These
organizational elements included a shared vision, employee commitment to HIT, consistent and
66
effective leadership, and a culture of change and continuous quality improvement
within the organization. One researcher characterized the implementation of HIT as “one part
technology and two parts culture and work processes” (Crandall et al., 2007, p. 42). Cultural
issues and the need to align clinical and business priorities were important to HIT adoption.
“Political issues were a major stumbling block to implementation of the IT system. The interests
of managers were different from those of the systems users. Cultural values were also not
aligned” (Wurster, Lichtenstein, & Hogeboom, 2010, p. 191). The bulk of the case studies
reviewed concerned the internal factors needed to improve success of HIT implementation.
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CHAPTER 5: DISCUSSION
In this study, HIT literature covering an eight-year period was evaluated for evidence of
transformation using the theory of punctuated equilibrium. The literature search focused on
transformational change during a period beginning in 2004 where transformation and adoption of
HIT emerged as a national priority with the creation of the office of the national coordinator by
then President Bush (Bush, 2004). The identified literature over the intervening years, however,
describes an HIT environment resistant to change with only incremental progress towards
transformation. The theory of punctuated equilibrium (TPE) defines periods of incremental
progress in terms of an equilibrium between the desire to maintain the status quo and the
potential for radical change from new technological innovation, knowledge and skills. Based on
the evidence found in the identified literature during this period, the high cost of purchasing and
replacing existing systems, the highly complex nature of healthcare and the flawed risks and
rewards inherent in the current fee for service environment, appears to have encouraged
continued incremental change over the risks and potential benefits of new innovative technology.
For HIT policies to succeed, TPE implies that policies must overcome the resistance
created by the forces of equilibrium and create a new more optimal deep structure (Figure 10). A
brief examination of other markets that have experienced technology transformation suggest that
transformation develops from technological discontinuities in the deep structure of these markets
(Anderson & Tushman, 1990; Tushman & Anderson, 1986). For automobiles, the discontinuity
was the rise in gas prices and the superior quality and manufacturing processes of the Japanese;
for banking it was the technological innovation of ATMs which altered the interaction with the
customer; for the travel industry it was the new capabilities and data offered by new and creative
web based services. In each instance a discontinuity significantly changed an element of deep
68
structure resulting in new processes, innovations and interactions with the consumer.
Anderson and Tushman describe these technological discontinuities as “dramatic departure[s]
from the norm of continuous incremental innovation” (Anderson & Tushman, 1990, p. 606).
HIT policy will need to facilitate such discontinuities to effectuate deep structural change and
transformation in healthcare.
A discussion on the role these technological discontinuities in transformation and the
resistance to transformation from both the equilibrium component of TPE and healthcare
complexity follow. The discussion concludes with the implications for current HIT policy based
on the study findings.
Figure 10 – Pattern of incremental change and transformation described by the theory of Punctuated Equilibrium. Equilibrium (green) is characterized by long periods of incremental change and resistance to transformation. Revolution (red) from a technological discontinuity results in transformation and a radical change in Deep Structure.
CURRENT DEEP STRUCTURE
NEW ALTERED DEEP STRUCTURE
EQUILIBRIUM 1
REVOLUTION
Technology Discontinuity
TIME
CHAN
GE
Radical ChangeNew Skills
New TechnologiesResistance toTransformation
Tran
sform
atio
n
BarriersSystem InertiaUncertainty
Incremental Change
EQUILIBRIUM 2
69
The Role of Technological Discontinuities in Transformation
Technological discontinuities represent a significant component of transformation
described by TPE. As described earlier (Chapter 2) these discontinuities represent the stage
setting events that can spur revolutionary periods and lead to transformation and a new deep
structure in the environment. Thus these events and how they occur are critical for policy
makers. Anderson and Tushman place these discontinuities at the beginning of a Technology
Cycle (Figure 11) that begins with a technological discontinuity and ends with a new dominant
design and period of incremental change (Anderson & Tushman, 1990).
Figure 11 - The Technology Cycle. The cycle is defined by eras of ferment and incremental change separated by technological discontinuities and a dominant design. From “Technological discontinuities and dominant designs: A cyclical model of technological change” by P. Anderson and M. L. Tushman, 1990, Administrative Science Quarterly, p. 606. Copyright 1990 by Sage Publications Inc. Journals. Reprinted with permission.
The technological discontinuities required for transformation emerge from either
competence-enhancing or competence-destroying pathways within a market (Figure 12) and
(Chapter 2) (Anderson & Tushman, 1990; Tushman & Anderson, 1986). These pathways are
differentiated from incremental change by the magnitude of change they create. Each pathway
TIME%
Era%of%Ferment%• Design%Compe55on%• Subs5tu5on%
Era%of%incremental%Change%• Elabora5on%of%Dominant%
Design%
Technological%Discon5nuity%1%
Technological%Discon5nuity%2%
Dominant%Design%1%
70
results in significant increases to efficiencies, outcomes, and benefits. While the
competence-enhancing pathway builds on existing market knowledge, skills, and resources, the
alternate competence-destroying pathway represents a destruction of current models and
processes that by definition requires the introduction of new skills, technologies and resources.
These alternate skills, technologies and resources often emerge in the form of new vendors or
new organizational structures.
Competence-enhancing discontinuities are identified by an order of magnitude increase in
the performance of an existing process or product. For example, the leap from mechanical to
electronic typewriters or the introduction of robotics into manufacturing processes represents
such competence-enhancing discontinuities. In each case the product or process significantly
improved the efficiency of the process or the capabilities of the product itself. Existing vendors
are favored during such continuities as the innovation builds on existing skills and knowledge
(Tushman & Anderson, 1986).
Alternatively, competence-destroying discontinuities result in an entirely new product
class or process and require new skill sets and technologies to support. The introduction of copy
machines by Xerox created a whole new product class. New processes, capabilities and services
were subsequently built around this new product creating new efficiencies. Transistors did not
introduce a new product, but did provide a far superior substitute to vacuum tubes, resulting in
the subsequent series of increases in processing capacity by computers. New entrants to a
market are favored during competence-destroying discontinuities (Tushman & Anderson, 1986).
The list of new products, processes, companies and services that have developed from this
innovation are countless.
71
Figure 12 – Competence enhancing and competence destroying pathways of technology transformation.
Over the period of the study incremental change in HIT was observed across a sustained
period of equilibrium. Current meaningful use policies under HITECH reinforce this incremental
approach by fostering the use of existing technologies. Two observations support this claim.
First, there is an absence of major entrants (vendors) into the HIT market. A similar list of
vendors appears in year after year rankings of HIT vendors such the Best in KLAS Reports
(KLAS Enterprises LLC, Various Years). Second there is a reinforcement of existing processes
created by HIT certification, reducing the probability of new processes and reinforcing
incremental changes.
Whether the incremental approach to transformation will succeed remains an open
question. Romanelli and Tushman suggest in a 1994 paper on TPE and organizations that small
changes over time do not accumulate and result in transformation. Transformation was
concluded to be “positively and significantly influenced by major changes in environmental
Exis%ng(technologies,(knowledge(and(processes(
Significant(increase(in(customer/pa%ent(benefit(
!"Improved"Skills"
!"New"uses"of""exis5ng"technologies"
!"Greater"leverage"
!"Voluntary*
Exis%ng(technologies,(knowledge(and(processes(
New(Business(Models,(Structures,(and(Processes(
!"Forced*
!"Radical"change"
!"New"Innova5on"!"New"Technologies"
!"New"skills"needed"
ENHANCING(PATHWAY( DESTROYING.PATHWAY(
72
conditions” and not incrementally over time. (Romanelli & Tushman, 1994, p. 1159).
The results of this literature review appear to support this conclusion as only evidence of
incremental changes in HIT were found and no explicit order of magnitude increases in
efficiencies or benefits were identified. If huge change in efficiencies, quality or other measures
were found, an argument could be made for successful competence-enhancing transformation
through current HIT policies.
The healthcare reform activities in Massachusetts and enacted through the ACA are
attempting to significantly alter the deep structure of healthcare. These reforms, if successful,
challenge current care processes and encourage new delivery models and market innovations.
The legislation attempts to remove obstacles to change, and increase creativity and
experimentation. Accountable Care Organizations and the Medicare Shared Savings Program
encourage and reward coordination of care across multiple care settings by eliminating barriers
to new care delivery models. The Center for Medicare and Medicaid Innovations rewards new
advances and experimentation in the delivery of care to patients that improve quality and reduce
cost. New Insurance Exchanges and payment bundling offer new payment and pricing
alternatives to providers and patients (Patient Protection and Affordable Care Act, 2010). These
policies represent potentially competence-destroying actions that target the deep structure of
healthcare directly. This suggests that such policies have more potential to create technological
discontinuity than the incremental changes that have been observed to date.
Uncertainty is another factor. In the Technology Cycle described by Anderson and
Tushman a period of uncertainty or era of ferment is described (Figure 11) (Anderson &
Tushman, 1990). During this period, competition for a new dominant design or process creates
uncertainty while the new innovation is understood and confirmed. Loch and Huberman in a
73
study of TPE and the diffusion of technology discuss uncertainty in terms of three
elements; the “inertia” created within organizations that resists radical change in existing
processes or procedures; the absence of a crisis demanding change or demise; and the complexity
of the external environment (Loch & Huberman, 1999). To the extent an organization feels no
pressure to change and there is ongoing uncertainty over the future structure or direction of their
environment, the status quo generally prevails.
The competence-destroying policies prescribed by current health reform create
tremendous uncertainty in the healthcare market. While TPE suggests that such competence-
destroying policies may succeed in creating a discontinuity and ultimately healthcare
transformation, the uncertainty around future repeal blunts their impact on deep structure. Risk
and uncertainty are highly related (Burkhardt & Brass, 1990) and the culture of risk aversion in
healthcare further increases resistance to change.
Resistance from the HIT Environment
The established culture of healthcare approaches change cautiously because unrecognized
risk to patients may be a by-product. New technologies are compared to existing processes and
only accepted once a higher standard of care is demonstrated. New technologies must exceed this
“gold standard” through experimentation, testing and peer review. The identified literature
referenced the frequent failure of HIT to replace paper or change workflows and processes.
Without a demonstrated improvement in patient outcomes, errors, or efficiencies, resistance to
innovation continues and transformation fails (Soleimani & Zenios, 2011). This pattern
exemplifies the tendency for incremental change within healthcare. Policies that push technology
transformation within healthcare face a high bar. While efficiency and quality may have been
74
enough to transform other markets, these benefits may be insufficient to create the
necessary technological discontinuity that produces transformation because they cannot
overcome the risk avoidance inherent in healthcare.
Healthcare Complexity and System Inertia
Coiera refers to resistant behaviors in healthcare as “system inertia” just as Loch and
Huberman referred to the inertia exhibited by organizations in resisting technological change
discussed above (Coiera, 2011; Loch & Huberman, 1999). System inertia according to Coiera
develops from health system complexity and the competing demands within the system.
Complexity in organizations and man made systems, like biological systems, increases over
time. This increasing complexity reflects the many interacting and growing number of agents
(patients, providers, organizations, insurers, policymakers, and others) within the system. The
many agents interact with each other, each trying to improve their own individual position or
“fitness” within the system. The competing demands of each agent in turn provide resistance to
improving the overall strength (financial health, physical health, community health, or other
measure) of the system. System inertia reflects the difficulty in finding new levels of fitness that
satisfy the competing demands and increasing complexities of the system. Change becomes
increasingly difficult and emergent rather than linear (intervention –> reaction) and is reflective
of the complexities of the system.
These observations parallel the theory of complex adaptive systems. Complex systems
theory has been used to explain policy resistance and unintended outcomes in healthcare.
Beginning with the 2001 IOM report “Crossing the Quality Chasm,” healthcare has been
increasingly evaluated as a complex system, resistant to change (Begun, et al., 2003; Coiera,
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2011; Hawe, et al., 2004; Institute of Medicine, 2001; Paina & Peters, 2011; Paley,
2007; Resnicow & Page, 2008; Rouse, 2008; Tan, et al., 2005). Complexity theory describes the
need to establish an appropriate balance between control (low complexity) and chaos (high
complexity) in developing policy interventions.
Coiera proposes that for healthcare to change successfully, system complexity must
decrease. This decrease is theorized as a combination of both building and destroying actions
that together improve the overall fitness of the system analogous to competency enhancing and
destroying actions in technological transformation. The complexity inherent in healthcare and the
need to establish a balance between competence enhancing (control) and destroying (chaos)
pathways of transformation only increase the uncertainty present in the market. Consumers have
often been the mediator of these competing pathways through their ability to exert significant
pressures on markets and their ability to decrease complexity through choice.
The Role of the Consumer in Transformation
Patients as consumers are noticeably absent from the bulk of the literature reviewed here.
Consumers have been an essential component of other market transformations. The ability of
consumers to demand quality and value has driven changes in markets from automobiles to
computers. For example, the increase in demand for greater quality and efficiency from
consumers forced American automobile manufacturers to change manufacturing and design
process to the point of building new factories from the ground up. The ATM, Internet and more
recently mobile technology have changed the way consumers manage data and perform
transactions. The consumer in each example has altered its relationship with the market and
influenced new processes and services.
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The extreme complexity of healthcare, however, may require new and creative
efforts beyond those seen in other markets to effectively integrate patients, medical data and
services. Patients must have the tools necessary to understand, interpret and place a value on the
care they receive in order to exert influence on the healthcare market. This influence, if it can be
generated, in turn will increase the demand for data, information and services back from
healthcare, generating tremendous pressure for change and innovation. A healthcare CEO stated
this point well:
“No investment has been made to help the consumer use our infrastructure more
effectively…. There isn't enough time and attention spent on technology investments that
enable customers in the broadest possible definition to use our systems in the same way
that Norwest Airlines and UPS and Amazon use systems to allow me to track my
packages, make my reservations, check on simple information that helps with my travel
schedule. We prevent the customer from getting close to the very information that could
make our relationships more intimate and valuable" (Ameer et al., 2004, p. 81)
Implications for Current HIT Policy
The existing healthcare environment described by the literature analyzed in this study is
one in which highly complex environmental barriers, uncertainty, and aversion to risk produce
considerable resistance to change. The theory of punctuated equilibrium suggests that
transformational change will require a revolutionary discontinuity in existing deep structure.
Current meaningful use policies are likely unable to overcome this resistance or produce such
discontinuities because they appear to support continued rational and incremental
HIT advancement.
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New patient centered models of care and an increased consumer role may be
the structural elements of the healthcare system where a revolutionary discontinuity can
occur. Policies focused on replacing existing models of care will likely be critical to effectuating
real HIT transformation. Health reform policies such as those seen in Massachusetts and in the
Affordable Care Act attempt to replace existing regulation, flawed risks and rewards and address
stagnant market complexity. These competence-destroying policies may have the potential to
break the incremental and rational pattern of HIT innovation by necessitating innovative
technologies that leverage patients and create new processes of care. The incentive to invest in
the innovations necessary to support new care models is defeated, however, by the ongoing
uncertainty of current healthcare reform. Policies with potential to alter deep structure will
continue to fail if uncertainty around reform continues. Patients too are likely to retreat to the
comfort of existing processes during this period. Reducing uncertainty and engaging patients
(consumers) is therefore essential to successful HIT transformation. Sustained uncertainty will
likely result in a continuation of incremental change and a failure to impact the deep structure of
healthcare, and its associated problems of cost, quality and access.
Implications to Nursing in HIT
The importance of the patient (consumer) in the transformation of healthcare places
nursing in a key position to identify patient needs and the innovations that may address them.
Nursing, through its code of ethics, has stated a commitment to the patient and an advocate for
patient health and safety (American Nurses Assocation, 2012). The Institutes of Medicine
(IOM), the National Institute of Nursing Research (NINR), and the Health Information and
Management Systems Society (HIMSS) also recognize the unique position of nursing in HIT.
The NINR states in their most recent strategic plan that “[n]ursing science can provide the
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foundation for innovative strategies and advances in technology that deliver real-time
personalized information to individuals, families, and communities” (2011, p. 22). In their
Future of Nursing report, the IOM states that “[t]here is perhaps no greater opportunity to
transform practice than through technology” (2010, p. 3-45). The implications to nursing of this
study are the need for new technologies that provide self-empowering data and information to
patients. Nurses as advocates for the patient community are in a unique position to influence
and/or create these new technologies.
Limitations
The study was limited by the period covered and the absence of newer literature
reflecting recent policy changes such as the meaningful use incentives of HITECH and the health
reform initiatives of ACA were noticeably absent. The effects of these recent policies reveal
steep increases in HIT adoption and use by both hospitals and providers (Jamoom, et al., 2012;
U.S. Department of Health & Human Services, 2012). Significant payments have been made
through the Medicare and Medicaid incentive payment programs and more products are being
certified by ONC under the EHR certification program (U.S. Department of Health & Human
Services, 2012). Alternative healthcare delivery models are emerging in the form of accountable
care organizations and patient centered models of care (Gilfillan, 2011; Patient Protection and
Affordable Care Act, 2010). And uncertainty around healthcare reform has declined somewhat
due to the recent ruling from the US Supreme Court in June 2012; although continued threats of
repeal persist (National Federation of Independent Business et al. v. Sebelius, Secretary of
Health and Human Services, et al., 2012).
While this recent progress reflects a significant and successful reaction to HIT policy, it
still does not reflect the radical and revolutionary changes described by TPE necessary for HIT
79
transformation. The basic processes of care and the face-to-face model of care
continue unchanged. Uncertainty in health reform remains and health information technologies
and applications remain similar in function to those used previously. There continues to be is an
absence in the literature of new innovative technologies that disrupt the existing market and
create the technological discontinuities necessary for transformation. HIT continues on the path
of incremental change and equilibrium described by TPE.
Other limitations include the potential bias of the reviewer. The author’s personal biases
and experiences may have impacted the interpretation and analysis of the literature and the
ultimate conclusions reached. Several steps were taken to address this limitation. The author
adhered to the concept of “bracketing” and set aside prior knowledge to ensure a fresh look at
the data being analyzed (Creswell, 2007). A codebook based on an existing framework was
utilized to structure the literature review and the data extracted. Two additional reviewers, using
a sample of the literature, further validated the coding schema. Adjustments to the coding
definitions were made based on consensus discussions with the additional reviewers to ensure a
consistent coding of the identified literature. Bias also exists in the collection of literature
included in the review. Relevant literature may have been missed and impacted the study
findings. To address this risk, a broad range of literature was reviewed from multiple sources,
erring on the side of inclusion versus exclusion. Ancestry and bibliography searches were also
added to decrease the likelihood of missing key relevant literature.
The use of a theoretical framework can introduce error by potentially favoring findings
that support the theoretical framework over those that do not. Also, reliance on a theory may
limit the researchers ability to recognize or contextualize new concepts that might not fit within
the existing theory. To address this, a structured methodology and detailed audit trail was
80
maintained by the researcher. The author applied directed content analysis to the study
data. Directed content analysis applies various evaluative methods including constant
comparison, data immersion, repeated questioning, probing and sorting, negative case and other
qualitative methods. The use of these methods ensured a complete and thorough review of all
data.
Lastly, the quality of the review is based on the strength and experience of the researcher
and the thoroughness of the review achieved. A single reviewer evaluated the majority of the
data. Careful adherence to the study methodology was therefore taken and the researcher
maintained a detailed log of all research steps.
Areas for Further Study
The goal of the study was only to identify evidence of technological transformation in
healthcare. The evidence presented here suggests an absence of transformation and a high level
of resistance to change. The components needed for revolutionary change focus on patient
(consumer) empowerment and new models of healthcare delivery that create viable value
arguments for HIT adoption. Future research should examine the potential effects of these
revolutionary forces on revolution. Comparisons can be made to revolutionary periods in other
markets. Specific models can potentially be derived based on the experiences in these other
markets to determine their impact. For example, the role of consumers in other market
transformations can be compared to the potential impact of patients on transformation in
healthcare. Combining the theory of punctuated equilibrium with systems dynamics modeling
for example could form the foundation of future operationalized models that could assist policy
adoption. System modeling represents a key tool for evaluating future policy options and
understanding the complex and dynamic environment of healthcare.
81
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Appendix A – Specific Search Strategies
1. MedLine/PubMed
1. Technology. Or technology.mp 2. limit 1 to abstracts 3. Informatics/ or informatics.mp 4. limit 3 to abstracts 5. information systems.mp or Information Systems/ 6. limit 5 to abstracts 7. practice framework.mp 8. limit 7 to abstracts 9. 2 or 4 or 6 or 8 10. organizational change.mp or Organizational Innovation/ 11. limit 10 to abstracts 12. organizational innovation.mp or Organizational Innovation/ 13. limit 12 to abstracts 14. transformation.mp 15. limit 14 to abstracts 16. Organizational Innovation/ or innovation.mp 17. limit 16 to abstracts 18. 11 or 13 or 15 or 17 19. 9 and 18 20. limit 19 to (english language and yr=”2004 – Current”)
2. Social Science Research Network
1. technology AND transformation and health 2. 2004 to Current
3. Business Source Complete
1. AB ( technology or "information system" ) AND AB ( transformation or "organizational change" ) AND TX ( health or healthcare or medicine )
2. Publication Date 2004 – 2012
4. Web of Knowledge
Source articles for ancestry search:
1. Anderson, P., & Tushman, M. L. (1990). Technological discontinuities and dominant designs: A cyclical model of technological change. Administrative Science Quarterly, 604-633.
2. Gersick, C. J. G. (1991). Revolutionary change theories: A multilevel exploration of the punctuated equilibrium paradigm. Academy of Management Review, 10-36.
3. Tushman, M. L., & Romanelli, E. (1985). Organizational evolution: A metamorphosis model of convergence and reorientation. Research in organizational behavior.
90
5. Factiva
Search Summary
Text technology AND transformation AND health AND delivery AND innovation
Date 01/01/2004 to 12/31/2012
Source Not Dow Jones Newswires Not Press Release Wires Not Reuters Newswires
Company All Companies
Subject All Subjects
Industry Not Accounting/Consulting Not Advertising/Public Relations/Marketing Not Aerospace/Defense Not Agriculture/Forestry Not Automobiles Not Banking/Credit Not Biotechnology Not Business/Consumer Services Not Chemicals Not Clothing/Textiles Not Computers/Electronics Not Construction/Real Estate Not Consumer Products Not Energy Not Environment/Waste Management Not Food/Beverages/Tobacco Not Hotels/Restaurants/Casinos Not Insurance Not Internet/Online Services Not Investing/Securities Not Leisure/Arts Not Machinery/Industrial Goods Not Media Not Metals/Mining Not Paper/Packaging Not Pharmaceuticals Not Retail/Wholesale Not Telecommunications Not Transportation/Shipping Not Medical/Surgical Materials Not Medical/Surgical Instruments/Apparatus/Devices Not Medical/Clinical/Diagnostic Services Not Veterinary Services
Region Not South America Not St. Pierre and Miquelon Not Mexico Not Greenland Not Canada Not Bermuda Not Africa Not Antarctica Not Asia Not Asia Pacific Not Australia/Oceania Not Caribbean Islands Not Central America Not CIS Countries Not Developing Economies Not Emerging Market Countries Not Europe Not Latin America Not Mediterranean Not Middle East
Language English
91
Appendix B – List of Identified Articles
American Health Care System. (2007). Congressional Record, H13952, H13953, H13954, H1395, H13956, Volume 153, Issue 176.
Health Care in America. (2007). Congressional Record, H11476, H11477, H11478, H11479, H11480, H11481, H11482 Volume 153, Issue 153.
The State of Health Care in America. (2007). Congressional Record, H11149, H11150, H11151, H11152, H11153, H11154, H11155, Volume 153, Issue 148.
Strategy to Support Health Information Technology Among HRSA's Safety Net Providers. (2008). 73 Fed Reg. 4584.
Abdolrasulnia, M., Menachemi, N., Shewchuk, R. M., Ginter, P. M., Duncan, W. J., & Brooks, R. G. (2008). Market effects on electronic health record adoption by physicians. Health Care Management Review, 33(3), 243.
Abraham, C., & Reese, B. (2010). Making music out of noise. The Sentara Healthcare Experience Implementing e-Care. Journal of healthcare information management: JHIM, 24(1), 44.
Abraham, C., & Rosenthal, D. A. (2008). Merging home and health via contemporary care delivery: Program management insights on a home telehealth project. Computers Informatics Nursing, 26(5), 273.
Addiego 3rd, J. (2005). Way to go live: a framework for new IT implementation. Healthcare financial management: journal of the Healthcare Financial Management Association, 59(1), 68.
Agarwal, R., & Angst, C. M. (2006). Technology-Enabled Transformations in US Health Care. Human-computer interaction and management information systems: applications, 6, 357.
Agarwal, R., Angst, C. M., DesRoches, C. M., & Fischer, M. A. (2010). Technological viewpoints (frames) about electronic prescribing in physician practices. Journal of the American Medical Informatics Association, 17(4), 425-431.
Agarwal, R., Guodong, G., DesRoches, C., & Jha, A. K. (2010). The Digital Transformation of Healthcare: Current Status and the Road Ahead. [Article]. Information Systems Research, 21(4), 796-809. doi: 10.1287/isre.1100.0327
Aitoro, J. R. (2006). Gingrich Speaks To IT Industry. [Article]. VARBusiness, 22(3), 22-22.
Alexander, G. L. (2008). A descriptive analysis of a nursing home clinical information system with decision support. Perspectives in Health Information Management/AHIMA, American Health Information Management Association, 5.
92
Alexander, G. L., Rantz, M., Flesner, M., Diekemper, M., & Siem, C. (2007). Clinical information systems in nursing homes: an evaluation of initial implementation strategies. Computers Informatics Nursing, 25(4), 189.
Alexander, I. (2007). Electronic Medical Records for the Orthopaedic Practice. Clinical orthopaedics and related research, 457, 114.
Amatayakul, M. (2004). the path to EHR. Healthcare Financial Management, 58(8), 98-99.
Amatayakul, M. (2010). Carrots and sticks for EHR implementation. Healthcare financial management: journal of the Healthcare Financial Management Association, 64(2), 60.
Ameer, A., Ecock, T., Fontenot, T., Lynn, G., Mecklenburg, G., Sadler, B., . . . Zenty 3rd, T. (2004). The CEO and the future of technology. Panel discussion. Hospitals & health networks/AHA, 78(10), 75.
Anderson, G. F., Frogner, B. K., Johns, R. A., & Reinhardt, U. E. (2006). Health care spending and use of information technology in OECD countries. Health Affairs, 25(3), 819-831.
Anderson, J. G., Ramanujam, R., Hensel, D., Anderson, M. M., & Sirio, C. A. (2006). The need for organizational change in patient safety initiatives. International Journal of Medical Informatics, 75(12), 809-817.
Anonymous. (2004). 2004 Top Health Care Business Issues. [Article]. Trustee, 57(2), 3-4.
Anonymous. (2004). AHIMA's electronic record standards. [Article]. AHA News, 40(2), 2-2.
Anonymous. (2004). Issues in Clinical Transformation. [Article]. H&HN: Hospitals & Health Networks, 78, 40-49.
Anonymous. (2004). 10-year outline unveiled to roll out health information technology. Quality Letter for Healthcare Leaders, 16(9), 9-10, 11.
Anonymous. (2004). 'Most wired' hospitals widen gap over others. [Comment]. Healthcare Benchmarks & Quality Improvement, 11(10), 116-117.
Anonymous. (2004). CHT Initiative Pushes for Strong Systems. Health Management Technology, 25(7), 6.
Anonymous. (2004). HHS Awards $139 Million to Drive Adoption of Health Information Technology. US Fed News.
Anonymous. (2005). Making the healthcare system safer with innovation and technology. [Congresses]. Quality Letter for Healthcare Leaders, 17(7), 2-11, 11.
Anonymous. (2006). Newt Gingrich: healthcare transformation advocate (Vol. 60, pp. 34-36): Healthcare Financial Management Association.
93
Anonymous. (2006). When it comes to IT, ED managers lag behind. ED Management, 18(7), 76-77.
Anonymous. (2007). Incremental approach is best with a new EDIS. ED Management, 19(5), 52-54.
Anonymous. (2008). The price of excess* Identifying waste in healthcare spending. PwC Views.
Anonymous. (2008). PwC HRI Top Nine Health Industry Issues in 2009: Outside forces will disrupt the industry. PricewaterhouseCoopers.
Anonymous. (2009). Technology will have major impact on shaping future EDs, say the experts. ED Management, 21(1), 1-3.
Anonymous. (2009). GE program could boost EMR adoption. Healthcare Benchmarks & Quality Improvement, 16(9), 102-103.
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Wood, J. T., 3rd, & Aceves, R. (2005). Five steps to electronic health record success. Healthcare Financial Management, 59(1), 56-61.
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130
Appendix C – Sample Coded Table of Identified Articles
Note: Appendix C does not contain a complete listing of all the data elements coded and represents only a sample of the information extracted from the study’s identified articles.
-- Begins on next page --
131
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
22004Development-of-a-W
eb2Basedent-Reporting-System-
in-an-Academic-environment
Journal-of-the-American-M
edical-
Inform
atics-Association
23
Academic-M
edical-Center
01
10
0
Case-Study
Ohio
Event2reporting-system
Equilibrium
The-implementation-of-the-error-reporting-system-represnts-an-incremental-change-within-an-
already-positive-reporting-environment.--The-authors-discuss-the-apparent-sustained-increase-in-
reporting-20-weeks-after-im
plementation-as-a-reflection-of-not-only-the-system,-but-also-the-existing-
culture-of-error-reporting.
22004Development-of-a-W
eb2Basedent-Reporting-System-
in-an-Academic-environment
Journal-of-the-American-M
edical-
Inform
atics-Association
23
Academic-M
edical-Center
01
10
0Case-Study
Ohio
Event2reporting-system
Deep-Structure
The-article-refers-to-the-desire-to-create-a-"cultural-shift"-in-the-reporting-of-medical-errors.--Barriers-
to-change-m
ust-be-idendified-prior-to-implementing-change.
32004Alamance-Regional-Medical-Center-im
proves-patient-
Safety-with-CPOE
Journal-of-Health-Inform
ation-
Management
22
00
10
0Case-Study
North-
Carolina
CPOE
Revolution
"ARMC-determ
ined-that-achieving-true-success-with-a-clinical-inform
ation-system-would-require-
merging-two-critical-parts-of-the-healthcare-delivery-process:-business-and-patient-care."-p-19
42004Physician-Use-of-IT:--Results-from-the-Deloitte-
Research-Survey
Journal-of-Health-Inform
ation-
Management
22
Office
01
00
0
Survey
National
Any
Deep-Structure
Study-discusses-at-an-early-stage,-2004,-the-feeling-of-sm
all-practice-doctors-towards-EMR.--Study-
found-that-96%-of-doctors-use-IT-(but-this-could-sim
ply-be-an-excel-spreadsheet),-but-few-12%-used-
clinical-systems-in-their-practice.--Age-was-not-a-factor.--H
igh-interest-in-IT.
52004How-do-integrated-Delivery-Systems-Adopt-and-
Implement-Clinical-Inform
ation-Systems
Health-Care-M
anagement-Review
23
01
10
0
Case-Study
National
Various
Equilibrium
Structure-of-organization-influences-inclusion-of-users-within-project-and-organization-of-IT-project.--
More-established-Integrated-Delivery-Systems-(IDS)-had-form
al-organizational-structures-that-could-
include-all-levels-of-participation-in-projects,-vs.-ad-hoc-committees-at-less-advanced-IDSs.
62004Physicians:-The-Key-to-IT-Success
Trustee
21
01
00
0
Opinion
Deep-Structure
Physicians-needed-to-ensure-success-of-IT.--Poorly-designed-and-implemented-systems-will-im
pede-
acceptance-by-physicians-and-therefore-to-rest-of-organization.--Phyusicians-needed-on-leadship-
committees,-training-and-system-design.
13
2004Indianapolis-I3:--the-third-generation-Integrated-
Advanced-Inform
aiton-System
Journal-of-the-M
edical-Library-Association
21
Health-System
00
01
0Historical
Indiana
Integrated-Inform
ation-
System
Deep-Structure
Integration-of-data-across-systems,-patients,-practices-im
protant-to-the-success-of-making-IT-and-
medical-inform
ation-accessable-across-disparate-systems
14
2004Too-m
uch-too-soon?
Modern-Healthcare
20
00
10
1Opinion
Deep-Structure
Regulations-and-regulators-such-as-JCAHO-are-influence-the-environment-and-priorities-of-insitutions
15
2004Commercial-Clinical-Data-W
arehouses:-From-W
ave-
of-the-Past-to-the-State-of-the-Art
Journal-of-Healthcare-Inform
ation-
Management
23
hospital
00
10
0
survey
Texas
Data-W
arehouse
Equilibrium
Combining-an-historical-perspectivce-on-the-use-of-Clinical-Data-W
arehouses-and-a-survey,-the-
authors-discuss-the-trend-toward-commercial-systems-over-in-house-systems.--The-historical-
perspective-highlights-the-incremental-nature-of-technology-advancement-in-healthcare.
16
2004102year-outline-unveiled-to-roll-out-health-
inform
ation-technology
Quality-Letter-for-Healthcare-Leaders
20
00
01
0
Opinion
National
Various
Deep-Structure
Outlines-10-year-plan-of-HHS-and-ONC-by-listing-four-major-goals:
12-Inform
ing-Clinical-Practice-and-encouraging-EHR-adoption
22-Interconnecting-Clinicians
32-Personalizing-care
42-Im
proving-Population-Health
17
2004'M
ost-wired'-hospitals-widen-gap-over-others
Healthcare-Benchmarks-&-Quality-
Improvement
20
hospital
00
10
0
News-Story
National
various
Deep-Structure
Most-wired-hospitals-have:
12-established-ROI-analysis-after-every-implementation
22-focus-on-education-and-training
Unsurprisingly-have-COPE-and-other-drug-related-systems-more-frequently-than-others-2-M
MA?
18
2004the-path-to-EHR
Healthcare-Financial-Management
21
General-healthcare
00
10
0Opinion
National
EHR
Revolution
To-achieve-transform
ation-a-"migration-path"-is-required-which-provides-a-series-of-steps-with-
corresponding-benefits-that-align-with-an-organizations-strategic-plan.
19
2004The-CEO-and-the-future-of-technology.-Panel-
discussion
Hospitals-&-health-netw
orks/AHA
40
hospitals
10
10
0
New-Story
National
Various
Revolution
Article-is-an-interview-with-top-CEOs-at-various-healthcare-institutions.--Several-key-points,-incistes-
come-from-the-discussion-about-creating-revolutionary-change:
12-you-have-to-include-the-whole-organization-in-change.
22-Issue-with-clicnicians-not-being-part-of-the-organization
32-No-connection-to-the-consumer-as-part-of-the-HIT-process-and-strategic-thinking.--"no-investment-
has-been-m
ade-to-help-the-consumer-use-out-infrastructure-m
ore-effectively….-There-isn't-enough-
time-and-attention-spent-on-technology-investments-that-enable-customers-in-the-broadest-possible-
definition-to-use-out-systems-in-the-same-way-that-Norw
est-Airlines-and-UPS-and-Amazon-use-
systems-to-allow-m
e-to-track-m
y-packages,-m
ake-m
y-reservations,-check-on-sim
ple-inform
aiton-that-
helps-with-m
y-travel-schedule.--W
e-prevent-the-sutomer-from-getting-close-to-the-very-inform
ation-
that-could-m
ake-our-relationshps-more-intimate-and-valuable."--pg-81
42-Can't-have-unique-practice-patterns-hospital-by-hospital.
20
2004Making-IT-ends-meet.-(cover-story)
Modern-Healthcare
30
Hospital
00
10
1
News-Story
Pennsylvani
a
Various
Equilibrium
To-address-the-high-cost-of-im
plementing-a-new-HIT-system,-sm
aller-hospitals-are-outsourcing-their-
IT-services-to-larger-hospitals.--Authors-describe-the-use-of-Seim
ens-new-Soarian-system-by-Sailors-
Memorial-hospital-who-leases-the-system-from-the-larger-Susquahana-Health-System.
23
2004Translating-ideals-for-health-inform
ation-technology-
into-practice
Health-affairs-(Project-Hope)
31
01
01
0
Opinion
National
EHR
Equilibrium
Describe-the-need-for-standards-and-the-difficulty-of-setting-standards.--Early-adopters-are-punished-
as-standards-evolve.--"One-single-private-organization-or-commission-would-be-vested-with-the-
authority-by-standard2development-organizations-to-determ
ine-which-standards-are-to-be-adopted,-
when-they-should-be-put-into-use,-what-the-schedule-for-future-standards-should-be,-and-what-gaps-
exist-in-existing-standards.-"-pg-W
42320
"The-first2m
over-disadvantages-that-accrue-to-early-adopters-of-standards-suggest-that-voluntary-
adoption-will-take-a-very-long-tim
e-and-m
ay-not-succeed-at-all."-pg-W
42319
132
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
23
2004Translating-ideals-for-health-inform
ation-technology-
into-practice
Health-affairs-(Project-Hope)
31
01
01
0
Opinion
National
EHR
Equilibrium
"Why-should-electronic-health-records-be-treated-differently-from-other-diagnostic-and-therapeutic-
tools-based-on-inform
ation-technology?-"-pg-W
42319--EHR-should-be-regulated-like-other-medical-
equipment.
24
2004Opening-the-black-box:-M
easuring-hospital-
inform
ation-technology-capability
Health-Care-M
anagement-Review
24
Hospital
00
10
0
Cross-sectional-
data-analysis
National
Various
Equilibrium
Authors-propose-a-m
odel-of-IT-m
unificence.--"Munificence-is-defined-as-a-m
easurement-of-resource-
abundance-and-the-resulting-capacity-to-support-growth.--IT-m
unificence-can-be-posoited-as-a-guage-
of-the-strategic-importance-of-IT.--It-measures-the-current-organizational-IT-capability."--pg-208--To-
measure-m
unificence-authors-propose-a-m
odel-consisting-of-"diffusion-of-innovation-theory"-and-the-
"Strategic-contingency-thory".--
Not-clear-authors-m
ade-the-argument-clearly-as-I-can-not-understand-what-is-being-used-to-validate-
that-munificence-is-a-proxy-for-IT-capability.--If-I-understand-it,-the-number-of-IT-systems-relates-to-
the-IT-capability-of-the-organization.-22-so-what
25
2004Using-electronic-health-records-to-help-coordinate-
care
Milbank-Quarterly
41
Various
00
01
0
Opinion
National
EHR
Revolution
Policy-should-focus-on:
National-Standard-for-health-record,-governance-structure-for-exchange-of-clinical-data,-and-
paym
ents-from-insurers-and-payors-for-use-of-EHR
25
2004Using-electronic-health-records-to-help-coordinate-
care
Milbank-Quarterly
41
Various
01
00
0
Opinion
National
EHR
Equilibrium
Authors-discuss-barriers-and-policy-considerations-for-im
proving-adoption-and-use-of-EHRs
Barriers-include:
12-no-common-form
at-or-standard
22-high-costs-of-im
plementation-2-"Many-now-believe-that-much-of-the-financial-benefit-from-using-
an-EHR-goes-to-health-plans,-not-physicians."-pg-462
32-no-demonstrated-clinical-and/or-financial-benefits-for-ambulatory-car-physicians
42-patient-concerns-about-privacy-and-safety
52-unknown-legal-liability
33
2004Keynote-address:-medical-inform
atics-and-
emergency-m
edicine
Academic-Emergency-M
edicine
31
Emergency-Department
00
10
0
Opinion
Washington
,-DC
Various
Equilibrium
contrary-view-of-current-inform
atics-priorities.
"Trivial-and-naïve-applications-are-being-advanced-on-an-equal-footing-with-solutions-that-have-
already-proven-to-yield-improved-outcomes-and-efficiencies."-pg-1119
Emphasis-of-the-author-is-the-"access-to-inform
ation"-and-that-local-inform
ation-is-the-priority-and-
NOT-national-connectivity.--"In-the-vase-m
ajority-of-cases,-the-inform
ation-that-is-needed-to-provide-
better-health-care-already-exists-locally."-pg-1119
Good-list-of-"advice"-on-systems-and-inform
atics-on-pg-1125-including:-make-things-as-simple-as-
possible,-secrecy-is-raily-protective,-make-things-obvious,-no-such-thing-as-user-error,-just-poorly-
designed-systems,-committees-are-bad-for-inform
atics.
35
2004CIS:-Where-are-we-going-and-what-should-we-
demand-from-industry?
Journal-of-critical-care
41
01
00
1
Opnion
National
VARIOUS
Equilibrium
Barriers-to-adoption-include-Leadership,-False-Starts,-and-Unfulfilled-Expectations.--There-has-also-
been-a-lack-of-communication-betw
een-clinicians-and-vendors-in-the-development-of-HIT.---Costs-and-
Standards-also-remain-barriers.
Future-requires-HIT-that-will-Capture-appropriate-data,-easily-present-and-report-the-data,-be-
portable-and-wireless-and-integrate-the-data-with-other-systems.
38
2004The-evolution-and-implementation-of-a-pediatric-
computerized-order-entry-system:-a-case-study
Journal-of-healthcare-inform
ation-
management:-JHIM
22
Large-Healthcare-System-
(Partners-2-Boston)
00
10
0Case-Study
Boston
CPOE
Equilibrium
Describes-in-detail-implementation-of-CPOE-system-within-a-large-pediatric-setting.--Importance-of-
Charter-to-success-of-project-which-outlines-goals,-costs,-plan,-etc.
40
2004Wiring-Docs
Hospitals-&-health-netw
orks/AHA
31
01
10
0
Opinion
National
VARIOUS
Equilibrium
Discusse-several-barriers-to-adoption-and-implementation-such-as-Cost,-resitance-by-docs-and-lack-of-
an-existing-m
odel.--A
lso-discussed-the-Stark-laws-and-fear-by-organizations-of-violating-these-anti2
trust-laws-by-sharing-data-across-institutions,-etc.
45
2004How-to-succeed-in-health-inform
ation-technology
Health-Affairs
31
Various
01
00
0
Opinion
National
CPOE
Equilibrium
Author-believes-a-"tipping-point"-has-been-reached.--Effort-has-moved-from-W
hy-HIT-to-how-to-
implement.--States-however,-that-health-system-is-complex-"Clearly,-themyriad-of-competing-
incentives-and-priorities-in-the-rest-of-the-U.S.-health-care-system-will-add-considerable-complexity-
that-is-only-beginning-to-become-clear."-pg-W
42322
Significant-local-variation-in-how-"practice-is-perform
ed".
133
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
46
2004Beyond-usability:-designing-effective-technology-
implementation-systems-to-promote-patient-safety
Quality-and-Safety-in-Health-Care
51
00
10
0
Opinion
National
Various
Equilibrium
Discusses-elements-that-lead-to-change-and-support-change-within-an-organzitaion.--The-author-
emphasizes-that-Norm
al-design-pricples-of-ease-of-use-and-usefullness-are-not-sufficient-to-ensure-
full-implementation-and-realize-the-safety-benefits-of-the-technology.
These-include:
Organizational-Factors-(Integration-of-technology,-m
anagement-commitment,-structured-
implementation,-traininng-and-end-user-participation-in-process,-feeling-treated-fairly-by-
organizatipon-"organizational-justice")
Technology-factors-(TAM)
job-Factors-(the-degree-of-job-change-caused-by-technology)
individual-factors-(self2efficacy,-age)
49
2004HIPAA-implementation:-measuring-change-and-
quality-improvement
Journal-of-healthcare-inform
ation-
management:-JHIM
12
Long-term
-care-organziation
01
10
0Case-Study
unavailable
HIPAA-Compliance
Equilibrium
Change-requires-support-of-management-in-term
s-of-statements,-money-and-personel.
50
2004Transform
ing-nursing-practice:-clinical-systems-and-
the-nursing-unit-of-the-future
Journal-of-healthcare-inform
ation-
management:-JHIM
22
Clarge-Hospital-System-2-
Cleveland-Clinic
01
10
0Case-Study
Ohio
Various
Equilibrium
Role-of-nursing-in-the-implementation-of-technology.--N
otes-increasing-demands-from-new-nurses,-
educated-with-technology-to-use-technologies-in-the-work-environment.
53
2004Evolving-to-clinical-term
inology
Journal-of-healthcare-inform
ation-
management:-JHIM
31
00
01
1
Opinion
National
Standard-Term
inologiesEquilibrium
"The-implementations-of-term
inologies-will-require-that-developers-of-EMR-systems-understand-
some-basic-proniciples-of-new-and-proposed-term
inologies,-as-well-as-the-challenges-that-lie-ahead.--
EMR-vendors-m
ay-not-posess-all-the-term
iniology-know2how-required-to-solve-all-the-issues."-pg-43
55
2004Clinical-inform
ation-systems-market2An-
insider’s-view
Journal-of-critical-care
21
00
10
0
Opinion
Natoinal
VARIOUS
Equilibrium
Discusses-basic-barriers-to-HIT-implementation-and-adoption
2Funding
2-No-Killer-App-
2Fragmented-M
arget-for-HIT-vendors
2Business-driver-for-adoptn
2-The-IT-Czar
59
2004Adoption-Factors-Associated-with-Patient-Safety22
Related-Inform
ation-Technology
Journal-for-Healthcare-Quality
33
hospital
00
10
0
survey
Florida
Various
Equilibrium
"Hospitals-have-traditionally-adopted-IT-for-admininstrative-functions-…-m
ore-rapidly-than-for-clinical-
or-patient-safety-uses-mainly-becase-of-more-easily-quatifieable-returns-on-investment.-Pg-40
Study-examined-relationship-betw
een-HIT-and-several-factors.
CIO-invovlement-in-patient-safety-was-correlated-with-a-higher-probability-of-HIT-adoption
strategic-alignment-of-CIO-and-organziation-correlated-as-well.
Physicians-play-a-critical-role-in-the-acceptance-and-use-of-HIT
64
2004An-assessment-of-the-readiness-of-hospice-
organizations-to-accept-technological-innovation
Journal-of-Telemedicine-and-telecare
33
Hospice
11
00
0
Survey
Missouri
Telehealth
The-survey-showed-a-willingness-of-employees-to-try-new-technology,-but-a-resistance-to-introducing-
technologoes-to-patients-"more-than-half-though-they-would-be-beneficial,-but-there-were-also-
concerns-about-introducing-new-technology-into-patients'-homes."-P.173
Early-adopters-of-technology-may-be-imporrtant-to-the-introduction-of-technology-within-an-
organization
65
2004Overcoming-barriers-to-adopting-and-implementing-
computerized-physician-order-entry-systems-in-US-
hospitals
Health-Affairs
55
Hospital
00
11
1
Case-Study
National
CPOE
Revolution
Policy-implications-2-pg-189
1-2-Excert-pressure-on-hospitals-to-improve-patient-safety
2-2-encourage-public-and-private-payors-to-provide-financial-incentives-to-institutions-for-adoption-
CPOE
3-2-Access-to-capitol
4-2-improve-interoperability-through-standardization-of-vocabularies-and-communication-protocols.
134
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
65
2004Overcoming-barriers-to-adopting-and-implementing-
computerized-physician-order-entry-systems-in-US-
hospitals
Health-Affairs
55
Hospital
01
10
0
Case-Study
National
CPOE
Equilibrium
Phycian-and-Organizational-resistance-to-adoption-of-CPOE--"Physician-resistance-…-greater-
impedim
ent-than-cost."--"overcoming-financial-barrier-alone-m
ay-not-be-sufficient-to-enable-
hospitals-to-adopt-CPOE.--Pg-189
Need-to-address-workflow-concerns-and-costs.--Strong-leadership,-physician-chanmpion-and-using-
house-staff-during-implementation.
65
2004Overcoming-barriers-to-adopting-and-implementing-
computerized-physician-order-entry-systems-in-US-
hospitals
Health-Affairs
55
Hospital
00
00
0
Case-Study
National
CPOE
Equilibrium
Product-vendor-im
maturity-a-barrier-to-CPOE-implementation.--Poor-design-a-big-factor-in-delay-or-
failure-or-resistance.
“[Company-A]-has-a-product-that-is-now-getting
to-be-only-two-years-[old]—
and-it-still-has-a-lot
of-work-to-do.-[Company-B]-has-a-brand2new
product-out-there-from-[University-X],-but-boy,
that’s-leading2edge-brand2new-software-that
now-needs-to-be-rewritten-[to-m
ake-it-compatible
with-Company-B’s-core-product].-You
wouldn’t-put-eight-or-ten-m
illion-dollars-in-one
of-[Company-C’s]-old-products-for-fear-they’ll
disappear,-so-you-put-[your-money]-into-their
new-product,-and-the-paint’s-still-wet-on-that.
And-that’s-less-solid-than-[Company-B’s]-basic
product.-[Company-D],-well,-their-forte-is…
considered
65
2004Overcoming-barriers-to-adopting-and-implementing-
computerized-physician-order-entry-systems-in-US-
hospitals
Health-Affairs
55
Hospital
00
10
0
Case-Study
National
CPOE
Equilibrium
High-CPOE-cost-and-capital.--"absence-of-a-strong-and-objective-business-case-for-CPOE"-pg-187
66
2004Win-the-technology-marathon.-Condition-your-
practice-for-long2term
-IT-strategy
MGMA-connexion/M
edical-group-
Management-Association
31
Medical-Practice
01
00
0
Opinion
New-Jersey
EMR-System
Equilibrium
Must-be-a-business-reason-to-invest-in-HIT.--Therefore-m
ust-examine-productivity-and-reports-to-
physicians.--Reports-provided-evidence-to-physicians-of-effectiveness-of-HIT-and-increased-use-and-
future-productivity.
73
2004New-Technology-Continues-to-Invade-Healthcare:-
What-are-the-Strategic-Implications/Outcomes?
Nursing-Administration-Quarterly
11
Nursing
01
00
0
Opinion
Various
Revolution
"Pace-of-change-in-HCT-is-so-rapid-that-inform
ation-becomes-obsolete-by-the-tim
e-it-reaches-the-
reader."-pg-93
"Clinical-transform
ation-is-clinical-and-nonclinical-process-improvement-supported-by-technology-not-
driven-by-it."-pg-92
73
2004New-Technology-Continues-to-Invade-Healthcare:-
What-are-the-Strategic-Implications/Outcomes?
Nursing-Administration-Quarterly
11
Nursing
01
10
0
Opinion
Various
Revolution
Clinical-transform
ation-is-much-m
ore-than-just-acquiring-and-implementing-an-advanced-CIS.-Clinical-
transform
ation-m
eans-optimizing-core-clinical-operations-using-inform
ation-technology-to-drive-
significant-quality-and-financial-im
provements.-To-realize-m
aximum-benefits,-healthcare-providers-
must-integrate-process-improvement,-organizational-change,-and-enabling-inform
ation-technology.-
When-this-is-accomplished,-in-addition-to-improvements-in-quality-and-patient-outcomes,-a-financial-
return-on-investment-can-be-quite-significant—
on-the-order-of-three-or-more-tim
es-the-total-cost-of-
ownership-of-the-inform
ation-system-over-its-lifetime-pg-96
From:--Toole-J.-The-need-for-transform
ation.-In:-Health-Care-Technology:-Innovating-Clinical-Care-
Through-Technology.-Vol-1.-San-Francisco:-Barry-Jacobs;-2003:22–24,-pg-22
74
2004Superiority-is-complex
Hospitals-&-health-netw
orks/AHA
31
00
10
0
Opinion
Equilibrium
Author-suggests-that-while-"wired"-hospitals-show-higher-credit-ratings,-outperform
-the-nation-on-
productivity,-efficiency-and-financial-measure-and-better-clinical-outcomes,-this-m
ay-be-m
ore-a-
factor-of-size-than-a-factor-of-the-level-or-"w
iredness".
75
2004The-100-m
ost-wired-2004
Hospitals-&-health-netw
orks/AHA
33
hospital
00
10
0Survey
National
Various
Equilibrium
"90%-of-the-m
ost-wired-conduct-either-pre-or-post2implementation-retrun2on2investment-analyses-
to-justify-exspenditures."-pg-41
76
2004Health-care's-m
ost-wired.-A-wired-exchange
Materials-m
anagement-in-health-care
23
Hospital
00
10
0
survey
national
Supply-and-Operations-
Management
Equilibrium
"In-the-past-five-years,-the-investment-in-clinical-IT-appears-to-have-outstripped-the-investment-in-
managerial-systems,-including-enterprise-resource-planning-aim
ed-at-im
proving-the-supply-chain."-pg-
27
77
2004Electronic-health-records:-How-close?-How-far-to-go
NHPF-Issue-Brief
51
01
00
0Opinion
National
EMR
Deep-Structure
135
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
77
2004Electronic-health-records:-How-close?-How-far-to-go
NHPF-Issue-Brief
51
11
00
0
Opinion
National
EMR
Revolution
Standards-at-a-national-level-a-m
ust
Propose-m
ore-acceptance-and-support-for-CCR-and-Personal-health-records.
77
2004Electronic-health-records:-How-close?-How-far-to-go
NHPF-Issue-Brief
51
00
10
0
Opinion
National
EMR
Equilibrium
Article-reinforces-in-a-well-articulated-way-the-m
ain-themes-around-technology-resistance
a.Cost
b.Practice-Disruption
c.Culture-–-changing-how-care-is-done-–-tradition-
d.Technology-Trepidation
e.Legal
82
2004An-adoption-study-of-a-clinical-reminder-system-in-
ambulatory-care-using-a-developmental-trajectory-
approach
Medinfo
33
hospital
11
00
0
Survey
Pennsylvani
a
CDSS
Deep-Structure
Established-nature-of-patient-provider-relationship-is-relatively-inflexible-to-change-from-technology.--
"the-system-was-time-consuming-and-inefficient,-primarially-due-to-the-nature-of-the-outpatient-
office-visit."-pg-1118
Three-m
ajor-im
pedim
ents-in-the-use-of-the-system-were-identified.
First,-physicians-expressed-general-discomfort-with-active
use-of-a-personal-computer-during-a-patient-encounter,-where-interactions
with-the-patient-may-be-impeded-by-glances-towards-a
computer-screen-and-tapping-on-a-keyboard.-Second,-CRS-offered
no-guidance-as-to-a-preferred-order-of-data-entry,-in-contrast
to-the-History-&-Physical-form
-that-physicians-were-used-to.-Finally,
CRS-often-generated-reminders-designed-to-elicit-inform
ation
from-patients-during-the-encounter,-e.g.-menopausal-status,
that-appeared-to-be-irrelevant-and-repetitive.-Pg-1118
119
20042004-TOP-HEALTH-CARE-BUSINESS-ISSUES
Trustee
10
hosptial
00
10
0
News
national
Various
Equilibrium
Business-goals-of-Hospitals-in-2004-include:--Strrengthening-business-rigor-in-m
aking-technology-
decisions;-Transform
ing-clinical-care-through-technology;-Redisigning-core-business-processes;-
Increasing-collaboration-betw
een-payers-and-providers-at-the-operational-level.
120
2004AHIM
A's-electronic-record-standards
AHA-News
10
national
00
01
0news
National
EHR
Equilibrium
American-Health-Inform
aiton-M
anagement-Association-has-released-standards-for-EHRs.--N
o-details-
provided.
122
2004Issues-in-Clinical-Transform
ation
H&HN:-Hospitals-&-Health-Netw
orks
30
hospital
00
10
0
news
National
Various
Equilibrium
Systems-out-there-do-not-meet-the-needs-of-hospitals:-"Ive-been-searching,-searching,-searching-for-
the-perfect-system-or-the-system-that-would-be-best-for-our-facility."-pg-48
Staff-m
ust-be-convinced-the-technology-will-help.
123
2004Digital-pens-and-paper-show-e2prescribing-promise
Drug-Store-News
10
hospital
00
10
0News
New-Jersey
eRx
Equilibrium
news-story-on-new-pen-technology-that-converts-hand-writing-to-data-for-prescriptions.
124
2004Clinical-transform
ation-initiative-starts-with-a-total-
vision
Managed-Healthcare-Executive
10
hospital
00
10
0
News
National
Various
Equilibrium
"A-healthcare-organization-has-to-begin-the-process-by-overhauling-its-clinical-vision.-…-'If-they-can-
articulate-where-they-want-their-clinical-delivery-systems-to-be-in-three,-five-or-10-years,-they-can-
begin-to-work-on-a-strategy-and-tactical-plan-to-get-there'"-pg-54
127
2004E2Health-Revives-Health2Care-IT
Inform
ationweek
10
Hospital
00
10
0
news
National
Various
Equilibrium
Increasing-spending-is-im
portant-to-HIT-success.--"Overall,-IT-spending-among-Inform
ation-W
eek-500-
health2care-companies-is,-on-average,-3%-of-their-worldwide-annual-revenue-on-IT,-down-slightly-
from-3.3%-last-year."-pg-102
128
2004FEDS-TARGET-HEALTH2CARE-I.T
Inform
ationweek
10
National
00
00
0News
Naitonal
Various
Revolution
Feds-are-putting-focus-on-HIT.
130
2004Transform
-workflow-through-selective-
implementation
Nursing-M
anagement
10
Hospital
00
10
0News
national
CPOE
Equilibrium
Summarizes-benefits-of-CPOE.--Little-detail
136
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
197
2004Medical-Ghost-in-the-E2Health-M
achine,-A
Health-M
atrix
41
National
11
01
0
Opinion
National
eHealth
Deep-Structure
"the-histpry-of-e2health-illustrates-the-way-that-healthcare-in-the-United-States-has-devalued-patient-
expectations-and-access-to-care-whiloe-over2investing-in-processes-and-technologies-that-serve-the-
few."-pg-225
"In-contrast,-companies-outside-of-the-health-sector-have-ore-readily-invested-in-Inform
ation-
Technologies-(IT)-and-e2commerce-applications-that-tent-to-increase-access,-im
porove-service-and-
reducde-costs-to-consumers."-pg-227
This-has-not-been-seen-in-health-care.--Dollars-going-to-technology-for-treatm
ent-that-is-not-evenly-
distributed.
201
2004Show-them-the-m
oney.-Healthcare-providers-say-it-
will-take-m
ore-than-vision-to-turn-the-government's-
health-IT-plans-into-reality
Modern-Healthcare
41
General
01
01
0
Opinion
National
Various
Revolution
"Noting-that-payors-are-the-likely-beneficiary-of-the-bulk-of-an-estim
ated-$100-billion-in-annual-
savings-from-clinical-IT-if-universaly-adopted,-he-recommended-that-Brailer-"m
ake-the-case-for-strong-
financial-incentives-from-payers-to-physician-practices""
201
2004Show-them-the-m
oney.-Healthcare-providers-say-it-
will-take-m
ore-than-vision-to-turn-the-government's-
health-IT-plans-into-reality
Modern-Healthcare
41
General
01
01
0
Opinion
National
Various
Revolution
"Physician-practices-will-adopt-inform
ation-technology-only-if-they-can-afford-the-significant-cost-of-
new-hardware-and-software-for-electronic-capture-and-storage-of-patient2care"-
"There's-an-economically-rational-behaviour-going-on-and-we-have-to-fix-it,-he-said-They're-not-given-
an-incentive-to-buy-IT-because-they-don't-get-the-benefits."
1002
2004CHT-Inititative-Pushes-for-Stronger-Systems
Health-M
anagement-Technology
10
National
00
01
0News
National
Various
Revolution
CHT-2-Center-for-Health-Transform
ation-introduced-new-intitiatve-to-m
ake-improvements-in-health
85
2005Way-to-go-live:-a-framework-for-new-IT-
implementation
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
21
01
10
1
Opinion
National
Various
Equilibrium
5-step-process-for-im
plementing-new-technologies-2Develop-a-plan-2-Chose-the-vendor-2-negotiate-
contract-term
s-2-appoint-a-project-m
anager-2-Monitor-ongoing-progress-2im
plement-product-2-
Monitor-results-2-Contend-with-Disputes.
86
2005Factors-and-forces-affecting-EHR-system-adoption:-
report-of-a-2004-ACMI-discussion
Journal-of-the-American-M
edical-
Inform
atics-Association
51
01
10
0
Opinion
National
EHR,-CPOE
Deep-Structure
"One-large-difference-betw
een-inpatient-EHRs-with-CPOE-and-ambulatory-EHRs-is-that-there-is-
considerable-international-experience-with-ambulatory-EHRs-from-which-those-in-the-United-States-
can-learn-a-significant-amount."-pg-8
87
2005Adding-insight:-a-qualitative-cross2site-study-of-
physician-order-entry
International-Journal-of-Medical-
Inform
atics
35
Hospital
01
10
0
Case-Study-2-
Structured-
analysis
Virginia,-
Seattle,-
California
CPOE
Equilibrium
Physicians-were-"proud-of-being-facile-with-CPOE-and-appreciated-the-decision-support-it-offered,-
but-were-resentful-of-the-additional-time-it-took."-pg-626
"Clinicians-often-believe-that-CPOE-is-more-advantageous-to-the-hospital-administrators-than-it-is-to-
them."-pg-626
"successful-im
plementation-…-depends-less-on-m
andating-use-…-and-m
ore-on-the-existence-and-
development-of-an-organizational-culture-of-collaboration-and-trust.-Pg-626
88
2005Active-error-management:-use-of-a-W
eb2based-
reporting-system-to-support-patient-safety-
initiatives
Journal-of-nursing-administration
22
Hospital
00
10
0
Case-Study
New-
Hampshire
Error-Reporting
Equilibrium
Article-discusses-many-of-the-benefits-of-a-web-based-error-reporting-system.--Implementation-issues-
were-focused-on-education-inlcuding-train-the-trainer-and-the-devleopment-of-"super"-users-to-
provide-readily-available-staff-during-implementation-to-answ
er-questions.
89
2005Rapid-implementation-of-an-electronic-health-record-
in-an-academic-setting
Journal-of-Healthcare-Inform
ation-
Management
12
medical-practice
01
00
0
Case-Study
Washington
,-DC
EHR
Equilibrium
Basic-discussion-of-steps-taken-to-implement-EHR-at-a-large-physician-practice.--Focus-on-workflow,-
workflow,-workflow.
Unique-training-m
odel,-with-open-training-during-12-hours-of-each-workday.
90
2005Quality-as-a-passion
Health-M
anagement-Technology
31
10
00
0
Opinion
Various
Equilibrium
Article-discusses-CIGNA's-approach-to-influencing-individual-health.--"CIGNA's-approach-is-to-m
eet-
the-inform
ational-needs-of-the-consumer."-pg-41--
Offer-health-risk-assessment-tools-to-healthy-members.
91
2005High-and-rising-health-care-costs.-Part-2:-technologic-
innovation
Annals-of-internal-medicine
41
heaqlth-System
00
01
0
Opinion
National
Various
Deep-Structure
"Acceptance-of-new-technologies-by-the-m
edical-profession-is-a-m
ajor-determ
inant-of-their-rate-of-
diffusion.-Physicians-in-the-United-States-expand-the-number-of-patients-deemed-eligible-for-new-
procedures-more-rapidly-than-do-physicians-in-other-nations,-in-part-because-the-fee2forservice-
paym
ents-m
ade-to-physicians-and-hospitals-that-use-new-diagnostic-and-therapeutic-procedures-are-
relatively-generous"-pg-933
94
2005Making-a-commitment-to-IT
Trustee
31
hospital
01
10
0
opinion
National
VARIOUS
Deep-Structure
Hospital-trustees-play-a-key-role-in-IT-projects.--IT-M
UST-solve-a-business-problem.--Suggest-the-
devleopment-of-a-"Social-Contract"-betw
een-hospital-and-physician.--Pg-324
need-to-define-roles-and-responsibilities-of-all-parties.
99
2005The-evolving-role-of-supply-chain-m
anagement-
technology-in-healthcare
Journal-of-healthcare-inform
ation-
management:-JHIM
21
hospital
00
00
0
Opinion
National
Supply-Chain-
Management
Equilibrium
Model-of-"evolution"-of-supply-chain-systems.--Incremental-evolution-over-three-phases.
Budetary-constrains-have-left-supply-chain-m
anagement-on-the-fringes-of-hospital-IT-budgets.
100
2005Uncle-Sam-wants-your-EHR
Hospitals-&-Health-Netw
orks
21
00
00
0Opinion
National
EHR
Revolution
Healthcare-implementation-is-more-complex-than-Apollo-m
oon-m
ission-which-had-the-same-10-year-
time-frame.--Unlikely-to-get-done-in-10-years.
137
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
102
2005What-works.(Alm
ost)-im
mediate-gratification.-
WellStar-Physicians-Group
Health-M
anagement-Technology
12
Medical-Group
01
00
0
Case-Study
Georgia
Claim
s-Paym
ent/Billing
Equilibrium
Basic-discussion-of-im
plementation-strategy-for-claim
s-system.--Need-to-support-business-case-of-
quick-claim
s-turnaround,-increase-clean-claim
-percentage-and-improve-customer-suport.--(Customer-
is-physician-in-this-case).
104
2005A-review-and-a-framework-of-handheld-computer-
adoption-in-healthcare
International-Journal-of-Medical-
Inform
atics
24
Various
01
00
0
literature-review
National
Mobile-health
Deep-Structure
Cost-is-potential-barrier,-but-literature-indicates-savings-from-such-technologies.--O
ther-barriers-
identified,-were-small-size-of-screen,-potential-to-break-device-and-W
ORKFLO
W-changes.
Education,-time-saving,-clinical-im
pact-are-all-positives-for-technology-use.
105
2005Returns,-not-burns:-how-to-ensure-successful-health-
IT-investments
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
31
00
10
0
Opinion
Various
Equilibrium
While-its-easy-to-m
easure-fnancial-im
pact-of-staffing,-HIT-improvements-focusing-on-"im
proving-
quality-and-patient-safety-2-an-imporant,-but-even-m
ore-difficult-return-to-m
easure."--pg-51-(see-
good-long-example-here)
2-Define-specifically-what-you-expect-fro-HIT
2-Evaluate-retrns-using-the-m
ost-appropriate-m
etrics
2-Retrospectively-review-your-original-investment.
106
2005Accelerating-US-EHR-adoption:-How-to-get-there-
from-here.-Recommendations-based-on-the-2004-
ACMI-retreat
Journal-of-the-American-M
edical-
Inform
atics-Association
51
01
11
1
Opinion
National
EHR
Deep-Structure
"Reasons-for-the-slow-adoption-of-healthcare-inform
ation-technology-include-a-m
isalignment-of-
incentives,-lim
ited-purchasing-power-among-providers,-variability-in-the-viability-of-EHR-products-and-
companies,-and-lim
ited-demonstrated-value-of-EHRs-in-practice"-pg-13
"little-work-has-been-done-that-demonstrates-the-impact-of-health-care-inform
ation-technology-on-
economic-outcomes"-pg-13--
"The-economic-analysis-suggests-that-the-benefits-of-HIT-do-not-accrue-to-those-who-m
ust-invest-in-
these-technologies.-For-example,-many-of-the-patient-safety-and-quality-effects-of-EHRs-accrue-
benefit-to-the-payer-or-employer–purchaser-of-health-care-services-who-is-at-greater-risk-for-a-
patient's-total-health-care-costs-given-decreasing-rates-of-provider-reim
bursement-under-capitation"-
pg-14
At-the-local-level,-however,-currently-there-is-no-financial-reward-for-im
proved-clinical-inform
ation-
exchange-among-health-care-entities-that-regularly-act-as-business-partners-providing-care-to-a-
common-set-of-patients—providers-are-not-reim
bursed-for-electronic-inform
ation-exchange."-pg-14
106
2005Accelerating-US-EHR-adoption:-How-to-get-there-
from-here.-Recommendations-based-on-the-2004-
ACMI-retreat
Journal-of-the-American-M
edical-
Inform
atics-Association
51
01
11
0
Opinion
National
EHR
Revolution
Table-1-pg-15-provides-a-laundry-list-of-actions/policies-to-encourage-EHR-adoption.
2Expand-the-HIT-Research-Agenda
2Financial-Incentives-to-Stimulate-EHR-M
arketplace
2HIT-Standard-Setting
2Enabling-Policy
2Educational,-M
arketing-and-Supporting-Activities
108
2005Factors-related-to-physicians´-adoption-of-electronic-
prescribing:-results-from-a-national-survey
American-Journal-of-Medical-Quality
33
Outpatient
01
00
0
Survey
National
Electronic-Prescribing
Equilibrium
"Electronic-prescribers-were-m
ore-likely-to-reside-in-southern-and-western-regions-of-the-United-
States,-whereas-traditional-prescribers-tended-to-reside-in-northern-and-eastern-regions-(P-=-
.0135).Electronic-prescribers-were-significantlym
ore-likely-to-be-general-practitioners-versus-
specialists-(P-=-.0031)-and-working-within-academic-m
edical-establishments-or-publicly-funded-health-
centers-or-clinics-versus-private-practice-(P-<-.0001).-Electronic-prescribers-were-also-younger-than-
their-traditional-prescriber-counterparts-(P-=-.0063)-and-correspondingly-had-fewer-years-of-
experience-in-m
edical-practice-(P-=-.0063)."-pg-25
Barriers-to-adoption-included-Themost-commonly-reported-barriers-across-both-physician-groups-
were-system-costs,-tim
e-required-to-install-E2RX-and-change-prescribing-behavior,-and-uncertainty-
about-which-local-pharm
acies-accept-electronic-prescriptions.-Less-than-half-of-all-physicians-agreed-
that-patient-confidentiality-concerns-and-the-tim
e-required-to-correct-prescriptions-were-barriers-to-
E2RX-adoption-(34.6%-and-32.8%,-respectively).-Pg-27
Of-note-is-the-fact-that-few-saw-confidentiality-as-an-issue-to-adoption.
138
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
109
2005The-Kaiser-Perm
anente-IT-transform
ation
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
32
IDS-2-integrated-delivery-
system
00
10
0
Case-Study
Western-USVarious
Equilibrium
Must-have-a-well-defined-business-case-for-im
plementation.--In-this-case,-the-business-case-was-easy-
as-it-represented-an-IDS-which-gains-significant-benefits-from-HIT.
"Most-system-benefits-are-back-loaded-while-costs-are-front-loaded.--Some-benefits-are-not-expected-
to-accrue-for-mnths-or-even-years."-pg-64
110
2005Economic-evaluation-of-medical-technologies
Israel-Medical-Association-Journal:-Imaj
21
01
10
1
Opinion
National
VARIOUS
Revolution
Discusses-widening-gap-of-supply-and-demand-in-m
edical-technologies.--Increasing-demand,-but-not-
an-equally-matching-increase-in-supply.--Authors-describe-this-as-a-"market-failure".--The-purchase-of-
technology-is-"not-fully-made-by-the-consumer-or-the-physician,-but-rather-by-a-separate-entity.--This-
lack-of-direct-accountablility-allows-for-over2consumption-or-possibily-even-inapppropriate-use-of-
healthcare-resources-and-m
edical-technologies."-pg-68
Authors-discuss-four-methodologies-for-evaluating-the-cost2effectiveness-of-medical-technoloies.
1-2-cost2effectiveness,-2-2-cost2m
nim
umization,-32Cost2utility,-and-4-cost-benefit.--Table-pg-69
112
2005Making-Sausage22Effective-M
anagement-of-
Enterprise2w
ide-Clinical-IT-Projects
Journal-of-Healthcare-Inform
ation-
Management
32
hospital
00
10
0
Case-Study
Alabama
Various
Equilibrium
Discuss-need-to-m
anage-HIT-projects-differently-based-on-uniqueness-of-healthcare-m
arket-2-namely-
that-the-workers-are-not-employees.--
Emphasis-on-Business-Case-and-Vision-which-can-be-used-to-validate-activities-along-the-way-
including-the-alignment-of-vendor-to-vision.
Measure-m
easure-m
easure.-22-importance-of-identifying-appropriate-m
easures-at-the-beginning-of-
project-so-successs-can-be-m
easured-and-communicated.
115
2005Factors-influencing-health-inform
ation-system-
adoption-in-American-hospitals
Health-Care-M
anagement-Review
54
Hospital
00
10
0
Cross-sectional-
Study
National
Various
Deep-Structure
Authors-propose-6-hypothesis-for-factors-effecting-HIT-adoption.--Factors-are-categorized-into-
Market,-Organizational-and-Financial.
Of-the-six-hypotheses-only-4-were-supported:
Hospital-Size-is-positively-related-to-HIS-adoption;-hospital-processing-needs-are-positively-associated-
with-HIS-adoption;-hospitals-in-strategic-alliances-positively-associated-with-HIS-adoption;-Operating-
revenue-was-positively-associated-with-HIS-adoption.
116
2005Five-steps-to-electronic-health-record-success
Healthcare-Financial-Management
21
Various
00
10
0
Opinion
National
EHR
Equilibrium
"When-healthcare-leaders-look-at-an-electronic-health-record,-they-must-resist-the-tempatation-to-
view-it-as-an-entity-unto-itself.--Instead,-it-is-im
portant-to-take-a-m
ore-organic-view-and-consider-how-
the-record-will-Integrate-with-existing-business-processes."-pg-57
134
2005HIT-and-M
IS:-IM
PLICATIONS-OF-HEALTH-
INFORMATION-TECHNOLO
GY-AND-M
EDICAL-
INFORMATION-SYSTEMS
Communications-of-the-ACM
41
national-system
00
01
0
Opinion
national
Various
Revolution
Challenges-to-HIT-adoption-inlcue-22-Complexity-of-health-care-enterprise;-magnatide-of-investment-
and-who-should-m
ake-it-"there-is-a-lack-of-a-clear2cut-business-case"-pg-72
Lack-of-evidence-for-benefit-of-HIT-in-either-savings-or-quality
"The-introduction-of-new-technology-increases-the-potential-for-error"-pg-73
"Commoditization-of-health-practices-due-to-the-distillation-of-scientific-evidence,-search-for-the-best-
practices,-their-dissemination-in-decision2support-technologyu-,and-the-use-of-EHRs-to-m
onitor-
perform
ance-(and-fear-of-litigation-from-deviating-from-accepted-care-prossess).-Pg-74
135
2005Transform
ing-Care:-Medical-Practice-Design-And-
Inform
ation-Technology
Health-Affairs
41
11
00
0
Opinion
Oregon
Various
Deep-Structure
the-process-and-reim
bursment-of-care-remains-unchanged-resulting-in-the-ineffectiveness-of-HIT.
"Over-the-past-fifty-years,-while-the-environment-of-care-has-changed-dramatically-with-the-
development-of-new-clinical-knowledge,-diagnostic-and-treatm
ent-technologies,-and-
pharm
aceuticals,-the-clinical-office-has-been-remarkably-stable-in-structure-and-function.-The-
physical-layout,-the-exam-room,-the-scheduling-system,-and-visits-as-the-m
echanism-of-care-are-all-
virtually-unchanged.-"-pg-1296
"A-critical-barrier-to-m
oving-toward-nonvisit-care-is-that-medical-practices-use-their-scheduling-
system-as-a-follow2up-system.-They-instruct-patients-to-schedule-return-visits-largely-because-visits-
are-the-only-way-practices-are-aware-of-their-patients."--pg-1298
136
2005Achieving-the-Vision-of-EHR-22-Take-the-Long-View
Frontiers-of-Health-Services-Management
41
national
01
11
0
Opinion
national
Various
Revolution
Adoption-is-im
plied-as-incremental-and-requires-the-inclusion-of-the-patient-22-"Nelson-would-suggest-
that-change-m
anagement-necessarily-implies-an-incremental-approach-to-technology-adoption-and-
process-redesign.-Finally,-Nelson-points-out-that-the-patient-connection-is-critical-not-only-for-IT-
adoption-but-ultim
ately-for-the-care-redesign-process-as-well."-pg-33
139
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
137
2005Achieving-U.S.-Health-Inform
ation-Technology-
Adoption:-The-Need-For-A-Third-Hand
Health-Affairs
51
00
01
0
Opinion
National
Various
Revolution
comments-and-builds-on-kleinke-article.--Supports-premise-of-broken-system-and-suggests-additional-
reasons-for-market-failure.--The-author-sugggests-three-issues-to-guide-"The-Third-hand-of-the-US-
federal-government-and-successfully-stim
ulate-HIT-adoption"-pg-1271.--1)-The-lack-of-a-health-care-
business-m
odel,-2)-RHIO-Organziation-Issues,-and-3)-Appropriate-federal-actions-which-refers-to-
considering-the-feds-as-the-business-owner-from-a-m
acro-persective.
Healthcare-is-a-"significant-public-good"--pg-1272.
139
2005Transform
ing-the-Health-System-from-the-Inside-OutFrontiers-of-Health-Services-Management
31
00
00
0
Opinion
National
Various
Revolution
provides-a-prediction-of-what-transform
ation-will-result-in.--States-that-transform
ation-will-occur-
over-10220-years.--This-is-not-in-line-with-the-punctuated-equilibrium-m
odel-of-transform
aiton.--
Envision-a-M
ORE-decentralized-landscape-of-medical-providers-with-greater-specialization.--
"Economic-and-Quality-of-care-dmeans-will-bring-a-health-delivery-land2scape-of-desease2-and-
condition2oriented-centers-organized-to-treat-specific-patient-needs.--Complrehensive-disease-
centers-will-be-organized-along-specialized-treatm
ent-needs-such-as-birthin-and-pediatrics,-urgent-
care,-diagnostic-cengers…"--pg-6
140
2005The-M
issing-Link:-Bridging-The-Patient2-Provider-
Health-Inform
ation-Gap
Health-Affairs
51
10
00
0
Opinion
national
PHR
Revolution
"The-m
ere-instalation-of-EHRs22even-with-comprehensive-interoperability22w
ill-not-sufficiently-
engage-patients-in-the-health-system."-pg-1290
"Even-in-a-digital-inform
ation-envoironment,-these-"design-rules"-[IOM-vision-of-HIT]-can-be-realized-
only-if-the-patient-is-a-full-inform
ation-partner-with-the-health-care-professional-and-institution."-pg-
1291
142
2005Promoting-Health-Inform
ation-Technology:-Is-There-
A-Case-For-More2Aggressive-Government-Action?
Health-Affairs
42
National
01
01
0
Policy-analysis
National
Various
Revolution
Arguments-for-government-invovlement-include:
"The-development-of-standard2based-netw
orks-of-interoperable-EMR-systems-cannot-be-left-to-
providers-alone;-they-lack-the-capacity-and-the-ability-to-appropriate-the-return-on-investment-in-
such-activities,-despite-the-broader-social-usefulness-of-such-activities."-pg-1238
Deepening-financial-crisis-in-healthcare
"As-the-custodian-of-the-public’s-health-and-the-largest-employer-and-health-care-payer-in-the-
country,-the-federal-government-has-a-direct-financial-and-fiduciary-interest-in-acting-to-improve-
health-care-quality,-efficiency,-and-equity.-"-pg-1238
142
2005Promoting-Health-Inform
ation-Technology:-Is-There-
A-Case-For-More2Aggressive-Government-Action?
Health-Affairs
42
National
00
01
0
Policy-analysis
National
Various
Equilibrium
"Three-key-elements-m
ust-be-in-place-to-enable-these-gains:-widespread-provider-adoption-of-
standard2based-EMR-systems,-improved-connectivity-among-providers-and-with-patients,-and-a-
strong-focus-on-improving-quality-and-efficiency-perform
ance.-Here-we-review-the-status-quo-for-
these-key-elements.-"-p-1236
261
2005The-impact-on-patient-safety-of-free2text-entry-of-
nursing-orders-into-an-electronic-m
edical-record-in-
an-integrated-delivery-system
American-M
edical-Inform
atics-Association
23
hospital
00
00
0
observational
Illinois
Nusing-Order-Entry
Equilibrium
Abstract-discsses-missuse-of-a-nurse-order-entry-system-which-evolved-to-a-m
edication-order-sytem-
by-nurses-sending-requests-for-medication-to-doctors-using-the-nusing-system.
Individuals-will-find-a-way-to-use-the-system-to-their-own-personal-efficiency,-sometimes-not-as-it-
was-intented.--This-results-in-broken-audit-checks-and-m
ultiple-processes.
262
2005Building-a-results-review-system:-a-critical-first-step-
in-transitioning-from-paper-medical-records
American-M
edical-Inform
atics-Association
33
hospital
01
10
0
Pre2Post-
implementation-
survey
Louisiana
Various
Equilibrium
system-design-and-ease-of-use-critical-to-acceptance-of-HIT.
264
2005An-electronic-health-record2public-health-(EHR2PH)-
system-prototype-for-interoperability-in-21st-
century-healthcare-systems
American-M
edical-Inform
atics-Association
32
Public-health
00
01
0
Case-Study
Unknown
HIE
Equilibrium
Standards-needed-for-IT-adoption-and-implementation:--"tw
o-thirds-of-time-building-the-prototype-
was-spent-on-m
apping-and-integrating-data-from-the-"siloed"-data-sources."-pg-578
265
2005Managing-the-alert-process-at-NewYork2
Presbyterian-Hospital
American-M
edical-Inform
atics-Association
22
hospital
00
10
0Case-study
New-York
CDSS
Equilibrium
Over-time,-incremental-changes-to-a-system-can-result-in-an-unweildy-set-of-rules-and-coding-that-
become-difficult-to-m
anage.
266
2005Human-and-system-errors,-using-adaptive-
turnaround-documents-to-capture-data-in-a-busy-
practice
American-M
edical-Inform
atics-Association
32
01
00
0
Case-Study
Deep-Structure
Ressearch-evaluated-the-implementation-of-a-scannable-form
-for-patient-inform
ation-entry-into-an-
electronic-patient-record.--This-was-done-to-m
inim
ize-the-workflow-disruption-caused-by-EHRs-and-
other-systems.--The-results-showed-a-high-level-of-error-7%-which-m
ay-have-been-exasperated-by-
human-intervention.
267
2005Physician-use-of-electronic-m
edical-records:-issues-
and-successes-with-direct-data-entry-and-physician-
productivity
American-M
edical-Inform
atics-Association
33
medical-system
00
00
0
Observational
Utah
EHR
Equilibrium
Outline-barriers/impedim
ents-to-system-use-and-implementation.--Impedim
ents-include:--Set2up-and-
trainning,-productivity/efficiency-concerns,-Connections-to-external-data-sources,-privacy,-system-
perform
ance.
Authors-note-that-"average-productivity-at-6-m
onths-post2implementation-was-not-significantly-
different-than-pre2implementation-levels."-pg-144
140
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
269
2005Connecting-the-providers-in-your-healthcare-
community:-one-step-at-a-tim
e
Frontiers-of-Health-Services-Management
31
01
00
0
opinion
national
various
Equilibrium
Discuss-the-need-for-an-incremental-approach-to-technology-im
plementation.--Does-not-support-PE-
model-of-transform
ation.--Barriers-to-transform
ation-include-cost,-clinitian-support,-insufficient-time,-
and-lack-of-ROI.
Requires-significant-change-in-workflows.
272
2005'Tablet'-m
akes-for-good-m
edicine.-Case-study:-tablet2
style-computers-can-enhance-physician-satisfaction,-
revenue-stream
MGMA-connexion/M
edical-group-
Management-Association
12
medical-group
00
00
0
case-study
Kansas
Billing/Coding
Equilibrium
Shows-benefits-of-integration-and-innovation-(tablet)-taking-place-at-a-small-practice.--Focus-though-
is-on-billing-with-obvious-financial-benefits-to-practice.
273
2005Research-opportunities-and-challenges-in-2005
Methods-of-inform
ation-in-m
edicine
31
10
00
0
Opinion
National
EHR
Deep-Structure
"The-so2called-"trip-wire"-in-the-US-that-so-far-has-prevented-this-development-is-the-widespread-
fear-of-a-national-identification-system."-pg-483.
Legal-and-privacy-and-security-are-a-huge-barrier-to-EHR.
277
2005Leading-the-Charge
Hospitals-&-health-netw
orks/AHA
31
health-system
00
11
0
Opinion
DoD
EHR
Equilibrium
Discusses-success-of-DoD-EHR-system.--Provides-support-for-clear-benefits-of-vertical-integration-and-
HIT.--If-you-own-hospitals,-doctors-and-in-this-case-patients,-no-issue-form
ing-a-business-case.--DoD-
also-does-not-have-to-m
ake-a-traditional-business-case-and-arguments-around-quality-and-other-
reasons-are-easer-justifications.
278
2005Action-through-collaboration:-a-conversation-with-
David-Brailer.-Interview-by-Robert-Cunningham
Health-affairs-(Project-Hope)
41
10
00
0Interview
National
Various
Revolution
278
2005Action-through-collaboration:-a-conversation-with-
David-Brailer.-Interview-by-Robert-Cunningham
Health-affairs-(Project-Hope)
41
01
00
0
Interview
National
Various
Revolution
"My-intent-was-to-spend-m
ost-of-my-time-focusing-on-demand2side-solutions:-how-to-get-doctors-to-
want-to-put-these-tools-in-place,-how-to-get-hospitals-to-put-them-in-place,-how-to-get-consumers-to-
start-using-health-inform
ation."-pg-1150
"Everyone-recognizes-that-the-Stark-and-antikickback-laws-are-critical-to-protecting-American-
consumers.-On-the-other-hand,-they-can’t-be-so-stringent-that-they-prevent-health-IT-from-being-put-
in-place,-which-itself-is-beneficial-to-consumers.-"-pg-1155
empahsizes-paym
ent-systems-as-an-issue-again
""Providers-lose-m
oney-when-they-put-in-health-IT,-because-we-have-obsolete-paym
ent-policies-that-
still-reward-volume-over-quality.-"-pg-1154
"We-didn’t-call-for-regional-inform
ation-netw
orks.-W
e-called-for-regional-organizations-to-bring-the-
stakeholders-together-but-called-for-a-national-architecture—national-netw
orks.-"-pg-1153
Call-for-standards-as-a-key-to-success.--Notes-that-the-M
MA-(medicare-drugs)-created-the-demand-for-
a-e2prescripbing-standard.--BUT-he-feels-that-"To-m
andate-standards-or-certain-technology-adoptions-
in-the-industry-would-be-disastrous,-I-think.-"-pf-1152
283
2005Competition-and-new-technology
Health-Affairs
51
11
10
0
Opinion
national
various
Deep-Structure
Discusses-the-economic-realities-that-im
pact-adoption-and-spending-on-new-technologies-in-
healthcare.--Several-relevant-quotes.--"We-should-want-all-of-the-new-technology-added-every-year-
that-is-worth-m
ore-than-its-cost-and-no-technology-added-that-is-worth-less-than-its-cost,-no-m
atter-
how-m
uch-good-it-does.-"-pg-1525
"Many-of-the-m
ore-effective-new-technologies-are-long2run-preventive-in-nature:-For-example,-
cholesterol2lowering-drugs-taken-today-im
prove-future-cardiovascular-health,-sm
oking2cessation-
programs-reduce-future-chronic-conditions,-and-even-disease-m
anagement-programs-usually-do-not-
generate-their-full-benefits-immediately…-W
hat-plans-will-lose-is-any-future-cost-savings-associated-
with-prevention;-the-consumer-keeps-the-improved-future-health.--Pg-1529
286
2005The-patient-safety-institute-demonstration-project:-a-
model-for-im
plementing-a-local-health-inform
ation-
infrastructure
Journal-of-healthcare-inform
ation-
management:-JHIM
32
hopsital-group
00
10
0
Case-Study
Washington-
(WA)
HIE
Equilibrium
"PSI-was-form
ed-to-empower-both-patients-and-physicians-by-providing-real2time-access-to-
requested-patientcentric-clinical-inform
ation-at-the-point-of-care-over-a-secure,-private,-
communications-netw
ork.-PSI-was-form
ed-with-a-sim
ilar-philosophy-and-approach-as-VISA-to-enable-
the-international-credit-card,-ATM,-and-retail-point2ofpurchase-cashless-banking-revolution-by-
providing-real2time-access-to-requested-financial-inform
ation-over-a-secure,-private,-open-
architecture-communications-netw
ork"-pg-77
Discusses-a-"distributed-clinical-database"-vs.-a-central-repository-m
odel-of-building-a-secure-HIE.--
Looks-a-lot-like-the-federated-m
odels-of-today.
141
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
287
2005Environments-for-innovation-in-healthcare-
inform
ation-technology
Journal-of-Healthcare-Inform
ation-
Management
31
00
10
0
opinion
national
various
Deep-Structure
Lack-of-suitable-environments-in-which-to-conduct-HIT-innovative-research.--Organizations-are-
reluctant-to-puchase-"bleeding-edge"-but-rather-look-for-proven-technologies.--This-m
ay-have-the-
result-of-stifling-innovation.
"By-and-large,-they-are-not-looking-for-“bleeding-edge”-ideas-but-for-proven-workhorses.-This-is-a-
sensible-strategy,-but-it-m
ay-have-the-negative-long2term
-effect-of-inhibiting-revolutionary-
improvements-in-healthcare-IT."-pg-66
Even-large-academic-centers-such-as-columbia-univ-are-m
oving-away-from-home2grw
on-systems-that-
can-foster-innovation-to-m
ore-safe-commercial-systems.
Regardless-of-the-domain,-innovative-ideas-are-often-m
et-with-resistance,-and-healthcare-is-no-
exception.-Because-m
ost-EPR-systems-now-are-developed-by-vendors-rather-than-in2house,-there-is-
little-incentive-for-innovation-that-is-too-far-“out-there,”-because-it-may-fail-to-find-a-m
arket.-So-even-
if-people-have-innovative-ideas-about-how-to-build-a-better-EPR,-they-probably-will-never-make-their-
way-into-a-real2world-system.-Pg-67
"To-promote-revolutionary-healthcare-IT,-new-environments-are-needed-where-innovation-could-
flourish"-pg-67
288
2005Inform
ation-technology:-changing-nursing-processes-
at-the-point2of2care
Nursing-Administration-Quarterly
22
telehealth
00
10
0
case-study
unknown
telehomecare
Deep-Structure
Nursing-is-an-important-stakeholder-to-include-when-implementing-technology.--A
rticle-list-several-
adoption-barriers-and-categorizes-them-by:--situational,-cognitive-or-physical,-legal-and-attitudinal-
barriers.
291
2005Emerging-benefits-of-integrated-IT-systems
Healthcare-executive
21
hospital
00
10
0
opinion
national
various
Equilibrium
Article-emphasizes-the-need-for-a-clear-Return-on-Invesm
tenet-(ROI)-which-is-not-realized-at-most-
hospitals.
Clear-benefits-notes-of-HIT-do-not-involve-patient-care-22-Asset-tracking-throiugh-RFIID-and-bedisde-
laboratory-m
anagement-and-wireless-platgform
s.
292
2005The-transform
ational-power-of-IT:-Experience-from-
patient-safety-leaders
Healthcare-executive
22
hostpial
01
00
0
Case-Study
maine
Various
Equilibrium
highhlights-m
any-of-the-same-issues-raised-by-other-institutions-im
plementing-technology:
Bwe-flexible-2-there-will-be-glitches,-Invest-in-users-including-the-use-of-"super2users",-Gather-and-
recognize-clinician-input.
293
2005Making-the-healthcare-system-safer-with-innovation-
and-technology
Quality-Letter-for-Healthcare-Leaders
31
Ambulatory/O
utpatient
10
00
0
Opinion
national
VARIOUS
Deep-Structure
Good-quote-from-david-Brailer-""[But]-how-do-we-m
ake-the-iunform
ation-change-the-way-consumers-
engage-in-healthcare22to-know-about-their-health-status,-to-know-about-their-optoins,-to-start-
looking-out-for-their-own-treatm
ent-chaoices,-to-be-able-to-begin-m
anaging-theor-own-care-in-a-way-
that-is-sim
ilar-to-how-we-m
anage-other-ghings-in-out-daily-lives."-pg-2
293
2005Making-the-healthcare-system-safer-with-innovation-
and-technology
Quality-Letter-for-Healthcare-Leaders
31
Ambulatory/O
utpatient
01
00
0Opinion
national
VARIOUS
Deep-Structure
294
2005The-adoption-gap:-health-inform
ation-technology-in-
small-physician-practices
Health-Affairs
31
group-practice
00
00
0
Opinion
national
EHR
Deep-Structure
Emphasize-the-need-to-view-IT-as-transform
ative-and-not-the-automation-of-technology.--"Some-
panelists-were-particularly-concerned-about-the-widespread-perception-that-IT-integration-is-merely-
a-m
atter-of-automating-current-practices.-"-pg-1365
295
2005Medical-groups'-adoption-of-electronic-health-
records-and-inform
ation-systems
Health-Affairs
33
Outpatient
01
00
0
Survey
National
EHR
Deep-Structure
Barriers-to-EHR-adoption-within-small-to-large-group-practices-include:
Cost,-im
plementation-difficulties-and-lack-of-support-from-physicians.
298
2005Functional-gaps-in-attaining-a-national-health-
inform
ation-netw
ork
Health-Affairs
41
01
11
0
Opinion
national
NHIN
Deep-Structure
Emphasizes-the-need-for-standards-to-stimulate-the-growth-of-an-NHIN.--Cites-example-of-HIPAA-
standards-in-the-high-rate-of-electronic-claim
s-and-eligibility-queries.
Excludes-patient-perspective-from-stakeholders.
299
2005Achieving-US-health-inform
ation-technology-
adoption:-the-need-for-a-third-hand
Health-Affairs
51
00
01
0
opinion
national
Various
Deep-Structure
Desribes-both-barriers-to-change-in-term
s-of-a-Broken-HIT-m
arket.--D
iscusses-the-"asymmetrical-risk-
and-reward-among-those-who-are-footing-the-bill-for-HIT-and-those-who-reap-the-lion's-share-of-the-
benefit.-…-we-found-that-while-provider-groups-are-footing-the-bill-for-HIT,-they-may-experience-only-
11-percent-of-the-net-potential-gain"-pg-1270
"there-is-no-direct-reward-to-providers-who-actually-take-the-trouble-to-do-clinical-inform
ation-
exchange….-This-is-simpley-not-the-standard-of-care."-pg-1271-either-electronically-or-on-paper.
Insurers-"fact-an-unresolvable-conflict:--W
hose-value-function-do-thay-maximize?"-pg-1270
142
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
300
2005Federal-investment-in-health-inform
ation-
technology:-how-to-m
otivate-it?
Health-Affairs
53
00
01
0
Opinion
national
Various
Revolution
Uses-comparisons-to-other-industries-and-the-gains-from-technology-experienced-in-those-industries.--
Other-markets-experience-an-8217-percent-increase-in-productivity-from-IT-versus-a-5%-or-lower-rate-
for-HIT.
Suggests-government-build-the-infrastructure-sim
ilar-to-highway-system.--Cost-of-highways-was-1%-of-
GDP-which-equates-to-$110-m
illion-based-on-current-GDP.
Politics-represent-a-huge-hinderance-to-such-actions.
301
2005Dot2gov:-m
arket-failure-and-the-creation-of-a-
national-health-inform
ation-technology-system
Health-Affairs
53
01
11
1Opinion
National
VARIOUS
Deep-Structure
Article-spells-out-extremely-well-the-controls-and-structure-of-the-healthcare-system-that-result-in-
the-lack-of-HIT-adoption-and-use-by-physicians,-hospitals,-insurers-and-others.
303
2005Strategic-action-in-health-inform
ation-technology:-
why-the-obvious-has-taken-so-long
Health-Affairs
31
01
01
0
Opinion
National
Various
Deep-Structure
Fragmentation-in-the-US-Healthcare-system-has-resulted-in-local-decision-m
aking-resulting-in-poor-
coordination-and-lack-of-standards.
Physicians-are-not-employees-of-the-entities-that-purchase-the-systems.
303
2005Strategic-action-in-health-inform
ation-technology:-
why-the-obvious-has-taken-so-long
Health-Affairs
31
00
01
0Opinion
National
Various
Deep-Structure
303
2005Strategic-action-in-health-inform
ation-technology:-
why-the-obvious-has-taken-so-long
Health-Affairs
31
00
01
0
Opinion
National
Various
Deep-Structure
Cultural-barriers-include:
IT-viewed-as-a-support-activity-and-is-"poorly-appreciated"-pg-1226
"Perception-that-IT-systems-provide-m
ore-of-a-threat-than-a-protection-for-data-confidentiality"-pg-
1226
Depersonalization-of-healthcare-through-technology
304
2005State-and-community2based-efforts-to-foster-
interoperability
Health-Affairs
32
Statewide-HIE
00
01
0
Case-Study
Tennessee
HIE
Revolution
Discusses-the-implementation-and-experiences-of-the-M
idSouth-Ehealth-Alliance-started-in-2004-
(now-2005-in-this-article).
Modeled-implementation-on-other-successes,-such-as-Indiana-and-Regenstreif,-Santa-Barabara,-New-
York,-and-M
assachusetts.---Early-experiences-from-the-six-m
onth-planning-effort-are-discussed-in-the-
article.--
Findings:--Form
al-governance-important,-expectations-from-users-2-some-thought-the-project-would-
replace-existing-systems,-felt-proposed-technology-would-be-less-efficient-than-current-regional-
collaboration,-might-not-address-immediate-business-needs,-financial-im
pact-m
ight-be-negative,-
finding-compromise-betw
een-collaboration-and-competition.
305
2005Medicare's-next-voyage:-encouraging-physicians-to-
adopt-health-inform
ation-technology
Health-Affairs
31
national-healthcare
00
01
0
Opinion
National
EMR
Revolution
Medicare-is-uniquely-positioned-to-promote-and-influence-physician-adoption-and-use-of-HIT.
Policy-ideas-discussed-in-article-include:--Incentives-for-adopting-an-implementation-plan,-adopting-a-
certain-type-of-HIT,-meeting-designated-quality-improvements,-or-adopting-certrified-technologies.
306
2005Can-electronic-m
edical-record-systems-transform
-
health-care?-Potential-health-benefits,-savings,-and-
costs
Health-Affairs
42
Healthcare-M
arket
00
01
0
Case-Study
National
EMR
Deep-Structure
Great-potential-for-EHR-Adoption-in-the-US.--Authors,-using-data-from-the-literature-and-national-
databases,-review-several-effects/benefits-of-EHR-adoption-on:--efficiency-savings,-safety-benefits,-
health-benefits,-Cost-benefits.
Barriers-to-realizing-benefits-are:--costs,-slow-and-uncertain-financial-payoffs,-disruptive-effect-on-
practices-and-providers-absorb-costs-and-consumers-and-payors-reap-the-benefits.
307
2005Practice-to-evidence-to-practice:-closing-the-loop-
with-IT
Nursing-M
anagement
21
Various
01
00
0
Opinion
National
Evidenced-Based-
Nursing
Deep-Structure
Discusses-various-barriers-to-improved-use-of-HIT,-specifically-knowldege-through-evidenced-based-
nursing.
Barriers-include:--lack-of-nurses-and-demands-on-tim
e,-inability-to-access-research-and-difficulty-in-
synthesizing-the-invorm
ation-available,-"cookbook"-nursing,-a-lack-of-form
alized-EBN-traininng-and-
undersgraduate-education,-and-a-need-for-postgraduate-training.
143
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
308
2005Comparing-knowledge-m
anagement-in-health2care-
and-technical-support-organizations
Inform
ation-Technology-in-Biomedicine,-
IEEE-Transactions-on
22
Hospital-vs.-IT-Support
01
10
0
Case-Study
Unknown
Knowledge-
Management
Deep-Structure
The-author-emphasizes-the-differences-in-how-healthcare-organziations-use-knowldege-and-data.--He-
compares-this-difference-with-IT-support-functions.
"a-technical-support-organization-relies-on-a-hierarchy-of-personnel-of-different-levels-of-expertise-
and-the-work-“episode”-is-m
oved-through-the-“chain.”-In-a-health2care-organization,-the-clinical-
professionals-usually-work-at-the-same-level-of-expertise-with-“webs”-being-form
ed-to-synthesize-
knowledge-sharing-differences-in-experience-and-domains-of-specialization.-Culture2based-
organizations-(such-as-health-care)-focus-more-on-collective-processes-while-technology2based-
organizations-(such-as-technical-support)-use-intelligent-systems-and-data-stores-to-focus-their-KM-
initiatives-[26]."-pg-165
Further-comparison-is-made-betw
een-the-nature-of-the-problem
"The-patient-is-a-m
uch-m
ore-complex-entity-than-customer-equipment,-and-usually-the-problem-
identification-and-resolution-involves-“expanding-the-domain”-through-the-involvement-of-
multidisciplinary-expertise,-which-a-single-person-does-not-possess.-In-the-technical-support-case,-the-
problem-identification-and-resolution-is-really-based-on-prior-inform
ation-which-has-been-captured-
by-the-organization’s-IT-and-validating-that-inform
ation-to-really-“narrow-down”-the-problem."-pg-
166
309
2005The-100-m
ost-wired-2005:-the-quality-connection
Hospitals-&-health-netw
orks/AHA
23
Hospital
00
10
0
Survey
National
Various
Equilibrium
Focus-of-this-years-survey-was-on-the-association-betw
een-IT-use-and-m
ortality/quality-and-
outcomes.--The-study-showed-a-7.2%-lower-risk-of-mortality-at-"m
ost-wired"-hospitals-versus-others.
312
2005Toward-a-procedure-for-integrating-m
oral-issues-in-
health-technology-assessment
International-Journal-of-Technology-
Assessment-in-Health-Care
41
Various
10
10
0
Opinion
Unknown
Various
Deep-Structure
"First,-the-point-with-integrating-m
oral-issues-in-HTAs-[Health-Technology-Assessments]-is-to-address-
important-aspects-other-than-outcome-and-costs.-Health-technology-shares-the-overall-(moral)-end-
of-health-care,-to-help-people,-making-HTA-a-m
oral-endeavour-and-giving-m
oral-issues-a-natural-
place.-
Sample-question-on-m
orality-in-Technology-Assessment-"D
oes-the-implementation-of-the-use-of-the-
technology-challenge-patient-autonomy?"-pg-314
Second,-outcome-and-cost-assessments-are-perform
ed-by-experts-in-an-expert-language.-They-often-
communicate-badly-in-the-public-sphere-where-m
any-of-the-issues-about-technology-are-debated.-
Moral-issues,-on-the-other-hand,-concern-common-subjects-in-ordinary-language-and-tend-to-work-
well-in-the-public-debate.
Third,-the-questions-presented-here-concern-a-wide-range-of-moral-issues,-also-issues-related-to-the-
basis,-m
ethod,-and-results-of-the-HTA-process-itself.-This-approach-m
ay-make-HTA-m
ore-transparent,-
open,-and-acknowledged.
Fourth,-integrating-m
oral-issues,-it-is-hoped,-can-lead-to-well2founded-decisions-and-success-in-
implementing-the-results-of-HTAs.-Dissemination-of-the-results-and-decisions-made-from-HTAs-still-is-
a-great-challenge.-Integrating-a-broader-range-of-value-issues-than-just-outcome-and-costs-potentially-
can-contribute-to-reduce-the-dissemination-problem."-pg-317
313
2005Inform
ation-technologies-in-Florida's-rural-hospitals:-
does-system-affiliation-m
atter?
The-Journal-of-Rural-Health
13
rural-hospitals
00
00
0
survey
Florida
Various
Deep-Structure
Little-relevence-to-Study.--Rural-hospitals-that-were-stand2alone-were-less-likely-to-utilize-clinical-IT-
and-had-a-lower-intention-to-adopt-IT-in-the-next-2-years.--Such-hospitals-were-less-likely-to-use-an-
intranet.
Financial-barriers-were-"by-far-the-m
ost-frequently-cited-barriers-and-was-significantly-different-from-
their-system2affiliated-counterparts."-pg-266
319
2005Ease-on-down-the-road.-Start-technology-
implementation-with-care-and-foresight
MGMA-connexion/M
edical-group-
Management-Association
21
Clinician
00
00
0Opinion
VARIOUS
EHR
Deep-Structure
Physician-resistance-and-cost-remain-the-top-two-key-barriers-to-EHR-adoptiona-and-use.
323
2005Physician-reim
bursement-and-technology-adoption
Journal-of-Health-Economics
31
01
00
0
Quantiative-
Model
National
Various
Deep-Structure
the-article-looks-for-linkages-betw
een-different-reim
bursement-systems-and-technology-adoption.----
"A-shift-from-fee-for-service-to-capitation-is-likely-to-display-undesirable-incentives-for-very-severe-
illnesses-by-iunducing-a-reduction-in-the-technocally-feasible-level-of-healing-or-an-increase-in-non2
monetary-costs-of-treatm
ent."-pg-907
144
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
389
2005Is-the-federal-government-serious-about-health-IT?
Healthcare-Financial-Management
41
00
00
0
Opinion
national
various
Deep-Structure
Government-support-is-im
portant-to-HIT-success.--Some-of-the-deep-structure-elements-are-related-
to-government-culture-and-vision.
Article-emphasizes-the-early-congressional-actions-to-delete-m
ooney-from-ONC-in-2005-and-the-
efforts-to-restore-it-by-President-Bush.--The-author-argues-that-HIT-will-continue-to-progress-because-
existing-pay-for-perform
ance-programs-and-consumer-interset-in-safety-demand-the-data-from-HIT-in-
order-to-report-on-quality-m
easures.
999
2005The-Costs-of-a-National-Health-Inform
ation-Netw
ork
The-Annals-of-Internal-Medicine
41
National-System
00
01
0
Expert-Opinion
National
HIE/N
HIN
Revolution
"In-conclusion,-IT-is-an-important-tool-to-improve-the-safety-and-efficiency-of-U.S.-health-care,-but-its-
adoption-remains-limited-largely-because-of-a-lack-of-aligned-financial-incentives-and-national-
standards,-although-progress-has-recently-been-m
ade-on-this-front.-An-NHIN-will-cost-$156-billion-in-
capital-costs-or-approximately-2-years-of-real-growth-in-U.S.-health-care-costs.-However,-the-benefits-
of-such-an-investment,-both-in-term
s-of-money-and-quality,-may-be-substantial."-pg-172
1003
2005pay-for-perform
ance:-a-win-for-the-NHIN?
Healthcare-Financial-Management
41
Various
00
01
0
opinion
national
NHIN
Revolution
Compares-efforts-to-link-RHIOS-into-an-NHIN-today-with-the-Community-health-inform
ation-netw
orks-
that-failed-previously.--A
uthor-states-that-the-same-obstacles-remain-22-no-standards,-culture-of-
competition-and-resstance-to-share-inform
aiton-remains,-EHRs-not-widely-adopted.
Believe-P4P-programs-can-provide-the-needed-incentive,-by-requireing-reporting-that-would-
otherw
ise-be-difficult-in-a-paper-based-system.--"Under-traditional-paym
ent-systems,-there-was-little-
or-no-incentive-to-undertake-the-potentially-costly-and-complex-process-of-im
plementing-an-EHR."-pg-
121
143
2006Newt-Gingrich:-healthcare-transform
ation-advocate
10
National
00
01
0News
National
Various
Revolution
"The-healthcare-system-on-which-we-depend-is-desease2focused-and-provicer2centered-and-price2
driven;-it-cannot-be-tweaked-at-the-m
argins-but-must-be-transform
ed."-pg-34
144
2006Gingrich-Speaks-To-IT-Industry
VARBusiness
10
National
00
01
1News
National
Various
Revolution
Standards-are-exscential-for-success-of-HIT.--Developers-m
ust-be-willing-to-share-knowledge-of-
acievements-and-proomte-standards,-not-maintain-secrecy-over-abilities-and-accomplishments.
147
2006health-care-in-crisis:-is-HIT-the-Rx?
hfm
-(Healthcare-Financial-Management)
30
national
10
00
0News
National
Various
Revolution
Patients-m
ust-become-better-consumers-of-care.--Transfomration-will-require-22-focus-on-value,-
better-consumers-of-care,-better-options-for-promoting-health-and-providing-care.
198
2006TECHNOLO
GY2ENABLED-TRANSFORMATIONS-IN-US-
HEALTH-CARE
Human2computer-interaction-and-
management-inform
ation-systems:-
applications
33
Unknown
10
00
0
Cross-Sectional-
Survey
Naitonal
PHR
Deep-Structure
Survey-of-patients-and-their-intention-to-use-a-PHR.--Study-found-that-younger,-less-educated-
individuals-had-a-greater-intention-to-use-PHR.--However,-this-intention-to-use-was-based-on-their-
belief-that-the-PHR-would-organize-and-help-m
anage-their-inform
aiton.--Convenience-and-
empowerm
ent-were-not-found-to-influence-PHR-usage-intention-despite-this-being-the-area-of-most-
potential-benefit.
324
2006Inform
ation-technology-strategy:-three-
misconceptions
Journal-of-Healthcare-Inform
ation-
Management
21
00
10
0
Opinion
National
Various
Revolution
IT-Strategy-plays-an-important-role-in-success-of-an-organziation.--The-IT-agenda-is-influenced-by-
efforts-to-improve-core-organziational-processes,-the-acquisition,-governance-and-data-standards-of-
new-appications-and-through-m
any-converstaions-with-stakeholders-at-all-levels.
325
2006Antecedents-of-clinical-inform
ation-technology-
sophistication-in-hospitals
Health-Care-M
anagement-Review
53
hospital
00
10
0
Survey/National-
Data
iowa
Various
Deep-Structure
Authors-use-data-from-a-survey-and-AHA-national-data-to-develop-a-m
odel-the-predicts-"Clinical-IT-
Sophistication"-.--Clinical-Spophistication-is-based-on-an-instrument-developed-by-Pare-and-Sicotte-
(two-of-the-authors).--The-theoretical-model-being-tested-is-that-of-organizational-capacity-which-
includes-(Structural-Capacity,-Financial-Capacity,-Leadership-Capadcity,-Knowledge-Sharing-Capacity).--
Based-on-this-framework-the-authors-hypothosized-several-predictors-if-IT-sophistication.---The-
results-were-that-Leadership-resources-and-knowledge-sharing-are-the-m
ost-important-predictors-of-
clinical-IT-sphistication.--M
anagerial-tenure-was-negatively-assocaited-with-IT-sophistication.
326
2006Crossing-the-quality-chasm
:-the-role-of-inform
ation-
technology-departments
American-Journal-of-Medical-Quality
23
IDS-(VA)
00
10
0
Delphi-Survey
National
Various
Equilibrium
IT-Department-sturcture-and-strategic-orientation-within-the-organzation-is-im
portant-to-future-
success-of-IT-transform
ation.--The-m
ost-important-aspects-from-the-delphi-study-realted-to-the-IT-
support-organziation-were:--Changing-work-processes-to-imporove-use-of-new-IT;-Maintaining-
computer-security;-IT-Participates-on-important-hospital-committees-and-independence-of-IT.
330
2006A-critical-change-in-a-day-in-the-life-of-intensive-care-
nurses:-Rising-to-the-e2challenge-of-an-integrated-
clinical-inform
ation-system
Critical-care-nursing-quarterly
22
hospital-ICU
01
00
0
Case-Study
Pennsylvani
a
CPOE
Equilibrium
Descxxribes-the-nurse-acceptance-and-perceptions-of-a-new-CPOE-system-implemented-in-the-
various-ICE-of-a-large-hospital-system.--Bulk-of-the-study-referrs-to-effects-on-workflow-changes-
within-the-ICU-as-a-result-of-paper-to-electronic-ordering-and-administration.-Main-fndings-relate-to-
system-design-isssues.--The-authors-conclude-that-usability-im
porance-to-HIT-acceptance-including-
user-satisfaction.--Concern-experessed-by-nursing-staff-about-loosing-the-human-touch-with-patients-
in-the-ICU.
331
2006Innovation-in-surgery:-a-historical-perspective
Annals-of-surgery
52
01
00
0
Case-Study
historical
Endoscopy
Deep-Structure
While-the-author-does-not-deal-with-clinical-inform
ation-systems,-he-m
ake-two-key-statements:--One,-
surgical-innovation-using-technology-is-alm
ost-always-focused-on-outcomes-and-not-cost-and-two,-
the-development-of-innovation-follows-an-"ebb-and-flow"-pattern-22>-This-sounds-a-lot-like-
punctruated-equilibrium!!!!
333
2006Expanding-the-scope-of-health-inform
ation-systems
IMIA-Yearbook-of-Medical-Inform
atics
21
00
01
0
Opinion
National
Various
Equilibrium
Discusses-the-trend-toward-Continuity-of-Care,-Patient-Empowerm
ent-and-ehealth.--These-trends-
combined-with-the-high-cost-of-HIT-diffusion-result-in-the-additional-challengees-of-integration,-
workflow-and-decision-support.
145
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
334
2006Computerized-provider-order-entry-system-field-
research:-The-impact-of-contextual-factors-on-study-
implementation
International-Journal-of-Medical-
Inform
atics
32
IDS
00
10
0
Case-Study
California
CPOE
Deep-Structure
It-is-im
portant-to-understand-the-contextual-factors-associated-with-both-CPOE-implementation-and-
implementation-research.--"Key-among-these-factors-are-organizational-IT-innovation-culture-and-
clim
ate,-linkage-of-the-IT-innovation-with-work-processes,-end2user-engagement-and-commitment,-
resource-availability-for-all-phases-of-im
plementation,-end2user-computer-literacy-and-training,-
quality-of-the-IT-innovation,-availability-of-vendor-support-for-commercial-applications-and-ongoing-
administrative-support-[6],-[7],-[8],-[9],-[10],-[11],-[12],-[13]-and-[14].-W
hen-attention-to-these-
contextual-factors-is-lacking,-the-potential-for-successful-IT-implementation-dim
inishes-[15],-[16],-
[17],-[18],-[19],-[20]-and-[21]."-pg-730
Table-2-pg-734-provides-a-summary-of-the-contextul-factors-identified-in-the-field-interviews.--O
f-note-
is-a-finding-concerning-the-evolution-of-CPO-systems.--"Health-care,-however,-has-been-slow-to-
embrace-these-innovations,-which-has-resulted-in-their-delayed-m
aturation.-"-pg-734
Cultural-variation-was-also-noted:--"Cultural-variations-within-and-across-study-hospitals-and-clinical-
units-were-also-viewed-as-im
portant-to-study-outcomes.-Cultural-characteristics,-such-as-openness-to-
change,-desire-for-inform
ation-technology,-and-cohesiveness,-were-identified-as-im
portant-
contextual-factors-that-could-potentially-influence-response-to-CPOE-system-implementation.-Insight-
into-the-innovation-culture-and-characteristics-of-study-clinical-units-was-obtained-from-user-
responses-to-survey-demographic-questions-that-addressed-this-topic."-pg-736
Overall-"Inform
ation-technology-innovation-occurs-within-a-larger-organizational-environment-and-
contextual-factors-occurring-internally-and-externally-to-this-environment-must-be-examined-for-their-
impact-on-study-methodology.-"-pg-738
338
2006Types-of-unintended-consequences-related-to-
computerized-provider-order-entry
Journal-of-the-American-M
edical-
Inform
atics-Association
33
hospital
00
10
0
Observational
MA,-IN,-NC
CPOE
Equilibrium
Authors-identified-9-categories-of-unintended-consequences-from-CPOE-implementation:
More/new-work-for-clinicians,-workflow-issues,-never-ending-system-demands,-paper-persistence,-
changes-in-communication-patterns,-emotions,-new-kinds-of-errors,-changes-in-the-power-structure,-
overdependence-on-technology.
340
2006EHR-and-other-IT-adoption-among-physicians:-
results-of-a-large2scale-statewide-analysis
Journal-of-Healthcare-Inform
ation-
Management
33
outpatient
01
00
0survey
Florida
Various
Deep-Structure
A-survey-of-phusician-in-florida-shows-that-practice-size-was-a-significant-contributor-to-HIT-use.--
Partices-greater-than-50-where-20x-more-likely-to-use-EHR-than-those-in-a-solo-practice.
341
2006The-California-Clinical-Data-Project:-a-case-study-in-
the-adoption-of-clinical-data-standards-for-quality-
improvement
Journal-of-Healthcare-Inform
ation-
Management
32
health-system
00
01
0
Case-Study
California
HIE
Equilibrium
Authors-review-the-implenmentation-of-data-standards-for-the-exchange-of-lab-and-pharm
acy-data-
as-part-of-the-California-Clinical-Data-Project-(CCDP).--Lessoons-learned-from-the-successful-adoption-
of-these-standards-were:--Sponsorship-by-a-financially-and-politically-independent-organziation,-
including-competators-and-key-stakeholders-on-executive-committee,-leverage-existing-data-
standards,-ground-standards-in-use-cases-of-the-stakeholders,-verification-m
echanism-to-verify-
compliance-with-standards.
342
2006Concepts-for-building-inter2organizational-systems-in-
healthcare:-lessons-from-other-industries
Journal-of-Healthcare-Inform
ation-
Management
51
HIE
01
11
0
Opinion
National
HIE
Deep-Structure
IOSs-are-not-new-22"These-exchanges,-aim
ing-to-support-care-delivery,-are-new-to-healthcare-in-the-
United-States.-W
hile-m
ore-than-200-communities-are-in-various-stages-of-im
plementing-them,1-there-
is-little-m
ature-experience-with-the-factors-that-contribute-to-the-successful-form
ation-and-
sustainability-of-these-exchanges.-Pg-55
Size,-cost-and-value-are-important.
"These-barriers-center-on-costs,-value-of-IOS-participation-and-the-capabilities-of-potential-IOS-
participants.-Many-of-these-barriers-confront-the-nation’s-small-providers.-There-is-a-big-risk-that-
they-will-be-unable-to-participate-in-the-full-spectrum-of-IOS-opportunities."-pg-61
IOSs-reflect-the-values-and-goals-of-the-organziation-2-"IOSs-tend-to-focus-on-one-of-tw
o-m
ajor-value-
propositions,-either-scale-economies-or-process-improvement.-The-type-of-value-being-sought-often-
determ
ines-the-attributes-of-an-IOS."-pg-55
Article-describes-several-attributes-of-IOSs-(Collectively-vs-privately-owened,-closed-vs.-public,-
horizontal-vs.-Vertical,-sproadic-vs.-systematic-and-proximal-vs,-remote).--
Specifically-with-regard-to-RHIOS-the-authors-state:
"It-is-very-unlikely-that-healthcare-will-see-only-one-m
ajor-type-of-IOS;-no-other-industry-has-
experienced-this-homogeneity."-pg-56
343
2006Health-care-IT-adoption-could-save-USD162-billion
World-Hospitals-and-Health-Services
31
Health-System
00
01
0
Opinion
National
Various
Deep-Structure
market-forces-presenting-obstacles-to-HIT-include:--Access-to-HIT,-Connectivity-to-other-data,-Return-
on-Investment.--G
overnment-should-act-now-to-take-advantage-of-system-wide-cost-advantages-of-
HIT.--Possible-government-actions-include-Expand-current-efforts,-accelerate-m
arket-forces-and-
subsidize-change.
345
2006When-it-comes-to-IT,-ED-m
anagers-lag-behind
ED-M
anagement
10
ED
00
10
0News-Story
ED
Equilibrium
ERs-lag-behind-with-only-30240%-having-any-IT-systems.--D
iscusses-benefits-of-HIT-in-an-ED-setting.
146
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
346
2006Evidence2based-practice:-How-nursing-
administration-m
akes-IT-happen
Nursing-Administration-Quarterly
11
01
00
0opinion
National
Various
Equilibrium
Discusses-Nursings-im
portant-role-in-defining-IT-needs-as-part-of-the-patient-care-process-and-
nursings-special-focus-on-patient-centered-care.
347
2006Using-diffusion-of-innovation-concepts-to-enhance-
implementation-of-an-electronic-health-record-to-
support-evidence2based-practice
Nursing-Administration-Quarterly
31
hospital
01
10
0
opinion
National
EHR
Equilibrium
Author-review-rogers-Diffusion-of-innovation-m
odel-as-well-as-Rogers-Innovation2decision-process-
which-suggests-5-stages-of-innovation-decision-m
aking:
12-knowledge
22-presuasion
32-Decision
42-Im
plementation
52-Confirm
ation
348
2006Barriers-to-accepting-e2prescribing-in-the-USA
International-Journal-of-Health-Care-
Quality-Assurance
33
eRx
10
00
0Survey
Pennsylvani
a
Eprescribing
Deep-Structure
Barriers-to-using-ePrescribing-by-patients-include:--Counterfeit-m
edications,-shipping-and-ahndleing,-
no-personal-connection-with-doctor,-paying-over-the-internet,-releasing-inform
ation.
349
2006Hospital-organization-culture,-capacity-to-innovate-
and-success-in-technology-adoption
Journal-of-health-organization-and-
management
54
hospital
00
10
0
Factor-analysis-
and-survey
National
Various
Deep-Structure
Absorptive-Capacity-(AC)-provides-a-m
easure-of-of-the-"organizational-culture-that-infulences-the-
capacity-of-hospital-organizations-to-innovate-by-absorbing-new-technlology-and-the-inportance-of-
this-absorptive-capacity-in-inform
ation-technology-im
plementation-success"-pg-194
AC-theory-has-tw
o-m
ain-constructs:
Managerial-IT-knowledge-2-"organizations-must-develop-inform
ation-processing-m
echanisms-capable-
of-detecting-trends,-events,-competitors,-markets-and-technological-developments-relevant-to-their-
survival,-and-it-is-assumed-that-such-inform
ation-converges-and-is-interpreted-for-the-organization-at-
the-top-m
anagement-level-"-pg-197
Communication-channels-2-"absorptive-capacity-for-new-technologies-is-enhanced-when-external-
inform
ation-is-added-to-IT-knowledge-already-within-the-organizational-context.-To-allow-external-
technical-knowledge-to-reach-organizational-members,-organizations-often-hire-new-employees,-
access-documents-describing-new-developments,-encourage-personal-contacts-with-knowledgeable-
individuals-outside-the-organization,-and-use-other-external-communication-channels-"-pg-198
Absorptive-capacity-=-"the-m
anagerial-IT-knowledge-and-communication-channels-that-enable-
organizations-to-recognize-the-value-of-new-inform
ation,-assim
ilate-it,-and-apply-it-to-commercial-
ends."-pg-199
Model-results-in-four-organization-culture-types:
350
2006Managing-the-ice-in-the-waters-ahead:-lessons-from-
the-Titanic
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
11
00
00
0
Opinion
National
Various
Deep-Structure
Many-failures-of-IT-can-be-attributed-to-the-following:
2-Technology-alone-is-not-the-solution
2-Arrogance-2-refrain-from-being-overconfident
2-plan-for-the-unexpected.
352
2006The-role-of-frontline-RNS-in-the-selection-of-an-
electronic-m
edical-record-business-partner
Computers-Inform
atics-Nursing
22
Hospital/IDS
00
10
0
Case-Study
Tennessee
Various
Equilibrium
A-case-study-of-a-vendor-selection-process.--Very-standard-and-straight-forw
ard-process-with-
Education-22-development-of-criteria-for-selection-22-vendor-on2site-visits-22-selection.--The-focus-is-on-
the-role-of-the-RN-and-the-ultim
ate-contribution-they-made-to-the-selection-process.
Authors-note-shift-in-strategy-from-"best-of-breed"-to-best-of-class-applications-from-a-single-vendor-
to-ensure-integration-across-functions.-Pg-194
353
2006Use-of-computerized-m
edical-records-in-home-
health-and-hospice-agencies:-United-States,-2000
Vital-and-health-statistics.-Series-13,-Data-
from-the-National-Health-Survey
23
home-and-hospice-care
00
10
0
National-US-
Survey
National
EHR
Deep-Structure
A-national-survey-of-home-and-hospice-health-agencies-done-in-2000.--"2000-National-Home-and-
Hospitce-care-Survey"--Found-that-population-size-of-the-organziation-was-correlated-with-the-
adoption-and-use-of-a-CMR-(EHR).--Suggests-size-m
ay-be-a-factor-in-HIT-adoption-and-use.
354
2006Racial-Differences-in-Attitudes-Toward-Innovative-
Medical-Technology*
Journal-of-general-internal-medicine
53
IDS-(VA)
10
00
0
Survey
Pennsylvani
a
Medical-Im
plant-
Technology
Deep-Structure
Describes-a-relationship-on-behalf-of-patients-regading-acceptance-of-new-innovative-m
edical-
technology.--W
hites-were-m
ore-likely-than-blacks-to-accept-new-innovated-technologies.--W
hile-the-
technology-described-here-was-for-a-new-implant-device,-it-is-interesting-to-think-about-how-the-
resw
ults-might-change-if-the-technology-was-EHR-or-similar.
355
2006Measuring-hospital-readiness-for-inform
ation-
technology-(IT)-innovation:-A-m
ultisite-study-of-the-
Organizational-Inform
ation-Technology-Innovation-
Readiness-Scale
Journal-of-Nursing-M
easurement
33
hospital
00
00
0
survey-tool-
development
California
CPOE
Equilibrium
Study-tests-a-new-psychometric-tool-for-evaluating-organizational-readiness-for-IT-innovatrion-scale-
(OITIRS).--The-study-identified-eight-factors-of-IT-Innovation-readiness:--Resources,-end2users,-
technology,-knowledge,-process,-values-and-goals,-management-structures-and-Administrative-
systems.
358
2006Evolution-of-health-inform
ation-m
anagement-and-
inform
ation-technology-in-emergency-m
edicine
Emergency-M
edicine-Australasia
23
ED
00
10
0Literature-ReviewVarious
Various
Deep-Structure
Limitation-cited-by-the-authors-were:--Cost,-Disruption,-Strategic-issues-(focus-on-other-hospital-
priorities),-data-security-and-lack-of-evidence.
359
2006Health-care-CIOs:-assessing-their-fit-in-the-
organizational-hierarchy-and-their-influence-on-
inform
ation-technology-capability
The-Health-Care-M
anager
23
hospital
00
10
0
survey
Florida
Various
Equilibrium
Study-shows-a-relationship-betw
een-the-tenure-of-CIOs-and-the-level-of-HIT-adoption.--No-
relationship-was-found-based-on-the-CIO-reporting-or-governance-structure-within-the-organziation-
nor-whether-the-CIO-was-promoted-from-within-or-from-the-outside.
147
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
360
2006Health-care-spending-and-use-of-inform
ation-
technology-in-OECD-countries
Health-Affairs
31
National
00
01
0
opinion
Natoinal
Various
Deep-Structure
Provides-a-comparison-to-other-OECD-countries-and-lists-several-barriers-to-change-including:-lack-of-
opeability,-privacy-and-confidentiality-concerns-and-the-direct-and-indirect-costs.--A
uthors-emphasize-
what-others-have-said-that-the-benefits-enure-to-the-patients-and-insurers-and-not-the-ones-investing-
in-HIT.--
"In-all-of-the-countries,-the-cost-of-im
plementing-an-HIT-program-is-borne-by-the-government-or-
health-insurers,-or-both.-It-is-recognized-in-these-countries-that-the-benefits-and-cost-savings-accrue-
primarily-to-patients-and-insurers,-not-to-providers.-Economists-recognize-that-use-of-IT-in-health-
care-has-a-strong-public2goods-component,-which-m
eans-that-a-particular-stakeholder-often-does-not-
reap-the-full-social-benefits-produced-by-new-HIT-investment.-Consequently,-according-to-economic-
theory,-the-private-sector-will-underinvest-in-IT-relative-to-its-social-benefits,-which-leads-economists-
to-recommend-that-public-subsidies-be-used-for-the-development-of-HIT-systems,-even-though-they-
will-be-used-by-private-stakeholders.-Also,-the-value-of-a-particular-HIT-system-installed-by-one-
stakeholder-tends-to-increase-with-the-number-of-other-HIT-systems-installed-elsewhere-with-which-
that-stakeholder’s-HIT-system-can-communicate.-For-these-reasons,-m
any-industrialized-countries-
have-subsidized-the-application-of-HIT-with-public-funds,-albeit-it-on-the-condition-that-those-HIT-
systems-can-interconnect.-The-United-States-has-begun-to-do-so-in-recent-years-as-well,-although-so-
far-on-a-m
uch-m
ore-m
odest-scale.-"-pg-829
361
2006Effects-of-im
plementing-computerized-practitioner-
order-entry-and-nursing-documentation-on-nursing-
workflow-in-an-emergency-department
Journal-of-Healthcare-Inform
ation-
Management
23
hospital
00
10
0
Survey/time2
motion-study/pre2
post-
implementation
Missouri
CPOE/N
ursing-
documentation
Equilibrium
Implementaiton-of-CPOE-and-documentation-system-resulted-in-little-perceived-(survey)-or-actual-
(tim
e2m
otion-data)-difference-in-tim
e-spent-on-documentation-or-patient-care-pre2post-
implementation.
363
2006Why-innovation-in-health-care-is-so-hard
Harvard-Business-Review
51
National
00
01
0
Opinion
National
Various
Deep-Structure
Discusses-compoents-of-deep-strucutre-and-their-effect-on-innovation.--The-author-lists-three-(3)-
types-of-innovation-(technology,-business-m
odel-and-consumers)-and-six(6)-forces-that-affect-them-
(Players,-funding,-public-policy,-technology,-customers,-and-accountablility.
364
2006Building-HR-capability-in-health-care-organizations
Health-Care-M
anagement-Review
41
00
10
0
Opinion
National
Various
Equilibrium
Provides-a-unique-perspective-on-organizational-design-and-effectiveness.--Author-looks-at-the-HR-
function-as-critical-to-healthcare-and-HIT.--W
ages-make-up-65280%-of-healthcare-budgets-and-
therfore-people-m
ake-up-the-bulk-of-the-production-or-service.--To-improve-efficiencies-and-quality-
requires-im
pacting-the-people-within-the-organziation.
"The-new-developments-in-customer-involvement-demonstrate-that-services-with-particularly-
intensive-and-personal-contact-lend-themselves-to-situations-where-customers-take-on-very-powerful-
roles…
.-Unlike-in-m
anufacturing-firms,-customers-of-service-firms-typically-interact-with-the-
production-process.-In-doing-so,-customers-inject-a-high-degree-of-variability-into-the-service-
production-process.-"-pg-46
Organziations-undervalue-the-role-of-HR:
"The-m
ajority-of-health-care-organizations-at-present-seem-to-have-predominantly-an-administrative-
or-a-one2w
ay-link.33-Only-a-handful-may-have-two2w
ay-or-integrative-link-betw
een-strategic-planning-
and-HR.34-This-is-because,-generally-speaking,-health-care-organizations-do-not-have-a-clear-
understanding-of-their-strategic-intent-and-initiatives"-pg-47
"Great-doctors-and-nurses,-not-great-organization-or-management,-have-been-seen-as-the-m
eans-for-
ensuring-that-patients-receive-quality-care"-pg-48
368
2006Form
ing-design-teams-to-develop-healthcare-
inform
ation-systems
Hospital-Topics
23
hospital
00
10
0
Survey
Unknown
Various
Equilibrium
it-is-im
portant-to-include-users-on-system-design-teams-should-be-selected-primarially-based-on-their-
system2related-and-functional-expertise-and-only-secondarially-on-communication-skills,-computing-
baqckground-and-personality.
372
2006A-survey-of-factors-affecting-clinician-acceptance-of-
clinical-decision-support
BMC-M
edical-Inform
atics-and-Decision-
Making
23
IDS
01
00
0
Survey
oregon
CDSS
Deep-Structure
Clinicians-were-found-to-be-m
ore-willing-to-accept-CDSS-when-patient-was-elderly-and-had-m
ultiple-
medications-or-chronic-conditions-and-less-willing-when-the-patient-was-presenting-for-acute-
condition.
Clinicians-who-were-behind-schedule-were-also-less-likely-to-accept-CDSS.
148
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
373
2006Personal-health-records:-definitions,-benefits,-and-
strategies-for-overcoming-barriers-to-adoption
Journal-of-the-American-M
edical-
Inform
atics-Association
31
national
00
00
0
opinion
national
personal-health-recordsDeep-Structure
Authors-discuss-the-barriers-to-adoption-and-use-of-PHRs.--These-include:
Limited-evidence-supporting-the-benefits-of-PHR
Lack-of-standards
potential-large-volume-of-"clinically-irrelevant"-info-within-PHRs-may-make-them-difficult-to-use-for-
clinicians.
Envrionmental-barriers-include:-many-vendor/PHR-failures,-legal-concerns,-and-segmented-nature-of-
healthcare
Individual-level-barriers-2-cunsumers-m
ust-understand-role-and-responsibliities-related-to-PHR,-PHRs-
may-threaaten-control-and-autonomy-of-some-health-care-providers,-challenges-traditional-
patient[provider-role,-accuracy-of-inform
ation.
Education-needed-at-early-age-sim
ilar-to-financial-education-that-is-now-taking-place-earlier.
374
2006Health-inform
ation-technology-and-quality-
improvement-for-community-health-centers
Health-Affairs
31
Community-health-Centers
00
01
0
Opinion
National
EHR
Deep-Structure
Federal-government-must-be-invovled-in-facilitating-the-adoptiokn-of-EHRs-in-Community-Health-
Centers-(CHC).--Reasons-cited-include-the-vulnerable-populations-servcied-by-CHCs-and-the-slow-HIT-
diffusion-caused-by-Costs,-Complex-selection-process,-misaligned-costs-and-benefits-and-tim
e-
consuming-implementation.--
Saving-acccrue-to-HHS-and-not-the-CHCs.--Beneftis-to-HHS-include-Reduction-in-costs,-better-patient-
data-and-equity-of-difusion-in-HIT.
376
2006Wired-for-success
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
31
hospital
00
10
0
opinion
varous
various
Equilibrium
Leadership,-planning-and-strategic-vision-continue-to-be-escential-in-IT-implemnetation-success-and-
therefore-an-important-component-of-equilibrium-within-organizatoins.
377
2006Technology.-Finding-funding
Hospitals-&-Health-Netw
orks
30
Rural-hospitals
00
10
0Opinion
Rural
various
Deep-Structure
Fiunding-a-particular-issues-in-small-and-rural-hospitals.--Leads-to-unique-relationships-to-obtain-
funding-for-HIT.
378
2006Factors-influencing-success-and-failure-of-health-
inform
atics-systems22a-pilot-Delphi-study
Methods-of-inform
ation-in-m
edicine
34
Various
01
10
0
Delphi
National
various
Equilibrium
Provides-a-list-of-success-(110)-and-failure-(27)-factors-for-HIT-implementation.--The-authors-note-that-
"None-of-the-110-success-and-27-failure-criteria-identified-were-condiered-irrelevent-by-the-expert-
panel."--pg-135--Escentially-im
plementation-is-complex-and-any-one-of-these-factors/criteria-can-and-
will-arize-in-any-im
plementation.
382
2006Health-inform
ation-systems:-Failure,-success-and-
improvisation
International-Journal-of-Medical-
Inform
atics
41
01
10
0
Opinion
national
various
Deep-Structure
highlights-gap-in-literature-relating-to-evaluation-of-HIT--"“m
ost-of-the-available-literature-refers-only-
to-pilot-projects-and-short2term
-outcomes,-and-in-m
any-cases-the-efficacy-of-the-application-was-
being-considered,-rather-than-its-effectiveness”"-pg-126
Literature-gaps-or-"traps"-are-m
ainly-the-generalizabiity-of-case-studies.----Author-proposes-a-m
eans-
to-address-the-HIS-failure-using-a-risk-assessment-tool-defined-as-the-"Reality-Gap-M
odel"-pg-131
383
2006Essential-prerequisites-to-the-safe-and-effective-
widespread-roll2out-of-e2w
orking-in-healthcare
International-Journal-of-Medical-
Inform
atics
51
00
01
0opinion
national
various
Revolution
Evidence,-evaluation,-equipment,-education-and-empowerm
ent-are-needed-to-effectuate-change.--
See-pages-1442145
383
2006Essential-prerequisites-to-the-safe-and-effective-
widespread-roll2out-of-e2w
orking-in-healthcare
International-Journal-of-Medical-
Inform
atics
51
00
01
0
opinion
national
various
Equilibrium
Author-describes-the-risks-of-moving-too-quickly-with-HIT-implementation-and-adoption.
"However,-an-alternative-way-of-viewing-this-drive-is-that-it-is-the-enforced-rapid-re2engineering-of-a-
complete-service-sector,-and-above-all-of-a-complex-and-personalised-series-of-professional-skills,-
without-a-sound-research-base-and-without-adequate-preparation.-"-pg-139
Differences-betw
een-alpha-sites-and-beta-sites.--Beta-sites-are-m
issing-in-current-HIT-adoption-
strategy.
"alpha-sites-are-atypical-in-that-they-are-well-supported,-primarily-in-the-form
-of-intellectual-support-
and-commitment-by-leading-advocates-and-technical-innovators,-but-usually-also-with-special-
practical-resources.-At-the-same-tim
e-the-environment-will-be-one-which-is-tolerant-of-
“failures”—the-purpose-is-to-see-if-the-technology-or-the-application-will-work,-and-to-learn-from-it.-
…-A-“beta”-site-is-quite-different-from-an-alpha-site,-and-has-a-very-different-purpose.-The-role-of-a-
beta-site-is-to-take-the-initial-innovation,-and-repeat-it-in-a-“norm
al”-and-“real-world”-setting."-pg-139
"Thus-in-the-whole-world-of-EPR-roll2out-policies,-and-other-e2health,-there-is-no-beta-in-the-
alphabet.-This-m
eans-that-once-an-approach-has-undergone-its-initial-adaptation-and-validation,-it-is-
considered-ready-for-universal-application-regardless-of-the-need-for-further-evidence.-"-pg-139
149
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
383
2006Essential-prerequisites-to-the-safe-and-effective-
widespread-roll2out-of-e2w
orking-in-healthcare
International-Journal-of-Medical-
Inform
atics
51
00
01
0
opinion
national
various
Equilibrium
Ethical-and-legal-issues-exist-in-adoption-and-transform
ation.
"Health-organisations-have-a-legal-requirement-to-provide-an-effective-health-care-system.-This-m
ust-
include-a-duty-to-provide-a-safe-environment,-and-safe-stable-systems.-"-pg-143
"A-m
anager-who-implements-a-policy-change-such-as-acquiring-goods-from-unauthorised-sources-or-
equipment-which-is-not-safety-certified-would-in-m
ost-jurisdictions-be-held-to-have-a-liability-for-that-
decision.-"-pg-143
".-In-order-to-practice-effectively,-clinicians-need-to-draw-upon-support-and-enabling-services-and-
technologies-in-line-with-their-original-professional-training.-If-the-organisation-chooses-to-force-
change-upon-them,-such-that-they-no-longer-either-have-the-same-technical-skill,-or-feel-confident-in-
discharging-their-professional-duties,-in-effect-the-organisation-has-underm
ined-their-professional-
competence,-and-thereby-has-reduced-their-ability-to-practice-effectively."-pg-143
383
2006Essential-prerequisites-to-the-safe-and-effective-
widespread-roll2out-of-e2w
orking-in-healthcare
International-Journal-of-Medical-
Inform
atics
51
01
00
0
opinion
national
various
Equilibrium
Employees-in-health-sector-are-different.
"it-is-not-the-policy-m
akers-who-have-to-m
ake-it-work,-but-rather-the-operational-staff-of-the-health-
sector.-But-unlike-other-service-sectors-which-have-harnessed-electronic-technology-successfully,-
such-as-the-banking-and-financing-sectors-and-retail-trade,-the-employees-of-the-health-sector-are-
not-line2command-employees-whose-job-is-to-m
ake-the-system-work."-pg-140
"Not-only-are-health-professionals-highly-educated-and-autonomous-individuals,-but-their-
professional-duties-give-them-a-personal-autonomy-and-responsibility-which-has-legal-and-ethical-
underpinning….they-are-also-within-their-professional-rights-to-resist-changes-which-by-their-nature-
or-by-the-way-which-they-are-implemented-put-at-risk,-or-appears-to-put-at-risk,-their-own-
professional-competence-and-confidence-in-discharging-their-duties."-pg-142
385
2006Assessing-the-level-of-healthcare-inform
ation-
technology-adoption-in-the-United-States:-a-
snapshot
BMC-M
edical-Inform
atics-and-Decision-
Making
54
various
01
11
1
Qualitative-2-
expert-and-
representative-
interviews
massachuse
tts,-
Colorado
various
Deep-Structure
"since-m
ost-physicians-working-in-community-hospitals-are-not-employees-of-the-hospital-and-can-
admit-their-patients-to-competing-hospitals,-hospitals-often-find-it-hard-to-the-enforce-the-use-of-new-
HIT-applications-such-as-CPOE.-"-pg-5--
"First,-usability-and-clinical-decision-support-among-vendor-products-vary-significantly.-Second,-fewer-
resources-may-be-available-to-train-physicians-in-the-community-setting.-Third,-many-sm
all-practices-
may-not-be-able-to-afford-the-fees-vendors-m
ight-charge-to-customize-the-HIT-products-to-fit-the-
local-workflow."-pg-7
"This-variation-in-the-use-of-HIT-across-stakeholders-is-noteworthy-from-several-standpoints.-Since-
patients-often-transition-from-acute2care-settings-to-non2acute-care-settings,-the-improvement-in-
quality-gained-through-HIT-investments-in-acute2care-hospitals-m
ay-be-attenuated-by-the-under2
investment-in-chronic-care-institutions-and-physician-practices."-pg-8
"People-are-not-beating-on-the-door-asking-for-that-stuff."-pg-5
"the-advent-of-diagnostic2related-group-reim
bursement,-acute-care-hospitals-have-been-financially-
motivated-to-discharge-patients-early.-"-pg-5-relates-to-skilled-nursing-facilities-and-rehab-hospitals.
"chronic-care-facilities,-particularly-nursing-homes,-are-heavily-regulated-and-m
any-are-required-to-
386
2006Technology-solutions-for-better-outcomes:-
integrated-inform
ation-m
anagement-in-key-to-
productivity-increases-in-m
edicine
British-journal-of-radiology
21
11
00
0
Opinion
National
Various
Revolution
Focuses-mainly-on-theraputic-and-diagnoistic-technologies,-but-does-emphasize-the-following-
characteristics-of-future-systems.--KEY-is-patient-focus-and-competative-open-environment.-(-pg-22)
2-they-will-be-patient-focused
2-the-patients-entire-histpory-will-be-accessable
2-the-poviders-will-be-in-a-competative-situation-and-be-forced-to-publish-outcome-statistics.
2-the-capability-of-sharing-best-practices-with-best2in2class-providers-will-be-a-differentiating-factor.
150
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
388
2006Predicting-the-adoption-of-electronic-health-records-
by-physicians:-W
hen-will-health-care-be-paperless?
Journal-of-the-American-M
edical-
Inform
atics-Association
53
small-practices
01
00
0
Obsrevational
National
EHR
Deep-Structure
Authors-note-that-based-on-their-diffusion-m
odel-for-EHR-adoption,-the-2014-goal-set-by-Bush-can-
not-be-m
et.--The-authors-identify-external-and-internal-factors-that-affect-or-influence-EHR-adoption.--
These-factors-are-based-on-a-product-growth-m
odel-developed-by-Bass-(1969).
External-Factors:
"Electronic-health-record-implementations-represent-a-disruptive-change-in-the-health-care-
workplace.-In-addition-to-the-introduction-of-new-equipment,-the-job-design-of-interconnected-
health-professionals-m
ust-be-reengineered-to-effectively-and-efficiently-accommodate-the-
technology.-In-this-respect,-EHRs-may-follow-the-slower-adoption-pattern-of-“general-purpose”-
technologies-that-are-pervasive-today,-such-as-electric-motors-in-m
anufacturing,-which-required-the-
transform
ation-of-entire-industries.-General-purpose-technologies-typically-take-relatively-long-
periods-to-reach-the-diffusion-tipping-point-and-do-not-deliver-productivity-gains-im
mediately-upon-
arrival"-pg-109
"In-other-mature-health-care-systems,-such-as-Australia-and-W
estern-Europe,-various-form
s-of-EHRs-
have-been-widely-adopted.30-In-those-systems,-there-have-been-significant-governmental-efforts-to-
partner-with-physicians-or-subsidize-the-cost-of-the-new-technology,-respectively.-...As-reporting-
requirements-increase,-the-only-feasible-m
echanism-for-gathering-such-data-will-be-the-EHR.-While-
such-programs-may-be-of-some-use,-they-may-not-advance-the-goal-of-full-EHR-adoption-significantly,-
because-U.S.-providers-tend-to-respond-negatively-to-such-m
andated2use-policies,32-33-particularly-
in-comparison-to-their-international-counterparts"-pg-109
"Pay2for2perform
ance-(P4P)-programs-would-reward-physicians-for-using-EHRs-in-their-clinical-
390
2006Preventing-m
edication-errors-in-hospitals-through-a-
systems-approach-and-technological-innovation:-a-
prescription-for-2010
Hospital-Topics
31
00
10
0
Opinion
natoinal
CPOE
Revolution
Presents-a-NON2IT-solution-for-medical-error-and-patient-safety-called-FEMA-(failure-m
ode-effects-
analysis).--Author-states-that-FEMA-has-been-used-in-anesthesia-resulting-in-95%-reduction-in-
mortality-over-the-past-15-years.
391
2006Computerized-provider-order-entry-and-patient-
safety
Pediatric-Clinics-of-North-America
21
hospital
00
10
0
Opinion
Unknown
CPOE
Deep-Structure
Desscribes-benefits-of-CPOE-to-organizations.--Reasons-cited-as-barrier-to-change-include-the-fact-
that-HIT-with-clear-financial-benefits-outw
eigh-those-with-safety-or-outcome-benfeits-
"Reasons-for-low-adoption-m
ay-include-issues-of-local-feasibility.-On-an-organizational-level,-despite-
national-agreement-that-CPOE-is-beneficial,-nonalignment-of-user-incentives-and-disagreements-on-
institutional-priorities-may-im
pede-local-adoption.-On-a-technical-level,-the-expertise-and-process-
control-needed-to-achieve-the-safety-and-quality-benefits-of-CPOE-while-m
aintaining-operations-may-
exceed-institutional-capabilities-and-resources.-On-a-financial-level,-the-initial-costs-of-adoption-and-
ongoing-costs-of-maintenance-of-CPOE-m
ay-be-prohibitive-to-institutions-in-a-competitive-m
arket.-
For-these-and-other-reasons,-the-adoption-of-form
s-of-health-care-inform
ation-technology-‘‘with-
financial-benefits’’-far-exceeds-‘‘adoption-of-those-with-safety-and-quality-benefits’’-pg-1171
393
2006Design-and-implementation-of-an-application-and-
associated-services-to-support-interdisciplinary-
medication-reconciliation-efforts-at-an-integrated-
healthcare-delivery-netw
ork
Journal-of-the-American-M
edical-
Inform
atics-Association
22
Large-m
etro-IDS
00
10
0
Case-Study
Massachuse
tts
Med-Reconcilliation
Equilibrium
home-Grown-system-developed-and-implemented-at-Partners-Healthcare.--Lessons-learned-from-
process-that-im
pact-equilibrium-are:--Let-the-clinical-processes-drive-IT-design-and-not-visa-versa,-
prototypes-and-pilots-are-out-friends,-Respect-the-power-of-paper,-Let-user-feeback-and-usage-data-
guide-the-incremental-enhancement-plan2don’t-over-anticipate-users'-needs,-do-not-underestim
ate-
training-needs.--Pg-591
400
2006Community-hospital-successfully-im
plements-
eRecord-and-CPOE
Computers-Inform
atics-Nursing
32
community-hospital
00
10
0
Case-Study
Pennsylvani
a
EHR/CPOE
Equilibrium
uses-Rogers-theory-of-Diffusion-of-Innovation-(good-picture-on-pg-308)--Authors-note-an-over2riding-
factor-that-influenced-the-succes-of-im
plementation-was-collegiality-and-the-unique-environment-of-
the-community-hospital-where-everyone-knows-one-another.--Common-themes-presented-including-
having-organizational-champions-(both-physician-and-clinical-and-administrative)-Pairing-IT-with-
users,-communication,-training-and-issue-resolution-process.
401
2006The-need-for-organizational-change-in-patient-safety-
initiatives
International-Journal-of-Medical-
Inform
atics
43
hospital
00
10
0
Case-Study
pennsylvani
a
Error-reporting
Revolution
Learning-Chain-m
odel-used-to-describe-process-of-organizational-change-wihtin-an-organization.--
Data-2>-Inform
aiton-2>-Knowledge-2>-Learning-(Fig-1-pg-811)--Escentially,-a-reporting-system-is-no-
good-unless-the-errors-reported-result-in-organizational-change.--Findings-of-the-study-indicated-that-
"organizational-actions-needed-to-reduce-the-risk-of-future-errors-occurred-less-than-48%-of-the-tim
e-
and-found-that-96%-of-the-actions-taken-in-response-to-reported-errors-invovled-individual-staff."-pg-
815
Using-s-systems-dynamnic-m
odel,-"the-m
odel-predicted-that-th-eim
plementation-of-a-basic-CPOE-
system-would-have-little-effect-on-the-rate-of-serious-medication-errors-over-12-quarters-[model-
projection-period].--In-the-m
odel-where-organizaitonal-learning-occurred-as-a-result-of-the-reported-
errors,-"the-m
odel-predicted-that-in-theis-case-the-intervention-would-reduce-m
edication-error-rate-
by-alm
ost-70%-over-time-and-prevent-705-serious-errors-that-could-have-harm
ed-patients-from-
occuring."-pg-815
151
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
402
2006Creating-technology2enhanced-practice:-A-university2
home-care2corporate-alliance
Nursing-Faculty-Research-and-Publications
32
home-Care
01
10
0
Case-Study
Wisconsin
eHealth
Equilibrium
"Sustainability-of-inform
aiton-system-innovations-is-m
ore-likely-when-implementation-planning-
occurs-cincurrently-with-systems-design-activities."-pg-4-
"Effective-partnerships-are-key-to-a-sustainable-technology-innovation,-but-are-challenging-to-build-
and-m
aintain.--They-require-tim
e,-patience-and-effective-communication-from-all-partners."-pg-8
Is-sustainability-a-variable-witihn-Equilibrium.
406
2006The-W
estern-New-York-regional-electronic-health-
record-initiative:-healthcare-inform
atics-use-from-
the-registered-nurse-perspective
Studies-in-health-technology-and-
inform
atics
22
hospital
01
00
0
Mixed/Case-
Study
new-York
EHR
Deep-Structure
"the-Rn-perspective-is-of-vital-im
portance-to-the-acceptance-and-use-of-all-healthcare-inform
atics-
initiatives"-pg-248
this-is-constant-theme-throught-paper.--
Nusring-students-identifried-SWAT-(stregths,-W
eaknesss,-Oportunities-and-Threats)-associated-with-
their-perceptions-about-EHR-and-inform
atics-at-their-places-of-work.--General-stregths-identified-
were-(IT-availablility,-easy-access,-saves-time)-Threats-included-(Cost,-adversity-to-change,-
confidentiality,-financial-crisis,-employees-intimiudated-by-IT,-Lose-human-experience,-threat-to-
patient-safety,-privacy)
409
2006How-common-are-electronic-health-records-in-the-
United-States?-A-summary-of-the-evidence
Health-Affairs
44
Physicians
00
01
0
systematic-
review
national
EHR
Deep-Structure
EHRs-are-not-well-defined-leading-to-lack-of-measurement-and-adequate-policy.
Adoption-rates-varied-by-practice-size-with-solo-or-sm
all-practicdes-having-m
uch-lower-adoption-
rates.
410
2006Clinical-inform
ation-technology-gaps-persist-among-
physicians
Issue-brief-(Center-for-Studying-Health-
System-Change)
33
physicians
01
00
0
Survey
National-
Survey
Various
Deep-Structure
Highlights-widening-gap-in-HIT-adoption-betw
een-large-and-small-practices.--The-gap-trippled-
betw
een-2000-and-2004.--This-gap-was-more-pronoucd-for-activities-associated-with-exchanging-
clinical-data-and-accessing-patient-notes.--"These-differences-in-adoption-gaps-suggest-that-such-
factors-as-high-costs-and-complexity-that-can-be-m
itigated-by-larger-practice-size-m
ay-be-m
ore-direct-
drivers-of-adoption-for-some-technologies-such-as-RMR-that-allow-physicians-to-access-patient-notes.--
The-relatively-flatter-rates-of-adoption-among-physicians-in-m
ost-practice-settings-for-other-clinical-
activites-may-reflect-that-those-adoption-decisions-are-influenced-by-factors-beyond-costs.--For-
example,-preventive-reminders-m
ay-be-a-m
ore-clinically-appropairete-tool-for-some-specialties-than-
others,-resulting-in-lower-adoption-across-all-practices."-pg-3
No-differences-noted-betw
een-IT-adoption-and-population-served-regardless-of-practice-size.
413
2006Effect-of-the-implementation-of-an-enterprise2w
ide-
Electronic-Health-Record-on-productivity-in-the-
Veterans-Health-Administration
Health-Economics,-Policy-and-Law
41
IDS-(VA)
00
11
0
Opinion
National
EHR
Deep-Structure
"The-VHA-was-transform
ed-from-a-‘hospital-system’-to-a-‘health-system’.-Structurally,-this-required-
the-transform
ation-of-the-m
odel-from-a-‘safety-net’,-providing-interventions-after-clinical-
catastrophes,-to-a-m
odel-focusing-on-health-promotion-and-disease-prevention"-pg-164
"“Perhaps-the-m
ost-significant-advantage-that-the-VHA-had-in-EHR-development-was-the-decision-to-
create-an-‘in2house’-product-rather-than-outsourcing-the-product.-Thus,-the-VHA-clinicians-did-not-
have-to-align-their-clinical-processes-to-‘off-the-shelf’-EHR-software;-a-perverse-alignment-of-
workflow-adaptation-to-a-support-system,-rather-than-the-m
ore-rational-tailoring-of-such-systems-to-
support-optimized-work-flow.”-pg-168
Significant-im
provements-in-cost-and-quality-were-experienced-by-VA-during-the-period-199622004--
Several-statistics-listed-in-article.
In-order-to-accomplish-this-the-VA-has-some-distinc-advantages:
"The-VHA-is-a-vertically-integrated-system-responsible-for-both-the-delivery-and-financing-of-health-
care-in-that-it:-(a)-owns-its-own-clinic-and-hospital-system;-(b)-employs-its-own-physicians;-and-©
-has-
a-m
inim
al-flow-of-patients-in-and-out-of-the-system"
152
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
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Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
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stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
419
2006Costs-and-benefits-of-health-inform
ation-technologyUnknown
54
national-Setting
00
01
0
Systematic-
Review-with-
Expert-Opinion
National
Various
Deep-Structure
thorough-review-of-the-costs,-benefits-and-barriers-to-HIT-perform
ed-by-AHRQ.--W
hile-the-focus-of-
the-study-is-the-the-impact-of-HIT-and-areas-for-futire-benfeits-on-the-costs-and-benefits,-barriers-
identified-by-the-study-were-categorized-as:
Situational-Barriers-22-time-and-finances
Cognitive-and/or-physical-barriers-22-Physical-disabilities-and-insufficient-computer-skills
liabilty-barriers-22-confidentiality
knowledge-and-attitude-barriers
"Cutting-accroll-all-of-these-categories,-however,-m
ay-be-the-need-for-a-m
ajor-structural-and-
idealogical-reorganization-of-clinical-medicine-as-it-is-now-practiced-in-athe-m
ajority-of-settings-to-be-
able-to-integrate-iself-with-and-enjoy-the-benefits-of-HIT."-pg-5
421
2006Valuing-hospital-investment-in-inform
ation-
technology:-Does-governance-m
ake-a-difference?
Health-Care-Financing-Review
13
hospital
00
10
0
Observational
national
Various
Deep-Structure
Discusses-the-potential-differences-in-investment-in-HIT-by-for-profit-and-not-for-profit-hsopitals.--The-
authors-hypothesize-that-for2profit-hospitals-purchase-HIT-to-m
aximize-profit-and-not2for2profit-
purchase-HIT-to-improve-quantity-and-quality.--These-both-relate-back-to-the-m
issions-of-these-
institutions.
The-study-uses-data-from-1990-2-1998-from-HIM
SS-and-m
edicare-to-examine-hospital-HIT-investment-
and-perform
ance-characteristics.--The-conclusions-reached-are-not-clear-and-poorly-communicated.--
A-clear-finding-was-larger-hospitals-are-m
ore-likely-to-invest-in-HIT,-but-do-not-necessarially-increase-
profit-margins.
422
2006The-role-of-e2health-in-the-changing-health-care-
environment
Nursing-Economics
21
11
11
0
opinion
national
ehealth
Deep-Structure
Broad-summary-of-ehealth-and-all-the-benefits-and-risks-associated-with-it.--A
rticle-is-unique-in-that-it-
does-address-the-patient-perspective-provding-some-stistics-on-patient/consumer-perceptions-of-
ehealth-and-its-current-use.
425
2006Im
pact-of-barcode-m
edication-administration-
technology-on-how-nurses-spend-their-tim
e-on-
clinical-care
AMIA-2006-Annual-Sym
posium-
Proceedings
13
IDS
00
10
0
Observations/tim
e-Study
Massachuse
tts
Bar-Code
Equilibrium
The-implementation-of-a-bar-code-system-did-not-increase-the-tim
e-spent-by-nurses-on-m
edication-
administation.
426
2006Top-barriers-and-facilitators-to-nurses'-PDA-adoptionAMIA-2006-Annual-Sym
posium-
Proceedings
13
hospital
01
00
0Survey
Maryland
PDA
Deep-Structure
The-physical-design-and-organizational-support-for-new-technology-(in-this-case-a-PDA)-is-imporant-to-
adoption.
427
2006EMR-competency:-supporting-quality,-safe-and-
effective-care
AMIA-2006-Annual-Sym
posium-
Proceedings
12
IDS
00
10
0Case-Study
Minnesota
EHR
Equilibrium
Training-an-important-component-of-HIT-implementation-success.--On2going-trainingn-and-the-
continuous-evaluation-and-correction-of-training-is-also-important.
428
2006Applying-direct-observation-to-m
odel-workflow-and-
assess-adoption
AMIA-2006-Annual-Sym
posium-
Proceedings
22
IDS
01
10
0
Case-Study
Tennessee
EHR
Equilibrium
thorugh-observation-of-a-chronic-disease-clinic,-the-researchers-m
ade-observations-realted-to-
adoption-of-inform
atics-tools-2-in-this-case-an-EHR.--Issues-raised-included:--Gaps-betw
een-user-
exspectations-and-system-perform
ance,-HIT-complicating-workflows-(need-to-understand-workflow-
prior-to-implementation).
429
2006Using-IT-to-Improve-Quality-at-NewYork2
Presybterian-Hospital:-A-Requirements2Driven-
Strategic-Planning-Process
AMIA-2006-Annual-Sym
posium-
Proceedings
22
IDS
00
10
0
case-study
New-york
Various
Deep-Structure
importacne-of-aligning-IT-strategy-with-Organizatoinal-strategy.
430
2006Inform
atics-implementation-in-the-Veterans-Health-
Administration-(VHA)-healthcare-system-to-improve-
quality-of-care
AMIA-2006-Annual-Sym
posium-
Proceedings
33
IDS-(VA)
00
10
0
Survey
national
Various
Deep-Structure
Elements-of-deep-structure-highlighted-by-the-survey-include-a-correlation-betw
een-urban-setting-
and-cooperative-culture-and-the-level-of-IT-adoption.--The-authors-refer-to-the-concept-of-"resource-
slack"-to-explain-this-relationship.--Resource-slack-refers-to-the-additional-resources-avaialbe-to-
invest-in-IT.
431
2006Clinical-inform
ation-system-availability-and-use-in-
urban-and-rural-hospitals
Journal-of-Medical-Systems
33
hospital
00
10
0
Survey
Iowa
Various
Deep-Structure
highlights-difference-in-adoption-and-use-of-HIT-betw
een-urban-and-rural-hospitals-"greater-than-
90%-of-urban-hospitals,-but-only-betw
een-30-and-40%-of-the-rural-hospitals,-are-using-inform
aiton-
technology-to-collect-basic-clinical-inform
ation."-pg-436
435
2006Considerations-in-change-m
anagement-related-to-
technology
Academic-Psychiatry
31
00
10
0
Opinion
Various
Deep-Structure
Reviews-concept-of-change-m
anagement-in-term
s-of-readiness-for-change,-resistance-to-change-and-
leadership.--Factors-listed-as-measuring--readiness-for-change-include-(sponsorship,-leadership,-
motivation,-direction,-measurements,-competitor-benchmarking,-customer-focus,-rewards-
communication,-morale,-prior-experience,-innovation)--Eight-essential-factors-are-listed-for-
encouraging-transform
aiton-(Establishing-a-sense-of-urgency,-form
ing-a-pwerful-guiding-coalition,-
creating-a-vision,-communicating-a-vision,-empowering-others-to-act,-planning-for-and-creating-short-
term
-wins,-consolidating-improvements-and-producing-still-m
ore-change,-institutionalizing-new-
approaches)
1004
2006The-Best-M
edical-Care-In-the-U.S.:-How-Veterans-
Affairs-transform
ed-itself22and-what-it-m
eans-for-the-
rest-of-us
Health-Hospitals
40
hospital-2-VA
00
11
0
News
national
Various
Revolution
Good-review-of-the-Vas-transform
ation-to-a-highly-technical-quality-intitution.--The-result-of-
investment-in-technology-and-instilling-a-culture-of-quality-and-accountablility.
151
2007Getting-to-the-Point.-(cover-story)
Health-M
anagement-Technology
20
Hospital
00
10
0Case-Study/NewsIllinois
Mobile-Carts
Equilibrium
utlized-the-Failure-M
odes-and-Effects-Analysis-(FMAE)-which-looks-at-workflows-from-the-point-fo-
view-of-potential-failures-and-wether-they-are-IT-or-workflow-related.
153
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ndix(C(–(Cod
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Hospital
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Vendor
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nTechno
logy
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(Eq
uilib
rium(
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nent
Notes
152
2007THE-INTERACTION-OF-INSTITUTIONALLY-TRIGGERED-
AND-TECHNOLO
GY2TRIGGERED-SOCIAL-STRUCTURE-
CHANGE:-AN-INVESTIGATION-OF-COMPUTERIZED-
PHYSICIAN-ORDER-ENTRY
MIS-Quarterly
32
Hospital
00
10
0
Case-Study
Unknown
CPOE
Equilibrium
The-authors-examine-the-impact-of-change-triggered-by-environmental-pressures-(National-push-for-
healthcare-efficiencies,-Push-for-HIT,-etc.)-and-those-changes-triggered-by-technology-change.--These-
two-change-pressures-intersect-and-interact-in-four-ways-22-Increase-in-m
ultidisciplinary-cooperation;-
increased-standardization-of-clinical-decision-m
aking;-deference-to-physicians'-preferences-for-CPOE-
use;-and-increased-interdependence-for-CPOE-optioation.--
Authors-compare-SPOE-implementation-to-immaging-technology,-stating-that-CPOE-had-a-m
uch-
greater-social-and-organizational-effect.
153
2007The-Right-Mix
Health-M
anagement-Technology
10
Hospital
00
10
0Case-Study-/-
News
West-
Virginia
EHR
Equilibrium
Study-largely-deals-with-Data-stroage-issues,-but-does-mention-the-resistance-from-doctors-and-use-
of-PCs-and-personal-stroage-devises-thus-circumventing-the-EHR-system.
157
2007PERSPECTIVE:-Moving-Closer-To-A-Rapid2Learning-
Health-Care-System
Health-Affairs
31
naitonal
10
01
0
opinion
National
Various
Revolution
New-Technologies-will-provide-better-measures-which-in-turn-will-provide-a-m
eans-of-tracking-access,-
outcomes,-and-research.--Patients-will-become-a-greater-component-of-the-care-process-and-be-
capabile-of-more-inform
ed-decisions.
158
2007ENTERPRISE-ARCHITECTURE-M
ATURITY:-THE-STORY-
OF-THE-VETERANS-HEALTH-ADMINISTRATION
MIS-Quarterly-Executive
42
Hospital-VA-system
00
11
0
Case-Study
National
Various
Revolution
Authros-provide-a-m
odel-for-how-technology-matures-over-time-from-siloed-tools-to-a-fully-
integrated-system-that-provides-strategic-and-competative-benefit.--See-Figure-1-pg-81
Authors-follow-the-progression-of-the-VA-through-these-same-steps-of-maturity-and-demonstrate-the-
value-of-having-a-fully-mature-system-in-term
s-of-cosw
t,-quality-and-access.
436
2007Clinical-inform
ation-systems-in-nursing-homes:-an-
evaluation-of-initial-im
plementation-strategies
Computers-Inform
atics-Nursing
22
nursing-home
00
10
0
Case-Study
Midwest
Portable-technology
Equilibrium
Factors-important-to-implementation-include:
Good-first-impressions,-frustration-from-employees-frustrated-by-change,-technology-support,-initial-
and-ongoing-training,-and-connectedness.
438
2007Adoption-of-order-entry-with-decision-support-for-
chronic-care-by-physician-organizations
Journal-of-the-American-M
edical-
Inform
atics-Association
33
physican
01
00
0
Survey
national
CPOE,-CDSS
Revolution
unsing-an-existing-national-data-set,-the-study-examined-the-relationship-betw
een-CDSS-and-CPOE-
use-and-certain-organizational-characteristics.--
"Our-findings-indicate-that-an-external-reporting-requirement-is-apartucularly-powerful-external-
inceitive,-more-so-than-additional-income-for-scoring-will-on-quality-or-better-contacts-with-health-
plans."-pg-437
439
2007The-extent-and-importance-of-unintended-
consequences-related-to-computerized-provider-
order-entry
Journal-of-the-American-M
edical-
Inform
atics-Association
33
hospital
00
10
0
Survey
National
CPOE
Equilibrium
Unintended-consequences-of-CPOE-implementation-effect-the-sustainability-of-HIT-within-an-
organization-(my-idea).--A
uthors-describe-the-m
any-types-of-unitended-consequences-realted-to-
CPOE-systems.
440
2007Development-and-psychometric-evaluation-of-the-
Impact-of-Health-Inform
ation-Technology-(I2HIT)-
scale
Journal-of-the-American-M
edical-
Inform
atics-Association
33
01
00
0
Survey/tool-
Development
national
Various
Equilibrium
"Measurement-is-an-important-step-in-achieving-quality."-pg-513
The-paper-describes-the-development-of-a-m
easurement-tool-for-"nurses'-perception-about-the-ways-
in-which-HIT-influences-interdisciplinary-communication-and-workflow-patterns-as-well-as-nurses'-
satisfaction-with-HIT-applications-and-tools-currently-available-in-hospitals."-pg-507
Tool-is-build-on-the-work-of-Coiera-and-looking-at-the-Connmmunication2inform
aiton-Continuum-
which-includes-individual-and-communication-spaces-crossed-with-Communication-and-inform
aiton-
tasks.-Fig-pg-509
441
2007Enhancing-existing-products-with-new-technologies
Medical-device-technology
21
00
00
0Opinion
Unknown
Various
Equilibrium
make-the-best-with-what-you-have.
442
2007Measuring-and-m
onitoring-IT-using-a-balanced-
scorecard-approach
Journal-of-healthcare-inform
ation-
management:-JHIM
22
00
10
0Case-Study
Missouri
Various
Revolution
Describes-score-card-used-for-tracking-the-value-added-by-IT-within-an-organization.
444
2007Incremental-approach-is-best-with-a-new-EDIS
ED-M
anagement
20
00
10
0
News-Article
Texas
ED
Equilibrium
"Doctors,-says-Ho,-are-m
ore-of-a-challenge-than-nurses."-pg-2
Article-is-brief-discussion-of-success-of-new-ED-system-and-challenges-getting-buy-in-from-Nurses-and-
Docs.
154
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ndix(C(–(Cod
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Hospital
National
Vendor
Design
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nTechno
logy
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(Eq
uilib
rium(
Compo
nent
Notes
449
2007Toward-an-effective-strategy-for-the-diffusion-and-
use-of-clinical-inform
ation-systems
Journal-of-the-American-M
edical-
Inform
atics-Association
41
01
11
0
opinion
National
Various
Revolution
Authors-discss-along-a-continuum-of-diffusion-(fig-1-pg-362)-the-reason-why-diffusion-is-not-taking-
place.--These-steps-include:
2-The-focus-of-developers-on-practice-m
anagement-systems-vs.-clinical-management-systems.--"o-
have-an-impact-on-the-health-care-system-as-a-whole,-IT-applications-must-be-available-widely.-Some,-
mostly-academic-m
edical-centers,-have-developed-their-own-systems-with-the-goal-of-im
proving-
practice-internally,-but-the-real-potential-of-IT-is-in-common-systems-that-are-familiar-to-and-used-by-
many-clinicians-and-others-across-m
any-health-system-organizations.-It-is-useful-to-think-of-tw
o-
major-categories-of-IT-applications:-1)-Practice-M
anagement;-and-2)-Clinical-Management.-M
uch-of-
the-commercial-development-to-date-has-been-of-practice-m
anagement-applications.-"-pg-362
Slow-adoptoin-of-HIT-2-"As-one-cynical-author-writes-about-a-seriously-ill-patient-taken-to-a-hospital-
emergency-department,-“the-less-the-hospital-knows-about-him
,-the-m
ore-services-it-can-render,-the-
more-it-can-bill-his-health-insurer,-and-the-m
ore-it-will-collect.”16-In-m
any-instances,-there-sim
ply-is-
no-“business-case”-for-im
proving-the-effectiveness-or-quality-of-care-with-or-without-IT."-pg-363
Work-process-changes-and-the-"considerable-variety-among-applications."-pg-364
The-m
agnitude-of-the-impact-on-HIT-on-quality-and-other-non-finacial-measures-is-not-significant-
enough-"Often,-however,-the-m
agnitude-of-the-gains-is-m
odest-and-a-substantial-part-of-the-practice-
is-unaffected-by-the-IT.-For-example,-in-one-study,-computerized-systems-that-reminded-physicians-
to-provide-specific-services-appropriate-to-patients’-conditions-showed-“statistically-significantly-
higher-rates-of-compliance-than-the-control-group-for-all-standards-combined,”-but-the-increase-was-
only-from-53.5%-to-58.8%."-pg-365
450
2007Health-care-technology-adoption-and-diffusion-in-a-
social-context
Policy,-Politics,-&-Nursing-Practice
51
10
01
0
opinion/consept
ual
Various
Equilibrium
Excellent-point-of-view-on-how-to-consider-the-public-health-and-patient-perspective-in-healthcare-IT-
adoption.--Technology-capabilities-and-outcomes-are-NOT-the-only-consideration.--You-m
ust-also-
consider-the-context-of-the-transaction-(patient2provider-–-this-is-my-idea!!!)-and-the-diffusion-of-the-
technology-within-society.--
"These-technologies-are-reshaping-the-contours-of-the-health-care-landscape-and-dramatically-
altering-the-m
anner-in-which-health-care-is-sought,-organized,-delivered,-and-received-(McKeever-&-
Coyte,-2002).-As-a-consequence,-a-comprehensive-assessment-of-the-sustainability-of-technological-
innovations-needs-to-consider-not-just-the-technology-itself-but-the-m
anner-in-which-these-
innovations-alter-the-context-in-which-health-care-transactions-occur."-pg-48
"We-are-concerned-with-the-distributional-effects-associated-with-the-adoption-and-diffusion-of-
health-care-technologies-but,-in-particular,-where-the-capacity-to-capitalize-on-the-health-gains-from-
the-adoption-of-technology-varies-in-society.-For-example,-only-a-segment-of-society-m
ay-have-the-
mental-and/or-physical-capacity-to-take-advantage-of-technologies-that-provide-the-opportunity-to-
self2m
anage-an-underlying-health-condition,-thereby-yielding-distributional-effects.-These-
distributional-effects-are-brought-about-by-the-actions-of-individuals-as-they-segment-or-stratify-
themselves-into-distinct-social-groups.-This-stratification-represents-a-separating-equilibrium-that-
may-be-considered-a-form
-of-social-exclusion-as-some-m
embers-of-society-m
ay-be-excluded-from-the-
potential-benefits-associated-with-a-new-technology."-pg-48
"Specifically,-the-article-shows-that-although-health-care-technology-may-be-developed-within-a-
laboratory-and-adopted-in-a-health-care-setting,-there-are-m
ajor-social-dim
ensions-to-the-diffusion-of-
technology,-especially-when-the-public-sector-plays-a-significant-purchaser-role.-Technologists-should-
155
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rium(
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Notes
450
2007Health-care-technology-adoption-and-diffusion-in-a-
social-context
Policy,-Politics,-&-Nursing-Practice
51
10
01
0
opinion/consept
ual
Various
Revolution
Authors-discuss-Ethics-of-change-and-diffusion-as-well-and-how-it-relates-to-policy-objectives:
They-discuss-distribution-concerns:
"In-fact,-there-are-m
any-circumstances-in-which-advancement-to-well2being-for-one-segment-of-
society-would-not-be-pursued-unless-such-benefits-are-also-available-to-others-in-society."-pg-51
"there-are-m
ajor-social-dim
ensions-to-the-diffusion-of-such-technology,-especially-when-the-public-
sector-plays-a-significant-purchaser-role.-Technologists-should-become-m
ore-aware-of-the-broader-
social-im
plications-associated-with-the-uptake-and-diffusion-of-technology-and,-accordingly,-develop-
strategies-to-m
inim
ize-any-potential-adverse-distributional-consequence.-Assurance-that-health-care-
technology-satisfies-safety-and-efficacy-considerations-is-not-sufficient-for-it-to-garner-a-m
arket-
niche.-Rather,-broader-social-issues-associated-with-the-uptake-and-diffusion-of-technology,-such-as-
costeffectiveness-and-distributional-considerations,-need-to-be-addressed-to-enhance-the-course-of-
product-design-and-m
arketing."-pg-53
"This-article-has-demonstrated-that-if-care-recipients-(and-their-unpaid-caregivers)-were-to-differ-in-
their-capacity-to-take-advantage-of-new-health-care-technologies-and-products,-then-the-potential-
increase-in-inequality-generated-through-the-diffusion-of-such-technologies-might-yield-restrictions-
on-the-level-of-public-funding-for-such-technologies-and,-hence,-limit-their-effective-diffusion."-pg-53
454
2007The-impact-of-converting-to-an-electronic-health-
record-on-organizational-culture-and-quality-
improvement
International-Journal-of-Medical-
Inform
atics
43
IDS
00
10
0
Survey
Illinois
EHR
Revolution
"The-ultim
ate-shape-and-"success"-of-IT-depends-upon-and-emerges-from-a-complex,-
multidim
ensional-interaction-betw
een-IT-and-its-individual-and-organizational-users."-pg-S174
Study-examines-the-relationship-betw
een-EHR-implementation-and-organizational-culture-and-
quality.--Culture-defined-as-belonging-to-one-of-four-cultural-groups-(Group,-Developmental,-Rational-
and-Hierarchical)--A
uthors-hypothesisze-that-Group-and-Developmental-culture-scores-would-
increase-over-time-following-EHR-implementation.--This-was-not-borne-out-statistically.--Q
ualitative-
data-suggest-this-is-occuring-however.
Hypothesis-tw
o-suggested-that-EHR-would-increase-the-presence-of-CQI-processes.--A
gain-the-study-
did-not-bore-this-out.--
The-last-hypothesis-was-that-EHR-would-increase-the-quality-of-care.--The-study-showed-a-statistically-
significant-negative-correlation-betw
een-EHR-and-quality-scores.
456
2007The-effect-of-payer-mix-on-the-adoption-of-
inform
ation-technologies-by-hospitals
Health-Care-M
anagement-Review
33
hospital
00
00
0
Survey
Florida
Various
Revolution
the-study-looks-for-relationships-betw
een-payer-mix-and-HIT-adoption.--Findings-of-the-study-suggest-
"only-m
anaged2care-companies-positively-influence-hospitals-in-the-adoption-of-IT.--Specifically,-as-
patients-with-m
anaged2care-insurance-incresaingly-m
ade-up-the-percentage-of-a-given-hospitals-
overall-discharges,-an-increase-in-IT-adoption-is-observed."-pg-107
higher-bed-size-and-m
emberhsip-in-a-m
ulti2hospital-system-were-also-positively-related-to-increased-
IT-use.
For-profit-tax-status-was-negatively-associated-with-IT-adoption.
457
2007The-Relationship-Betw
een-Pediatric-Volume-and-
Inform
ation-Technology-Adoption-in-Hospitals
Quality-M
anagement-in-Healthcare
33
hospital
00
10
0
Survey
Florida
Various
Revolution
"After-controlling-for-a-number-of-covariates,-our-findings-suggest-that-hppitals-that-care-for-a-large-
number-of-children-in-Florida-are-adopting-bothe-clinical-and-non2clinical-IT-applications-more-
frequently-than-theor-counterparts."-pg-149
"hospitals-that-serve-an-increasingly-larger-patient-base-convered-by-Medicaid,-Child's-M
edical-
Assistance,-or-other-form
s-of-state2level-public-coverage-are-less-likely-to-adopt-clinical-and-
nonclinical-inform
ation-systems."--pg-151
458
2007Electronic-M
edical-Records-for-the-Orthopaedic-
Practice
Clinical-orthopaedics-and-related-research
21
Practitioner
01
00
0
Opinikon
Various
EHR
Equilibrium
Outlines-criteria--for-selection-of-an-EHR-vendor-including-the-examination-of-2-underlying-
technology,-security-and-HIPAA-compliance,-structure-of-content,-Functionality-and-features,-Coding,-
decision-support,-reporting-and-implementation.
156
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
459
2007Five-constants-of-inform
ation-technology-adoption-
in-healthcare
Hospital-Topics
21
00
10
0
Opinion
Various
Deep-Structure
Components-of-successful-technology-adoption-in-healthcare-are-listed-and-expanded-upon.--The--
five-constants-dsicussed-by-the-authors-are-budget,-supportive-leadership,-project-m
anagement,-
umplementation-and-end-user-involvement.
"Perhaps-one-of-the-m
ost-significant-barriers-to-successful-IT-integration-is-insufficient-funding-in-the-
IT-budget.--…
Relative-to-other-industries,-healthcare-executives-may-be-m
ore-willing-to-absorb-
extensive-investments-in-new-IT-if-the-technology-promises-to-substantially-im
prove-the-overall-
quality."-pg-19
461
2007The-case-for-e2prescribing
Hospitals-&-health-netw
orks/AHA
11
hospital
00
00
0Opinion
national
eRx
Equilibrium
Implementation-requires-organizations-to-addres-training-and-support,-workloads-and-workflow-
changes,-costs,-communication
462
2007Stark-redo.-Hospitals-hesitate-to-help-digitize-
doctors'-offices-until-the'relaxed'rules-are-further-
clarified
Hospitals-&-health-netw
orks/AHA
41
hsopital
01
11
1
Opinion
National
EHR
Deep-Structure
Key-component-of-deep-structure-is-regulation.--Author-specificlly-targets-the-Stark-Laws-which-
address-anti2kickback-rules-and-the-ability-of-hospitals-to-fund-affiliated-physician-HIT.--IRS-also-has-
limitations-on-such-transactions-for-non2profit-entities-donating-anything-of-value-to-a-for2profit-
entity.
463
2007Making-the-case-for-a-clinical-inform
ation-system:-
the-chief-inform
ation-officer-view
Journal-of-critical-care
41
National
11
11
0
Opinion
Natoinal
Various
Deep-Structure
Who-gets-the-benfeit-22-"According-to-a-joint-report-by-the-M
assachusetts-Technology-Collaborative-
and-the-New-England-Healthcare-Institute-[8],-the-reality-m
ay-be-otherw
ise.-Benefits-do-not-
consistently-accrue-to-the-providers-who-m
ake-the-investment;-rather,-profits-m
ay-surface-only-
when-the-health-care-system-is-considered-as-a-whole."-pg-58
PATIENT-2-"Health-care-consumers-have-not,-as-yet,-been-an-active-force-in-demanding-the-sorts-of-
increased-efficiencies-that-would-result-from-the-adoption-of-CIS-technologies.-Two-important-
components-of-consumerism
-are-paym
ent-for-services-and-judgment-about-value-received-for-dollars-
spent.-Health-care-services-are-unusual-in-that-the-consumers-of-services-(the-patients-and-their-
families)-have-not-been-the-principal-payers-for-those-services."-pg-58
With-regard-to-transform
ation-2-"There-are-powerful-forces-moving-toward-electronic-exchange-of-
health-care-inform
ation,-and-they-are-the-same-forces-that-have-been-at-the-core-of-other-business-
transform
ations,-such-as-banking.-They-include-the-quality-of-the-product-(in-this-case,-health-care),-
the-financial-return,-increased-consumerism
,-and-compliance-with-federal-and-state-direction.
Of-these-forces,-perhaps-the-m
ost-subtle-but-most-compelling-is-consumerism
:-protecting-and-
empowering-patients."-pg-64
465
2007Health-Inform
ation-Technology:-Does-It-Facilitate-Or-
Hinder-Rapid-Learning?
Health-Affairs
21
00
01
0Opinion
Various
Deep-Structure
Barriers-to-learning-from-HIT-include-2-collection-of-consistent-data,-standards,-privacy.
466
2007Im
plementation-and-use-of-an-electronic-health-
record-within-the-Indian-Health-Service
Journal-of-the-American-M
edical-
Inform
atics-Association
33
Indian-health-service
01
00
0
IDS
National
EHR
Deep-Structure
Barriers-to-implementation-include-geography,-which-m
ay-be-unique-to-this-setting.--Other-barriers-
idenfified-included-clinician-belief-in-the-system-and-lack-of-time-using-the-system-(avg-1.5-years).--O
f-
note-was-the-gap-betw
een-perceived/anticipated-improvements-in-quality-of-care-and-the-resulting-
lack-of-a-belief-that-the-EHR-actualy-helped-improve-quality.--"only-about-one2third-felt-that-the-
electronic-health-record-actually-helped-them-to-improve-quality-of-care-or-patient-safety."-pg-195
468
2007Measuring-IT-benefits:-let-us-count-the-ways
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
11
hospital
00
10
0
Opinion
Various
Equilibrium
IT-success-invovles-the-m
easurement-of-benefits-including-the-idenfiation-of-appropatie-m
easures-
before-implementation-and-then-using-these-m
easures-after-to-show-success.
IT-governance-also-critical-together-with-Executive-buy-and-support-of-projects.
469
2007Im
plementation-of-an-obstetrics-EMR-m
odule:-
overcoming-user-dissatisfaction
Journal-of-Healthcare-Inform
ation-
Management
21
OB/G
YN
01
00
0
Case-Study
Michigan
OB-EMR
Equilibrium
Common-case-study-of-im
plenetation-of-HIT.--Recomends
2involving-a-variety-of-clinicians-in-design
2-Allow-adequate-tim
e-for-testing
2-Measure-critisim-accuratela-dn-do-not-overreact
2-Anticipate-workflow-change
2-Communication
2-risk-assessment
2-make-program-changes-quickly
470
2007Showing-"what-right-looks-like"22how-to-improve-
perform
ance-through-a-paradigm-shift-around-
implementation-thinking
Journal-of-Healthcare-Inform
ation-
Management
32
IDS
00
10
0
Case-Study
Delaware
various
Revolution
Article-m
ainly-focuses-on-Chanign-the-m
anagement,-vision-and-perform
ance-of-the-IT-Department.--
Of-significant-to-revoution-is-the-impetus-for-change-at-the-health-System-22-leadership-change-at-the-
CEO,-COO-and-CIO-level-within-an-eight-month-period.
471
2007Quality-and-efficiency-successes-leveraging-IT-and-
new-processes
Journal-of-Healthcare-Inform
ation-
Management—Vol
12
hospital
00
10
0
case-study
Various
Various
Equilibrium
Minim
al-signifiant-to-PE.--Discusses-change-process-m
ethod-of-"Path-Innovation"-which-describes-
combining-Process-improvement,-IT-desdign-and-clinical-experts-when-implementing-a-new-CLINICAL-
IT-system.
157
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
473
2007Regional-Health-Inform
ation-Organizations:-A-
Vehicle-for-Transform
ing-Health-Care-Delivery?
Journal-of-Medical-Systems
53
Nealth-System
11
10
0
comparative-
Case-Study
MA,-IN,-CA
HIE
Revolution
Study-framework-is-the-Healthcare-Inform
ation-Technology-Factor-Model-(pg-37).--The-m
odel-
consists-of-three-demention-and-several-factors-that-define-"healthcare's-readiness-for-the-
acceleration-of-cahnge-through-the-advancement-of-inform
ation-technology"-pg-37--The-three-
dim
entions-are-22-Innovation-and-diffusion,-adaptation-and-m
anaging-change.--GOOD-CHART-ON-
PAGE-38.--For-each-dim
ention-factor-and-assocaited-innhibitng-and-accelerating-property-is-defined.--
For-example,-the-factor-"M
arket-and-competative-pressures"-can-both-inhibit-and-accelate-the-golas-
of-the-organziation.
Several-conclusions-are-reached-by-the-author:
Varying-roles-and-impacts-on-stakeholders22
"The-advancement-by-MHDC-of-simpler,-m
ore-cost2effective,-and-convenient-financial-data-exchange-
to-reinvent-the-business-m
odel-for-EDI-among-payers-and-providers-is-indicative-of-the-
transform
ation-of-a-service-m
odel-that-can-occur-with-a-disruptive-innovation.-The-electronic-
delivery-of-non2proprietary-and-standardized-clinical-inform
ation-to-the-clinician-at-the-point-of-care-
by-all-the-RHIOs-has-similar-disruptive-attributes-but-is-inhibited-by-the-adaptation-of-clinician-
workflow-and-decision2m
aking-processes-to-eliminate-the-complexities-and-access-problems-of-the-
traditional-methods.-The-need-for-the-RHIO-leadership-to-allocate-its-finite-capital-to-addressing-the-
challenges-with-clinician-adoption,-plus-the-concerns-regarding-privacy-and-ownership-of-PHI,-has-the-
undesirable-effect-of-precluding-the-health-care-consumer-from-being-an-active-participant.-As-a-
result,-clinical-IT-innovations-with-the-potential-to-transform
-the-care-delivery-m
odel-are-lim
ited-to-
those-that-im
prove-clinician-decision2m
aking.-Health-care-consumer-self2service-and-particularly-
internet2mediated-collaborative-care-innovations-that-can-have-a-m
ajor-effect-on-changing-the-
patient2physician-relationship-(and-therefore-transform
-the-care-delivery-m
odel)-are-not-in-the-RHIOs-
cache.-The-current-state-of-the-organization,-unless-it-evolves-to-include-health-care-consumers,-
474
2007Planning-for-pharm
acy-health-inform
ation-
technology-in-critical-access-hospitals
American-journal-of-health2system-
pharm
acy
22
hospital
00
10
0
Case-Study
Florida
Pharm
acy
Equilibrium
Barriers-identified-during-the-implementation-of-the-new-m
edication-system-were:
12-Funding-both-of-IT-and-physical-space
22-Staff-resistance-to-change
32-Staff-tim
e-needed-for-training,-planning-and-implementation.
476
2007The-value-of-electronic-health-records-in-community-
health-centers:-policy-implications
Health-Affairs
43
health-centers
00
10
0
comparative-case-
study
natoinal
EHR
Deep-Structure
Good-evaluation-of-the-issues-faced-by-community-health-centers.--Authors-look-at-the-value-of-EHRs-
from-both-a-financial-and-QI-perspective.--From-a-financial-perspective-"Revenue-enhancement-
benefits-were-negligible.--CHCs-could-not-use-EHRs-to-increase-visit-coding-levels-because-M
edicad-
paid-m
ost-CHCs-a-flat-rate-per-visit."-pg-209
From-a-QI-perspective-significant-benefits-were-seen-to-the-community-as-a-result-of-EHR-however,-
"Despite-theor-satisfaction-with-the-siable-EHR2related-QI-gains,-interviewees-felt-that-they-were-only-
beginning-to-use-the-EHR-effectively-for-QI."-pg-211
"EHRs-in-CHCs-were-a-clear-value-to-patient-and-payer-stakeholders."-pg-211
Barriers-identified-by-the-study-include-2-complexity-of-patient-mix-at-CHCs,-lack-of-resources.--
Authors-recommend-policies-in-the-form
-of-financial-help-and-pay-4-perform
ance-payemnts.
477
2007A-systems-approach-to-purchasing-and-
implementing-new-technology
Nursing-Administration-Quarterly
11
01
10
0Opinion
Various
Equilibrium
Superficially-refers-and-decsribes-common-activities-associated-with-ANY-IT-implementation,-Assess,-
Recommend,-im
plement-and-m
easure.
481
2007Clinician-use-of-enabling-technology:-creating-a-new-
healthcare-system-through-the-use-of-enabling-
technologies-requires-changes-on-a-profound-scale
Journal-of-healthcare-inform
ation-
management:-JHIM
31
01
00
0
Opinion
Natoinal
Various
Deep-Structure
"'technology-amounts-to-a-forced-cultural-revolution,-'-w
rites-Dr.-Joseph-M
arin,-dean-of-Harvard-
School-of-Medicine"
Authors-describe-the-concept-of-"thoughtflow"-which-is-the-process-by-which-physicians/nurses-
others-obtain,-assess,-prioritize-and-act-on-inform
ation.--Critical-to-understand-this-process-which-
varies-based-on-culture,-education,-patient-mix,-etc.--Nearly-im
possible-to-design-a-system-that-is-
flexible-enough-to-deal-with-these-variations.
Education-will-be-important-to-reducing-resistance.
158
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
482
2007Enterprise-project-m
anagement-is-key-to-success:-
addressing-the-people,-process-and-technology-
dim
ensions-of-healthcare
Journal-of-healthcare-inform
ation-
management:-JHIM
21
00
10
0
Opinion
National
Various
Equilibrium
highlights-the-importance-of-change-m
anagement-and-project-m
angaement.--D
escribes-a-basic-
change-m
anagement-process-and-what-organziations-need-to-do-to-be-prepared-for-and-implement-
change.--Transition-is-more-important-than-the-change-itself.
483
2007EMRs-in-the-Fourth-Stage
Journal-of-Healthcare-Inform
ation-
Management
22
health-system
00
10
0Case-Study
Utah
EHR
Equilibrium
good-outline-of-benefits-and-costs-of-HIT,-but-nothing-particularly-relevent-to-PE.--Outline-
implementation-and-planning-process.
484
2007Determ
inants-of-personal-health-record-use:-a-large-
population-study-at-Cleveland-Clinic
Journal-of-healthcare-inform
ation-
management:-JHIM
44
hospital
10
00
0
Observational-
with-control
Ohio
PHR
Deep-Structure
"Consumers-have-embraced-the-Internet-and-become-accustomed-to-ordering-goods-and-services,-
and-conducting-their-banking-online.-The-exponential-growth-of-the-Internet-has-fueled-the-desire-for-
consumers-to-experience-the-convenience-and-empowerm
ent-that-comes-with-having-electronic-
personal-health-records.-Surveys-conducted-in-the-last-several-years-have-demonstrated-the-
increasing-desire-of-healthcare-consumers-to-become-m
ore-actively-involved-in-m
anaging-their-
healthcare,-communicating-with-providers-and-having-health2related-services-available-online."-pg-44
Good-point-about-patient-involvement-2-"W
inkelm
an-et-al-conclude-that-technology-is-an-important-
support-tool-that-will-not-directly-affect-outcomes-because-access-to-inform
ation-alone-is-
meaningless-if-it-does-not-connect-with-the-larger-framework-of-measures-enabling-self2care-and-
support.-They-also-conclude-that-respondents’-self2reports-of-use-tend-to-overestim
ate-actual-
behaviors."-pg-45
Findings
485
2007Digital-transform
ation-in-home-care.-A-case-study
Journal-of-healthcare-inform
ation-
management:-JHIM
22
Community-Health
00
10
0
Case-Study
New-Jersey
EHR
Equilibrium
Implementation-case-study.--Emphasizes-the-importance-of-process-change-and-change-m
anagement-
tools.--The-organization-utilized-six-sigma-process.
Factors-influencig-the-process-were-Leadership-changes,-lim
ited-system-adminstrator-support,-and-
the-nature-of-home-care-which-functions-with-very-independent-clinicians.
486
2007Redesigning-care-delivery-through-health-IT-
implementation.-Exploring-Trinity-Health's-IT-m
odel
Journal-of-Healthcare-Inform
ation-
Management
32
IDS-2-health-system
00
10
0
Case-Study
Iowa
Various
Equilibrium
Describes-the-process-of-im
plementing-a-new-HIT-system.--Discusses-the-planning-process-"one-part-
technology-and-two-parts-culture-and-work-proceses."-pg-42
Key-point-was-the-notation-that-change-in-a-healthcare-environment-can-be-tim
e-consuming-2-"The-
journey-will-span-years-and-spread-across-the-continuum-of-care."-pg-47
Training,-Planning,-processes-and-workflow-are-all-key-to-implementation.
487
2007Economic-Externalities-of-Health-Inform
ation-
Technology
Journal-of-Healthcare-Inform
ation-
Management
33
11
10
0
Theoretical-
Model
EHR
Deep-Structure
Develops-a-m
odel-of-EHR-adoption-using-the-economic-influences-on-each-party-involved-in-the-EHR-
adoption-question.--Three-players-in-the-m
odel-are-payer,-provider-and-consumer.--A
pplying-Game-
theory,-the-author-demonstrates-how-a-m
odel-can-help-policy-m
akers-identify-the-best-areas-for-
influence-if-the-goal-is-EHR-adoption.--In-the-sample-m
odel-a-subsidy-is-given-to-the-provider-by-the-
payer,-resulting-in-a-shift-in-equilibrium.--No-spcific-subsidy-amounts,-costs,-etc.-are-provided-and-the-
author-suggests-this-is-an-area-for-future-research.
493
2007Optimizing-the-acceptance-of-medication2based-
alerts-by-physicians-during-CPOE-implementation-in-
a-community-hospital-environment
22
Hospital
00
10
0
Case-Study
California
CPOE
Equilibrium
Highlghts-the-difficulty-in-a-community-hospital-setting-with-voluntary-m
edical-staff.
494
2007Recommendations-for-clinical-decision-support-
deploym
ent:-synthesis-of-a-roundtable-of-medical-
directors-of-inform
ation-systems
32
hospital
00
10
0
Focus-Group
CDSS
Deep-Structure
States-the-finding-from-a-focus-group-of-30-CMIOs-that-"currently-available-technology-is-inadequate-
to-satisfy-this-need."--Reasons-cited-include-"lack-of-tools-for-incorporating-and-m
anipulating-clinical-
knowledge-in-inform
aiton-systems,-which-in-tirn-can-lead-to-such-adverse-phenomena-as-alert-
fatigue."--pg-362
497
2007Hospital-adoption-of-inform
ation-technologies-and-
improved-patient-safety:-a-study-of-98-hospitals-in-
Florida
Journal-of-healthcare-
management/American-College-of-
Healthcare-Executives
33
hospital
00
10
0
Survey
Florida
Various
Equilibrium
Study-shows-a-correlation-betw
een-IT-Adoption-with-specific-outcome-m
easures-(AHRQ-patient-
safety-index).---Study-found-"Eight-different-PSI-measures-were-statistically-significantly-related-to-at-
least-one-m
easure-of-IT-adoption.-[In-the-beneficial-direction]."-Pg-404--A
lso,-hospitals-with-a-higher-
level-of-IT-sophistication-were-significantly-related-to-the-greatest-number-of-patient-safety-
outcomes.
498
2007Transform
ational-change-in-health-care-systems:-an-
organizational-model
Health-Care-M
anagement-Review
53
hospital
00
10
0
Comparative-
Case-Study
National
Various
Revolution
Proposes-a-m
odel-of-technology-transform
ation-Based-on-five-(5)-elements-that-must-all-work-
together-to-achieve-SUSTAINED-transform
ation.--The-5-elements-are:--Impetus-to-transform
,-
"Leadership-commitment-to-quality,-im
provement-initiatives-that-actively-engage-staff-in-m
eaningful-
problem-solving,-alignment-to-achieve-consistency-of-organization2w
ide-goals-with-resource-
allocation-and-actions-at-all-elvels-of-the-organization-and-integration-to-bridge-traditional-intra2
organizational-boundaries-betw
een-individual-components"-pg-314--M
odel-depicted-in-Figure-1-pg-
314
"The-analyses-show-that-systems-with-stronger-presence-of-model-elements-also-scored-higher-on-
survey-items-reflecting-progress-to-transform
ation,-including-ratings-of-patient-care-quality-in-the-
organization-and-judgments-regarding-the-impact-of-the-organization's-QI-efforts-on-
productivity/efficiency,-patient-outcomes,-m
edical-errors,-and-staff-involvement-in-QI-efforts."-pg-
318
159
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
499
2007Technology-acceptance-among-physicians
Medical-Care-Research-and-Review
54
01
00
0
Systematic-
Review
Various
Deep-Structure
Good-article-for-modleing-deep-structure-within-PE-theory.--Literature-was-reviewed-over-the-
previous-10-years-and-the-authors-propose-an-update-to-the-TAM-for-looking-at-physcian-acceptance.--
The-authors-conclude-that-a-barriers-component-needs-to-be-added-to-the-TAM-m
odel-and-suggest-
development-of-a-new-scale-in-future-research.
Barriers-considered-based-on-the-literature-include-cost,-organizaitonal-structure-(i.e.-reim
bursement-
levels)-unique-relationship-with-patients,-and-physician-percenptions-of-utility.
New-TAM-m
odel-page-669
500
2007Exploring-physician-adoption-of-EMRs:-a-m
ulti2case-
analysis
Journal-of-Medical-Systems
33
Small-practice
01
00
1
Comparative-
Case-Study
Unknown
EHR
Equilibrium
The-case-studies-of-EHR-implementation-experience-comparing-pre2and-post-expectations.--The-
findings-of-the-authors-are-summarized-in-two-themes:--Financial-(Cost,-supplier-presence,-and-trust)-
and-innovation-(sustomizablility-and-reliability)
501
2007Streamlining-W
orkflow-Using-Existing-Technology
Computers-Inform
atics-Nursing
22
Hospital
00
10
0Case-Study
Unknown
Various
Equilibrium
Emphasizes-the-importance-of-change-m
anagement-during-implementation.
502
2007Patients-m
eet-technology:-The-newest-in-patient2
centered-care-initiatives
The-Health-Care-M
anager
11
10
00
0
Opinion
Patient-Technology
Deep-Structure
Discusses-need-for-patient-involvement-in-care-and-list-several-examples-of-patient-technologies.
E2registration,-Telemonitoring-devisces,-RFID,-Smart-Beds,-Patient-Portals,-PHR
504
2007Technologies-of-health-policy
Health-Affairs
31
00
01
0
Opinion
Various
Revolution
Major-factors-for-adopting-new-technologies-include:--1-2-a-crisis-or-perceived-oportunity;-22-a-
persuasive-diagnosos-of-what-is-needed;-32-a-prescription-for-new-policies-and-42-new-policies-that-
are-ready-to-go.
507
2007Don't-LOL-at-virtual-visits.-Technology-is-allowing-
more-doctors-and-patients-to-consult-via-e2m
ail,-and-
insurance-companies-are-reim
bursing-for-it
Modern-Healthcare
21
11
00
0
Opinion
eVisits
Deep-Structure
highlight-the-benfeits-and-legal-issues-with-electronic-or-virtual-offie-visits.--The-m
ain-legal-obstacle-is-
licensing-when-either-the-patient-or-doctor-are-not-in-the-state-the-doctor-is-lisenced-in.
509
2007Decision-support-technology-in-knowledge-
translation
Academic-Emergency-M
edicine
31
00
10
0
Opinion
CDSS-and-CPOE
Deep-Structure
Barriers-to-implementation-and-effectiveness-of-new-IT-are-lack-of-coordination-betw
een-health-care-
providers,-reminders-not-bein-provided-while-the-clinician-is-with-a-patient-workload-factors,-lack-of-
flexibility-and-poor-interface.---A
uthors-propose-a-10-commandments-of-successful-deploym
ent
12-Speed-is-everyhting
22-antiipate-needs-in-real-time
32-Fit-into-user-workflow
42Little-things-make-a-big-difference
52-Recognize-that-physicians-will-strongly-resist
62-changing-direction-is-easier-than-stopping-
72-Sim
ple-interventions-work-best
82-Ask-for-additional-inform
aiton
92-Monitor-im
pact
102-Manage-and-m
aintain-your-knowledge
512
2007Designing-and-evaluating-healthcare-ICT-Innovation:-
A-cognitive-engineering-view
Studies-in-health-technology-and-
inform
atics
31
00
10
0
Opinion
Various
Deep-Structure
Authors-discuss-a-proposed-m
odel-of-the-interactions-betw
een-staekholders-in-healthcare-2-"Patients-
to-politicians"-m
odel.--The-m
odel-identifies-the-various-people-stakeholders-and-influencers-on-these-
stakeholders-(political-to-clinical-pathological).--M
odel-pg-??
Suthors-propose-using-sim
ulation-to-fully-understand-HIT-impact-prior-to-implementation.
513
2007Costs-of-im
plementing-a-computerized-prescription-
system-in-a-public-mental-health-agency
Psychiatric-Services
22
Phychiatric-Clinic
00
10
0
Case-Study
Unknown
Eprescribing
Equilibrium
Examines-cost-of-im
plemening-an-electronic-prescription-system-at-a-small-psychiatric-clinic.--Focus-is-
on-cost-of-the-sytstem-and-the-authors-found-that-in-a-PUBLIC-envoironment-the-quality-benefits-
were-worth-the-expense-of-the-system-software.
Did-not-address-ROI,-just-the-patient-and-quality-benefits-from-impleentation.
160
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
517
2007Computerized-physician-order-entry-with-clinical-
decision-support-in-long‚Äêterm
-care-facilities:-costs-
and-benefits-to-stakeholders
Journal-of-the-American-Geriatrics-Society
31
LTC
00
10
0
Opinion
CPOE-CDS
Revolution
"Recognition-of-the-costs-and-benefits-borne-by-the-various-participants-and-the-substantial-time-lag-
in-the-realization-of-benefits-suggests-that-incentives-may-be-necessary-to-enhance-adoption-of-these-
systems.-For-instance,-under-a-fee2for2service-m
echanism,-payers-could-offset-costs-to-the-nursing-
home-for-im
plementing-the-system-through-direct-subsidies-or-other-form
s-of-incentive-paym
ents.
Successful-adoption-of-health-inform
ation-technology-depends-on-physician,-nurse-practitioner,-and-
nurse-receptivity-to-using-these-systems.-Incentives,-nonmonetary-or-monetary,-may-need-to-be-in-
place-to-encourage-and-ensure-widespread-use.-Insurers,-such-as-Blue-Cross-and-Blue-Shield,-are-
starting-to-m
ake-bonus-paym
ents-to-physicians-for-im
plementation-of-health-inform
ation-technology-
and-electronic-communications;-such-initiatives-can-play-an-important-role-in-adoption-and-use-of-
health-inform
ation-technology-in-the-LTC-setting."-pg-1456
517
2007Computerized-physician-order-entry-with-clinical-
decision-support-in-long‚Äêterm
-care-facilities:-costs-
and-benefits-to-stakeholders
Journal-of-the-American-Geriatrics-Society
31
LTC
00
10
0
Opinion
CPOE-CDS
Equilibrium
identify-several-compoents/factors-affecting-the-unltim
ate-costs-and-benefits-of-a-new-HIT-system-2-
level-of-system-functrionality,-unintended-consequences,-differences-in-software-systems,-level-of-
connectivity,-late-vs.-early-adoptor,-level-ot-IT-knowledge,-Size,-purchase-price-and-hosptial-
population.--Good-table-on-pg-1455.
"This-consideration-of-the-costs-and-benefits-related-to-implementation-of-CPOE-with-CDS-in-the-LTC-
setting-indicates-that-multiple-stakeholders-will-incur-the-costs-of-im
plementing-and-m
aintaining-
these-systems-but-that-the-costs-that-each-incurs-m
ay-not-be-fully-aligned-with-the-benefits.-"-pg-
1456
518
2007The-politics-of-inform
ation-technology
Nursing-Administration-Quarterly
21
Hospital
01
00
0Opinion
Various
Equilibrium
Politics-play-an-important-role-in-IT-implementation.--"A-clinical-system-implementation/installation-
highlights-nursing's-traditional-conflics-with-physicians,-administration-and-itself."-pg-357
520
2007Organizational-technologies-for-transform
ing-care:-
measures-and-strategies-for-pursuit-of-IOM-quality-
aim
s
The-Journal-of-ambulatory-care-
management
21
00
00
0
Opinion
Various
health-system-is-complex-adaptive-system:
"Successful-pursuit-of-transform
ation-requires-a-holistic-view-that-attends-to-m
ultiple-agents-and-
their-interactions-affecting-work-in-complex-adaptive-systems.-"-pg-300
"Knowledge-of-these-technologies-in-the-pursuit-of-disruptive-transform
ational-strategies-considered-
here-are-critical-to-attaining-the-organizational-learning,-cultural-change,-and-growing-developmental-
capacity-of-health-organizations-to-attain-the-IOM's-ambitious-aim
s."-pg-300
"we-encourage-the-pursuit-of-organizational-strategies-and-research-that-look-toward-the-
contribution-of-the-m
ultiple-organizational-technologies-in-identifying-m
easures-of-success-and-
progress-toward-attaining-the-IOM-aim
s."-pg-300
521
2007Adoption-of-health-inform
ation-technology-in-
community-health-centers:-results-of-a-national-
survey
Health-Affairs
43
Health-centers
00
10
0
Cross-Sectional
National
EHR
Deep-Structure
Based-on-a-national-survey,-"Patient2mix-characteristics-are-the-m
ost-ikportant-factors-in-
understanding-EHR-adtopn-rates-ampong-CHCs…
.-Unlike-other-health-care-providers,-health-centers-
will-not-be-able-to-shift-adoption-costs-to-proviate-payers,-nor-can-they-be-expected-to-have-the-level-
of-access-to-proviate-lending-capital-enjoyed-by-providers-with-robust-provately-sponsored-
operations."--pg-137921380
522
2007Health-inform
ation-exchange:-'lex-parsim
oniae'
Health-Affairs
41
00
01
0
Opinion
National
Various
Deep-Structure
Local-flexibility-in-designing-national-infrastructure-is-Key.--"The-aparent-paradox-of-this-approach-is-
that-the-best-way-to-support-heterogeneity-and-evolutionary-innovation-across-a-wide-variety-of-
participans-in-a-large-netw
ork-is-to-enforce-homogeneity-for-a-small,-well2choseen-set-of-intergaces-
at-the-center."-pg-w597
524
2007Unintended-consequences-of-inform
ation-
technologies-in-health-care22an-interactive-
sociotechnical-analysis
Journal-of-the-American-M
edical-
Inform
atics-Association
41
hospital
00
10
0
Opinion/theoreti
cal
Various
Deep-Structure
Authors-propse-a-new-m
odel-to-explain-unintended-consequences-from-HIT-implementation.--The-
research-is-based-on-the-m
elding-of-several-existing-social-technical-frameworks-into-the-prposed-
model-"Interactive-Sociotechnical-Analysis"-(ISTA)-2-figure-1,-pg-544.--
the-m
odel-proposes-that-technology-is-not-simply-a-tool-but-because-of-its-interactive-ability-im
pacts-
the-social-system-of-the-organization-as-well-as-the-technical-and-physical-infrastructure.--By-
interacting-both-physically-and-socially,-sytems-have-a-greater-effect-often-than-what-was-intended.--
This-effect-can-lead-to-unintended-consequences.--Table-1-lists-several-of-these-consequences-and-
their-relation-to-the-ISTA-m
odel.
527
2007Telemedicine's-Adolescent-Angst
Hospitals-&-Health-Netw
orks
21
00
00
0opinion
Telemedicine
Deep-Structure
Rebim
bursement-structures-are-barrier-to-telemedicine-as-well-as-other-technologies.
529
2007Ten-lessons-from-the-top-100
Hosp-Health-Netw
13
00
10
0
Cross-Sectional
National
Various
Equilibrium
"The-nation's-100-M
ost-W
ired-Hospitals-and-Health-Systems-have-better-outcomes-than-other-
hospitals-on-four-key-measures:--m
ortality-rates,-AHRQ-patient-safety-m
easures,-the-Joint-
commission's-Core-M
easures-and-average-length-of-stay.--This-is-the-strongest-evidence-in-the-nine2
year-history-of-the-survey-of-an-assocaition-betw
een-the-implementation-and-adoption-of-
inform
ation-technology-and-the-quality-and-cost-of-patient-care."-pg-1
164
2008Health-Care-Sheds-Its-Tech2Laggard-W
ays
Inform
ationweek
30
hospital
00
10
0
News
National
Various
Equilibrium
Spending-on-HIT-is-low.--"Inform
ationWeek-500-health-care-companies-are-spending-a-m
eadian-4%-of-
revenue-on-IT-budgets-this-year,-just-as-in-2007,-but-still-a-stunning-increase-from-the-m
easly-2.7%-of-
revenue-spent-on-IT-in-2002."-pg-113
161
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
165
2008Beginning-at-the-End
Health-M
anagement-Technology
20
Hospital
00
10
0
news
National
Various
Equilibrium
most-projects-fail-22-"According-to-the-Standish-Group's-2006-Chaos-Report-survey,-nearly-one-in-five-
implementations-fail,-and,-nearly-half-run-over-time-or-budget."-pg-38
need-to-identify-VALU
E-at-the-beginning-of-a-project-to-help-ensure-success.
199
2008Digital-Quality-of-Life:-Health-Care
Digital-Quality-of-Life:-Understanding-the-
Personal-and-Social-Benefits-of-the-
Inform
ation-Technology-Revolution
21
Hospital
00
10
0
Opinion
National
Varoius
Equilibrium
Author-discusses-the-benefits-of-HIT-to-access,-cost-and-quality.--Does-not-add-m
uch-to-discussion,-
than-what-is-already-known.
Emphasize-that-technology-has-huge-benefit-and-that-failures-of-prior-studies-may-be-m
ore-the-result-
of-poor-im
plementation-than-poor-technology.
606
2008A-m
andate-in-M
ass.-Massachusetts-wants-CPOE-in-
place-by-2012.-Will-CIOs-be-willing-and-able-to-
comply?
Healthcare-inform
atics:-the-business-
magazine-for-inform
ation-and-
communication-systems
30
hospital
00
10
0
news
Massachuse
tts
CPOE/EHR
Revolution
MASS-has-passed-a-new-law-m
andating-use-of-CPOEs-by-2012-and-EHR-by-2015.--The-study-
anticipates-that-hospitals-will-have-to-comply-and-m
ay-benefit-from-the-implementation.
611
2008The-future-of-healthcare-IT:-what-can-we-expect-to-
see?
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
30
00
10
0
news
Various
Revolution
mentions-2005-survey-by-Deloitt-which-found-that-"m
ost-CEOs-predicting-that-healthcare-sector-
change-would-be-evolutionary-rather-than-revolutionary.--Although-concerned-about-operating-
margins,-these-CEOs-believe-that-their-organizations-would-m
aintain-a-steady,-m
odest-bottom-line."-
pg-84
612
2008Transform
ing-m
ental-health-and-substance-abuse-
data-systems-in-the-United-States
Psychiatric-Services
31
Phychatric-substance-abuse
01
00
0
Opinion
EHR
Deep-Structure
Privacy-and-security-issues-represent-a-large-barrier-to-HIT-adoption-and-use-in-psychiatric-and-
substance-use-practices.--These-issues-are-particularly-relevent-when-considering-the-exchange-of-
inform
aiton.
615
2008The-promise-of-simultaneous-transform
ation-of-
practice-and-research-with-the-use-of-clinical-
inform
ation-systems
Nursing-Outlook
31
Nursing
01
00
0
Opinion
National
Various
Deep-Structure
There-is-a-gap-in-nursing-inform
aiton-due-to-a-lack-of-data-sets-specific-to-nursing.--The-result-is-a-lack-
of-electronically-avaialble-nursing-knowledge-available-for-research-and-improving-patient-care.--
"Usually,-clinical-nursing-data-have-to-be-generated-specficially-for-a-research-study-or-found-in-
manual-searches-of-paper-patient-records."-pg-233
617
2008Factors-influencing-physician-use-of-clinical-
electronic-inform
ation-technologies-after-adoption-
by-their-m
edical-group-practices
Health-Care-M
anagement-Review
32
group-practice
01
00
0
cross-sectrional-/-
survey
No-
specified
eRx
Deep-Structure
"First,-Van-de-Ven,-Polley,-Garud,-and-Venkataraman-(1999)-propose-that-the-"innovation-journey"-is-
not-a-linear-process-but-rather-follows-different-pathways-at-different-stages-of-im
plementation-and-
in-different-organizational-units."-pg-362
"Our-data-indicate-that-the-practice-culture-is-the-m
ost-important-factor-influencing-these-use-rates-
in-27-group-practices-owned-by-a-university-hospital"-pg-366--The-authors-note-that-cultures-are-not-
easy-to-change-and-represent-a-challenge-for-change-m
angement-within-a-group-practice.
"econd,-the-culture-of-the-practice,-especially-in-the-areas-of-practice-cohesiveness-and-the-value-
placed-on-efficiency,-may-have-an-influence-on-use-of-electronic-inform
ation-systems-because-the-
physicians-in-these-practices-are-m
ore-likely-to-use-inform
ation-aids-and-practice-like-their-
colleagues.-Third,-the-range-in-age-of-the-physicians-within-a-specialty-has-been-shown-to-be-
important-in-that-older-physicians-may-be-m
ore-committed-to-existing-practice-patterns-and-be-less-
computer-literate,-and-a-wider-range-of-ages-in-the-practice-could-decrease-cohesive-responses-to-
technology-use.-"-pg-363
618
2008Inform
ation-technology-from-novice-to-expert:-
implementation-implications
Journal-of-nursing-m
anagement
21
Nursing
01
10
0
Opinion
CDSS
Equilibrium
Authors-discuss-the-m
any-failures-of-inform
ation-systems-in-health-care.--Failures-can-be-attributed-
to,-individual-end-users,-attributes-of-the-technology-and-attributes-of-the-clinical-practice.--This-is-
based-on-a-framework-developed-by-Ammenwerth-(2006).--The-remainder-of-the-article-discussed-
how-to-invorporate-nursing-into-CDSS-design.
619
2008Adoption-of-anesthesia-inform
ation-m
anagement-
systems-by-academic-departments-in-the-United-
States
Anesthesia-&-Analgesia
23
hospital
00
10
0
Cross-Sectional-/-
Survey
National
Anesthesia-System
Deep-Structure
Minim
al-inform
aiton-provided-in-the-study-paper.--Barriers-to-implementation-notes-by-survey-
respondents,-which-descxribe-deep-structure-were-lim
itation-of-funds-and-competition-for-funds-
from-other-departments.--Additionaly-the-anticipated-low-ROI-was-also-cited.--None-of-the-findings-
were-statistically-significant.
622
2008Change-readiness-assessment-for-conversion-to-
electronic-m
edical-records
Journal-of-nursing-administration
22
hosptial
00
10
0
case-study
tennessee
Various
Equilibrium
Authors-discuss-the-change-m
anagement-process-at-a-large-health-system-in-Tennessee.--The-steps-
followed-by-project-leasders-included-establishing-a-vision,-readiness-assessment,-strategies-for-
change,-building-a-team,-communicating-plan-and-ongoing-evaluation-of-efforts.--
3-barriers-were-noted-by-the-authors-2-fear,-apathy-and-competing-priorities.
623
2008A-descriptive-analysis-of-a-nursing-home-clinical-
inform
ation-system-with-decision-support
Perspectives-in-Health-Inform
ation-
Management/AHIM
A,-American-Health-
Inform
ation-M
anagement-Association
22
nursing-home
01
00
0
case-study
Missouri
CDSS
Equilibrium
Study-largely-about-quality-impact-of-several-CDSS-tools-recently-im
plemented-at-three-nursing-
homes.--Implementation-issues-related-to-staff-perceptions-about-the-system,-level-of-support-and-
preparation-for-process-change.
162
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
624
2008Continuous-innovation-in-health-care:-im
plications-
of-the-Geisinger-experience
Health-Affairs
42
IDS
00
10
0
Case-Study
Pennsylvani
a
Various
Revolution
The-authors-note-that-the-key-problem-with-US-healthcare-policy-is-its-lack-of-focus-on-value-and-
sustainability.
"These-problems-have-resulted-in-a-loss-of-value-within-the-health-system-and-have-generated-
various-reform
-proposals,-with-m
ost-focusing-on-providing-greater-access-to-or-controlling-the-costs-
of-care.-Although-laudable,-this-focus-ignores-the-fundamental-problem:-health-care-value-(defined-
here-as-outcomes-relative-to-input-costs)-sim
ply-m
ust-increase-to-achieve-these-diverse-goals."-pg-
1235
"Innovative-care2process-change-occurs-when-(1)-consumers-are-actively-engaged-in-behavior-that-
mitigates-disease-or-im
proves-purchasing;-(2)-safer-and-m
ore-effective-drugs-or-devices-are-
developed-and-adopted;-(3)-clinicians-deliver-more-rapid,-appropriate,-and-reliable-care;-(4)-
unnecessary-tests-and-therapies-are-eliminated;-or-(5)-supply2chain-costs-are-systematically-lowered.-
These-changes-are-m
ost-sustainable-within-a-care-system-that-measures-innovation-returns,-focuses-
on-value-creation,-and-is-appropriately-rewarded-in-the-m
arket.-But-how-can-this-kind-of-innovation-
occur?-"-pg-1236
Key-to-Geisengers-success-is-their-structure-as-an-Integrated-Delivery-System-"Because-of-its-group-
practice-m
odel-and-financial-success,-it-can-m
ore-easily-engage-physicians-with-both-financial-and-
nonfinancial-incentives-and-also-cross2subsidize-important-but-nonprofitable-functions-(such-as-
primary-care,-autism
-treatm
ent,-and-so-forth)."-pg-1243
625
2008Health-inform
ation-technology:-Strategic-initiatives,-
real-progress
Health-Affairs
21
00
00
0
Opinion
EHR
Revolution
Opinion-pience-is-in-reaction-to-Diamond-article-on-EHR-adtopion-policy-(added-to-data-as-part-of-
bibliography-search)-and-recently-released-Federal-Health-IT-strateic-Plan-in-June-2008.--Article-
summarizes-activities-of-US-since-the-creation-of-ONC.
627
2008Merging-home-and-health-via-contemporary-care-
delivery:-Program-m
anagement-insights-on-a-home-
telehealth-project
Computers-Inform
atics-Nursing
22
VA
10
10
0
Case-Study
National
TeleHealth
Deep-Structure
some-of-the-lessons-learned-from-the-described-telehealth-case-study-are-staffing-issues-and-
acceptance-by-patients-of-the-new-technology.--The-article-states-that-participants-accepted-the-
technology-because-it-gave-the-perception-of-"someone-is-actively-engaged-in-m
onitoring-their-care"-
pg-280
628
2008Adoption-and-perceptions-of-electronic-health-
record-systems-by-ophthalm
ologists:-an-American-
Academy-of-Ophthalm
ology-survey
Ophthalm
ology
33
Small-practice
01
00
0
Survey/Cross-
Sectional
National
EHR
Equilibrium
Survey-results-show-a-sim
ilarly-low-adoption-rate-among-Opthamologists-as-with-other-medical-
specialties.--Barriers-are-sim
ilar-as-well-and-relate-to-resources,-tim
e-and-expertise-available-to-
implement-EHR-systems.
631
2008Clinical-microsystems,-part-2.-Learning-from-m
icro-
practices-about-providing-patients-the-care-they-
want-and-need
Joint-Commission-Journal-on-Quality-and-
Patient-Safety
41
01
00
0
Opinion
Various
Equilibrium
Article-specifically-talks-about-various-form
s-of-intertia-within-equilibrium:
Mindset-Inertia-2-inability-to-understand-what-patient-centered-care-m
eans-within-context-of-
personal-environment.--"our-practice-is-different"
Resource-Inertia-2-health-systems'-inability,-in-the-face-of-their-large-investment-in-personnel-and-
fixed-assets,-to-see-beyond-their-current-methods-for-doing-business.
Regulatory-Inertia-2-large-amount-of-documentation-required-for-regulatory-purposes
633
2008Seeking-perfection-in-health-care
Healthcare-executive
42
Hospital
00
10
0Case-Study
Wasshinton-
(Seattle)
change-M
anagement
Equilibrium
Discusses-a-continuous-quality-imporovement-process-which-is-typical-of-the-equilibrium-period-
which-emphsizes-continuous-incremental-im
provement.
634
2008HHS-shifts-IT-into-high-gear.-New-plan-to-promote-
inform
ation-technology-released-to-m
ostly-good-
reviews,-but-concerns-remain-about-its-scope-and-
funding
Modern-Healthcare
20
00
01
0
News-Story
Various
Revolution
Article-discusses-recently-released-updated-healthcare-IT-development.--The-development-plan-
targets-two-key-goals-2-patient2focused-healthcare-and-improviemetn-of-population-health.--Four-
objectives-are-promoting-widespread-IT-adoption-and-use,-interoperability,-ensuring-trust-in-
electronic-healthcare-infomraoitn-exchange,-and-establishing-structures-of-collaborative-governance.
GAO-was-stated-to-have-"repeatedly-critisized-HHS-for-failing-to-develop-a-national-IT-plan-that-
contains-measurable-benchmarks."-pg-3--A
nother-critisim
-is-for-congress-and-its-lack-of-funding-to-
meet-the-goals.
635
2008How-technology-solutions-can-impact-nursing-
retention
Nursing-economic$
10
Hospital
00
10
0News/Opinion
Various
Equilibrium
Author-questions-whether-technology-can-impact-nursing-retention.--The-author-concludes-that-she-
doesn';t-know.
636
2008Great-project-m
anagement=-IT-success
Physician-Executive
10
01
00
0News/Opinion
Various
Equilibrium
Good-IT-implementation-requires-clear-roles-nd-responsibilities,-effective-project-m
angement,-a-
governance-structure-for-decision-m
aking.
638
2008Enhance-your-technology-and-enrich-your-bottom-
line
MGMA-connexion/M
edical-group-
Management-Association
10
01
00
0News/Opinion
Various
Equilibrium
Condier-easing-into-EHR-adoption-by-adopting-smaller-technological-steps-such-as-eRx,-scanning,-
ebillings-among-others.
639
2008Making-it-to-the-EHR-promised-land.-How-to-solve-
common-EHR-adoption-problems
MGMA-connexion/M
edical-group-
Management-Association
10
01
00
0News/Opinion
EHR
Equilibrium
EHR-implm
entation-requires-leadership,-invovlemente-of-all-organziational-areas,-good-support-and-
training.
640
2008The-duality-of-health-technology-in-chronic-illness:-
how-designers-envision-our-future
Chronic-Illness
31
11
00
0
Opinion
Telehealth
Equilibrium
Demonstrates-a-different-influence/relationship-betw
een-HIT-and-chronic-illness.--The-authors-note-
that-unlike-technologies-that-treat-acute-disease,-chroinic-disease-creates-an-ongoing-relationship-
betw
een-patient-and-practitioner.
Good-Figures-throughout-article
163
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ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
643
2008Market-effects-on-electronic-health-record-adoption-
by-physicians
Health-Care-M
anagement-Review
33
Small-practice
01
00
0
Cross-Sectional
Florida
Various
Revolution
Study-looks-at-market-condisions-and-theor-im
pact-on-HIT-adoption.--The-study-hypothesizes,-based-
on-m
arket-theory,-that-"Physicians-located-in-counties-with-high-ratios-of-physicians-per-capita-
(indicating-high-competition)-are-m
ore-likely-to-adopt-EHR-than-physicians-located-in-counties-with-
fewer-physicians-per-capita,-all-other-things-remaining-equal."-pg-244.--The-authors-also-look-at-
counties-with-high-HMO-penetration-and-high-poverty-rates.
The-authors-find-that-"variables-measured-at-the-physician-level-show-that-practice-size,-technology-
readiness,-years-since-graduation-from-m
edical-school,-and-high-percentage-of-Medicare-patients-
seen-are-all-significant-and-independent-predictors-of-EHR-adoption."-pg-247
"variables-measured-at-the-county-level-show-that-competition-(H1),-as-measured-by-nonfederal-
physicians-per-10,000-capita,-is-a-significant-independent-predictor-of-EHR-adoption.-However,-both-
HMO-penetration-rate-(H2)-and-poverty-rate-(H3)-were-not-found-to-be-significant-in-this-sample-that-
focuses-on-small2group2-and-solo2practice-physicians.-"-pg-247
and-"Physicians-who-saw-greater-than-50%-M
edicare-patients-were-29%-m
ore-likely-to-adopt-EHRs-as-
compared-with-physicians-who-saw-less-than-25%-M
edicare-patients-(OR-=-1.29,-CI-=-1.0121.66).-"-pg-
248
644
2008Predicting-computerized-physician-order-entry-
system-adoption-in-US-hospitals:-Can-the-federal-
mandate-be-m
et?
International-Journal-of-Medical-
Inform
atics
53
hospital
00
10
0
Theory-
Development/Cr
oss-Sectional
national
CPOE
Revolution
Develops-a-predictive-m
odel-for-CPOE-adoption-in-US-Hospitals.--The-m
odel-uses-three-years-of-
Leapfrog-data-to-build-a-predictive-m
odel-of-CPOE-adoption.
Findings:
"The-results-of-our-study-indicate-that-the-current,-commercially-available-CPOE-systems-are-unlikely-
to-achieve-significant-market-penetration-as-desired-by-2010.-Therefore,-the-answ
er-to-the-first-
question-posed-in-this-article-is-no.-While-the-Optimistic-and-Best-estim
ate-scenarios-do-indicate-that-
CPOE-technology-will-eventually-achieve-significant-market-penetration,-this-is-predicted-to-occur-
only-in-relatively-distant-timeframes.-The-answ
er-to-the-second-question-m
otivating-this-project-is-
that-it-will-take-at-least-10-years-longer-than-hoped-for-by-the-IOM-and-President-Bush.-The-
Conservative,-or-worst-case,-scenario-is-particularly-troubling-for-those-hoping-to-promote-the-CPOE-
system-adoption-among-hospitals-as-its-time-horizon-extends-well-into-the-future,-with-only-20%-
adoption-predicted-by-2038."-pg-542
649
2008Perceptions-regarding-electronic-health-record-
implementation-among-health-inform
ation-
management-professionals-in-Alabama:-a-statewide-
survey-and-analysis
Perspectives-in-Health-Inform
ation-
Management/AHIM
A,-American-Health-
Inform
ation-M
anagement-Association
33
hospital
00
10
0
cross-
sectional/survey
Alabama
EHR
Deep-Structure
Barriers-to-implementation-of-EHR-found-in-the-study-were:-lack-of-funding,-lack-of-knowledge-of-
EHRs,-suport-from-m
edical-staff,-lack-of-employee-traininng.
Correlations-were-found-betw
een-hospitals-in-rural-areas-and-a-lower-incidence-of-EHR-
implementation.
651
2008Challenges-to-EHR-implementation-in-electronic2
versus-paper2based-office-practices
Journal-of-general-internal-medicine
33
Ambulatory
01
00
0
comparative-case-
study
New-York
EHR
Deep-Structure
Identified-differences-in-implementation-betw
een-paper2based-and-electronic-ambulatory-practices.--
IT-Challenges-reported-included-2-Increase-technolcal-training-and-ongoing-technical-support,-high-
practitioner-reistance,-decreased-productiuvity,-decrease-patient-privacy.
"Using-qualitative-analysis-of-interviews-with-leaders-in-paper2-and-EHR2based-practices,-we-found-
that-both-had-sim
ilar-concerns-regarding-practitioner-productivity-and-training.-We-also-found-
differences.-Leaders-of-paper2based-systems-prioritized-the-following:-sufficient-workstations-and-
printers,-a-physician-IT-champion-at-the-practice,-workflow-education-to-ensure-a-successful-
transition-to-a-paperless-m
edical-practice,-and-a-high-existing-comfort-level-of-practitioners-and-IT-
support-staff.-In-contrast,-leaders-of-EHR2based-systems-prioritized:-open-recognition-of-physician-
resistance-especially-for-those-who-were-loyal-to-the-legacy-EHR,-im
proved-technical-training,-
ongoing-technical-support,-and-sufficient-protection-of-patient-privacy.
Resistance-to-change-is-always-a-crucial-challenge-for-the-success-of-any-innovation."-pg-759
653
2008Adoption-of-health-inform
ation-technology-for-
medication-safety-in-US-hospitals,-2006
Health-Affairs
33
Hospital
00
10
0
Cross-Sectional
National
Various
Deep-Structure
Study-largely-concurs-with-m
any-other-studies-using-this-same-database.--
2-Larger-hospitals-have-greater-probability-of-adoption-than-smaller-hospitals
2-Private-not-for-profit-hospitals-have-a-higher-IT-adotpion-rates-than-investor-owned.
2-Teaching-hospitals-have-a-higher-rate-of-adoption.
2-Hospitals-in-states-with-safety-coalisions-had-a-higher-health-IT-adoption-than-hositals-in-states-
without-these-initiatives.
164
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ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
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levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
655
2008Crossing-the-implementation-chasm
:-a-proposal-for-
bold-action
Journal-of-the-American-M
edical-
Inform
atics-Association
41
00
10
0
Opinion
Various
Revolution
Atuhors-discuss-the-complexity-of-HIT-implementation-and-propose-several-questions-for-future-
researchers.
Complextity-comes-not-only-from-the-four-domains-of-Design,-Management,-Organization-and-
Assessment,-but-the-interaction-betw
een-these-domains.--"Figure-6-depicts-the-interaction-of-the-
four-domains.-W
e-m
aintain-that-focused-research-and-development-in-each-domain-is-necessary,-but-
not-sufficient-to-achieve-significant-gains-in-the-utility-of-health-IT.-Investment-in-the-interaction-
among-these-domains-will-return-not-only-new-knowledge-about-im
plementation,-but-better-
products.-"-pg-294
the-authors-propose-that-these-interactions-create-two-gaps-"Chasm
s"-in-the-Diffusion-of-Innovation-
Thoery/M
odel.--The-gaps-occur-betw
een-the-early-adoptors-and-early-majority-and-betw
een-the-late-
majority-and-the-laggards.
New-research-questions-porposed-are:
----W
hat-are-the-generalizable-lessons-that-can-be-gleaned-from-highly-successful-im
plementations?
----Can-inform
ation-from-implementation-challenges-be-systematically-incorporated-into-m
odels-that-
allow-prediction-of-im
plementation-issues?
656
2008Describing-the-influence-of-technologies-on-
registered-nurses'-work
Clinical-Nurse-Specialist
32
hospital
01
00
0
Focus-Group
Unknown
Various
Deep-Structure
"Nurses-are-skilled-at-establishing-work2arounds.--They-learn-to-navigate-around-problems-rather-
than-fixing-problems.--Findings-indicate-that-nurses-respond-to-technology-system-problems-by-
solving-the-immediate-problem-using-whatever-strategy-works,-in-other-words,-first2order-problem2
solving-strategies.13-These-strategies-include-hiding-infusion-devices,-borrowing-m
edications,-
manipulating-equipment-components-to-fit-incompatible-sets,-and-incorrectly-setting-intravenous-
(IV)-pumps.-Nurses-meet-the-immediate-patient-care-needs-but-do-not-solve-larger,-system-
problems.-"-pg-139
System-design-is-critical-to-success.
"Study-findings-suggest-that-technologies-appeal-to-nurses.-Nurses-want-the-newest-and-the-best,-
providing-that-these-technological-innovations-are-efficient-and-user2friendly."-pg-140
657
2008The-adoption-of-hospital-inform
ation-systems
Health-economics
53
Hospital
00
10
0
Cross-Sectional
national
Various
Deep-Structure
Looks-at-hospital-characteristics-and-IT-adoption,-but-adds-an-element-of-time-to-these-regression-
models.--The-finding-is-that-some-of-the-correlations-betw
een-characteristics-and-IT-adoption-have-
dissipated-over-time-and-are-not-longer-im
pacting-adoption.--In-particular-hospital-size-(admissions)-
and-m
embership-within-a-system.--Also-describes-market-failure-scenarios-based-on-economic-theory-
of-diffusion.---
Findings-are-as-follows-and-below:
"Overall,-these-results-suggest-that-hospitals’-IS-adoption-behavior-is-not-interdependent.-
Furtherm
ore,-these-results-are-not-generally-consistent-with-epidemic-learning-or-netw
ork-
externalities,-which-would-generate-a-positive-relationship-betw
een-IS-penetration-and-adoption-
behavior.-Rather,-the-results-suggest-that-hospitals’-individual-preferences-for-ISs-are-driving-their-
behavior."-pg-661
"These-alternative-m
echanisms-have-different-welfare-implications.-If,-for-example,-the-adoption-
decisions-are-driven-by-hospital-competition-or-strategic-behavior,-m
arkets-are-unlikely-to-produce-
socially-optimal-diffusion.-Thus,-the-rate-of-diffusion-m
ay-actually-be-too-slow-(or-fast)-in-a-norm
ative-
sense.-Conversely,-if-adoption-is-solely-driven-by-technological-and-hospital-characteristics,-the-
argument-for-market-failure-is-dim
inished….-I-find-no-evidence-that-competition-or-strategic-behviour-
affect-the-adoption-of-hospital-Iss."-pg-662
"I-also-observe-that-academic-hospitals-are-early-adopters-for-all-three-types-of-ISs.-Furtherm
ore,-I-
observe-a-strong-correlation-betw
een-IT-utilization-and-academic-status-in-m
y-raw-data,-but-the-
relationship-does-not-significantly-persist-in-m
ultivariate-hazard-m
odels.-This-suggests-that-factors-
165
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ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
660
2008Health-care-inform
ation-technology-in-rural-
America:-electronic-m
edical-record-adoption-status-
in-m
eeting-the-national-agenda
The-Journal-of-Rural-Health
41
Hospital
00
10
0
Opinion
iowa
EHR
Revolution
Relavence-due-to-its-unique-vantage-point-of-rural-hospitals.--Small-size-and-lim
ited-resources-im
pact-
the-ability-of-rural-hospitals-to-adopt-EHRs.--A
uthors-emphasize-m
any-of-the-same-barriers-to-
implementation.
Recommend-the-following-policy-activities:
"Piecemeal-approaches,-requiring-providers-to-respond-to-several-different-demands-(eg,-different-
pay2for2perform
ance-programs,-requests-for-inform
ation-from-m
ultiple-payers)-may-end-up-delaying-
the-overall-objectives,-adding-new-costs-to-an-already-high2cost-industry,-and-creating-m
ore-
resistance-to-transform
ation."-PG-103
Sugggest-unified-perfrm
ance-m
easures,-unified-infrastructures-for-exchange-of-healthcare-
inform
ation-and-Incentives-for-provider's-adoption-of-EMR-Systems.
661
2008The-role-of-organizational-factors-in-the-adoption-of-
healthcare-inform
ation-technology-in-Florida-
hospitals
Health-Care-M
anagement-Science
33
Hospital
00
10
0
Cross-
Sectional/Survey
Florida
Various
Deep-Structure
Study-shows-that-organizational-characteristics-such-as-size,-tax-status,-and-system-affiliation-play-a-
significant-role-in-m
otivating-the-adoption-of-various-HIT-applications,-and-HIT-applications-in-
general….-Geographic-location-seems-to-have-no-significant-im
pact-on-HIT-adoption-patterns."-pg-6
HIT-adoption-was-based-on-counts-of-various-types-of-systems-labeled-by-HIT-groups-(Clinical-HIT,-
Administrative-HIT,-and-Strategic-HIT)
662
2008The-riches-of-e2prescribing.-Insurers-will-say,-do-
pretty-much-anything-to-get-physicians-to-prescribe-
medications-electronically.-Ever-wonder-why?
Modern-Healthcare
20
01
00
0
News/Opinion
ePrescribing
Deep-Structure
Discusses-the-barriers-to-implementing-eRx-systems.--A
uthor-believes-insurers-need-to-be-involved-to-
financially-support-implementation.--One-problem-is-legal-where-the-IRS-has-been-questioning-non2
profit-insurers-like-Blue-Cross-paying-for-these-systems-for-participating-physicians.
"This-could-be-a-'killer-app'-but-it-has-to-be-supported-by-those-who-are-paying-the-claim
s."-pg-2--
"Unless-you-have-the-health-plans-pushing-this,-it-will-take-a-m
andate-from-Congress-or-decades-for-e2
prescribing-to-be-adopted-widely."-pg-3
With-the-push-by-insurers,-physicians-feel-insurers-could-use-eRx-to-m
arket-specific-drugs.
663
2008Exploring-a-m
odel2driven-architecture-(MDA)-
approach-to-health-care-inform
ation-systems-
development
International-Journal-of-Medical-
Inform
atics
31
01
10
0
Opinion/Explorat
ory
Various
Deep-Structure
Authors-list-several-challelnges-to-implementaiton-of-HIT:--Complexity-of-healthcare-processes,-
Backlog-of-applications,-lack-of-standards,-lack-of-inmteroperability,-vendor-lock-in,-portability,-hoigh-
cost,-redundency-of-data-applications.--These-challenges-are-provided-in-the-context-of-development-
of-software-code,-but-resonate-well-in-the-general-context-of-HIT-adoption.
666
2008Variation-in-electronic-prescribing-implementation-
among-twelve-ambulatory-practices
Journal-of-general-internal-medicine
33
ambulatory
01
00
0
Comparative-
Case-Study
new-Jersey
Eprescribing
Deep-Structure
Study-emphasizes-the-imfluence-of-"expectation"-on-the-success-or-failure-of-an-ePrescribing-system.--
Despite-the-full-reim
bursement-of-costs-and-a-honoraria-of-$1002$500/quarter,-some-practices-never-
implemented-the-system.
"These-m
ore-m
odest-expectations-may-indicate-relatively-widespread-inform
ation-sharing-within-the-
practice-and-m
ay-also-have-conferred-protection-from-the-common-challenges-of-HIT-
implementation.-By-contrast,-those-m
embers-of-unsuccessful-practices-who-were-aware-of-the-
upcoming-installation-had-expected-that-the-program-would-speed-their-clinical-work,-function-
“flawlessly”-and-be-implemented-with-m
inim
al-disruption-to-existing-routines.-W
hen-e2prescribing-
was-“less-than-perfect”-and-failed-to-m
eet-these-expectations,-practices-either-failed-to-complete-
installation-or-discontinued-use.-"-pg-368
667
2008Uptake-of-electronic-prescribing-in-community2
based-practices
Journal-of-general-internal-medicine
33
Ambulatory
01
00
0
Cross-Sectional
Massachuse
tts
eRx
Deep-Structure
Clinitians-were-offered-at-no-cost-anm-ePrescribing-tool.--U
se-of-the-tool-was-measured-over-the-12-
month-study-period.--Lower-ages-were-associated-with-high-ePrescribing-levels-and-pediatricians-
were-m
ore-likely-to-eprescribe-than-others.--Larger-practices-have-higher-ePrescribing-rates.
669
2008Im
plementing-computerized-physician-order-
management-at-a-community-hospital
Joint-Commission-Journal-on-Quality-and-
Patient-Safety
32
IDS
00
00
0
Case-Study
Ohio
CPOE
Equilibrium
Implementation-requires-a-sound-project-structure,-good-communication,-evaluation-and-redesign-of-
workflows,-a-training-plan-and-significant-support-during-the-transition.--All-of-this-is-"change-
management-on-a-large-scale"-pg-83
Didn't-m
ention-patients-in-the-case-study.--O
ther-im
plementation-projects-have-highlighted-patient-
centeredness-as-key-driver-of-success-and-decision-m
aking.
671
2008IT-at-a-Crossroads
Hospitals-&-health-netw
orks/AHA
30
00
10
0
News/Opinion
Various
Deep-Structure
HIT-Budgets-changing-vs.-other-markets.--10%-for-finance-and-insurance-versus-2-percent-for-
healthcare.--M
ore-recetnly-this-has-risen-to-7%-pg-45
Barriers-to-change-include-costs,-legal-im
plications-of-new-electronic-data,-new-m
easures-in-reaction-
to-P4P-incentives,-resistance-from-clinical-staff,-new-regulations,-increased-scrutiny-from-insurers-and-
government,-new-job-descriptions-for-CIOs.
166
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
672
2008A-national-health-IT-policy-proves-elusive
Hospitals-&-Health-Netw
orks
30
11
11
0
News/Opinion
Various
Revolution
Debate-over-whether-standards-should-be-m
andated-like-HIPAA-or-come-from-the-stakeholders-or-be-
a-public2private-partnership-process.--
Sim
ilar-debate-about-whether-patients-should-have-full-control-over-data,-or-whether-data-resides-at-
each-intitution-and-will-be-interoperable-and-transferable.
672
2008A-national-health-IT-policy-proves-elusive
Hospitals-&-Health-Netw
orks
30
01
10
0News/Opinion
Various
Deep-Structure
Barriers-to-HIT-adoption-include-2-costs,-lack-of-interoperablity,-lack-of-trained-HIT-experts.
675
2008Identifying-organizational-capacities-and-incentives-
for-clinical-data2sharing:-the-case-of-a-regional-
perinatal-inform
ation-system
Journal-of-the-American-M
edical-
Inform
atics-Association
32
hospital
00
10
0
Case-Study
California
HIE
Equilibrium
Obstacles-to-implementation-were-noted-to-be:--Complexity-of-such-projects,-securing-funding-($),-
commitment-of-top-m
anagement,-form
al-governance-structure-(this-specific-to-HIE-in-that-the-
cooperation-of-several-entities-is-required),-and-appropriate-expertise-of-IT-staff.
676
2008Measuring-the-benefits-of-IT2enabled-care-
transform
ation
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
32
Hospital
00
10
0
Case-Study
Arizona
Various
Equilibrium
Describe-a-"transform
ation"-process-at-a-new-hospital-within-an-existing-health-system.--Key-to-
achieving-their-transform
ative-goal-was-their-patient2focused-planning-2-success-"requires-setting-
aside-tradition-and-ego,-maintaining-a-rigerous-focus-on-doing-what's-best-for-the-patient-and-m
aking-
significant-investments-of-time,-energy-and-m
oney."-pg-80
Ongoing-clinician-invovlement-was-also-critical-as-was-identifying-appropriate-m
easures-to-quantify-
the-benefits-of-care-transform
ation.
Savings-of-$2.6-m
illion-as-well-as-im
porivement-in-quality-m
easures-such-as-ALO
S-and-ADE
677
2008Payer2provider-connectivity-progress-elusive-but-
possible
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
41
Insurance
00
01
0
Opinion
National
Claim
s-Admin
Deep-Structure
Lessons-learned-from-the-HIPAA-claim
s-adjudication-process-suggest-that-even-the-m
andate-of-
standards-did-not-result-in-significant-cost-savings-to-the-industry.--The-author-states-that-the-
insurance-industry-is-too-complex-with-too-m
any-different-reim
bursement-plans-to-m
ake-a-
communication-standard-to-work.--
"There-is-never-a-ROI-for-regulatory-compliance."-pg-66
678
2008Electronic-health-records:-which-practices-have-
them,-and-how-are-clinicians-using-them?
Journal-of-Evaluation-in-Clinical-Practice
33
ambulatory-practice
01
00
0
cross-sectional-
survey
Massachuse
tts
EHR
Deep-Structure
"Practice-size-appears-to-be-one-of-the-m
ost-important-correlates-of-EHR-adoption.--…-larger-
practices-with-financial-and-technologfical-resources-and-the-ability-to-achieve-economies-of-scale-
are-generally-the-only-segment-of-the-population-that-has-been-able-to-intest-in-EHR-systems."-pg-45
Barriers-noted-were-lack-of-adequate-funding,-no-physician-support,-lack-of-technical-knowledge,-
would-interfere-too-m
uch-with-workflow-and-can't-find-EMR-that-fits-our-needs.-Pg-45
679
2008Hospital-quality-of-care:-Does-inform
ation-
technology-matter?-The-relationship-betw
een-
inform
ation-technology-adoption-and-quality-of-care
Health-Care-M
anagement-Review
43
Hospital
00
10
0
Cross-Sectional
Florida
Various
Deep-Structure
"Our-findings-suggest-that-an-increase-in-IT-adoption-is-associated-with-improvements-in-several-
important-measures-of-hospital-quality."-pg-56
"…mature-inform
ation-systems-[those-having-strategic-systems-in-place]-will-be-related-with-a-
maximum-level-of-clinical-benefits."-pg-57
681
2008Early-experiences-with-personal-health-records
Journal-of-the-American-M
edical-
Inform
atics-Association
33
Hospital
10
10
0
Comparative-
Case-Study
Massachuse
tts
PHR
Deep-Structure
Results-of-the-three-case-studies-mainly-invovle-communication-challenges-with-PHRs.--Examples-
include-the-types-of-inform
aiton-to-be-communicated-via-a-PHR-(HIV/psychiatric-diagnisis-and-m
eds-
for-example).--Security-and-legal-issues-are-also-a-concern.
683
2008From-the-ground-up:-building-an-all2digital-hospital
Physician-Executive
22
hospital
00
10
0
Case-Study
Wisconsin
Various
Equilibrium
Authors-review-the-process-of-building-a-hospital-from-the-ground-up.--The-m
ain-focus-of-the-article-
was-building-a-sense-of-culture-that-involved-long2term
-thinking,-process-efficiency,-repsecting-and-
challenging-people-and-an-environment-of-contiunuous-learning-and-improvement.--They-also-added-
a-value-of-"having-fun-and-working-together"
This-culture-was-the-backdrop-of-every-activity-from-hiring-new-staff-to-project-m
anagement-to-
ongoing-process-improvement.
167
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
690
2008Critical-Access-Hospital-Inform
atics
Journal-of-Healthcare-Inform
ation-
Management
33
Hospital
00
10
0
Comparative-
Case-Study
iowa
Various
Equilibrium
Article-compares-tw
o-iowa-Critical-Access-Hospitals-that-were-awarded-M
ost-W
ired-Status-in-2006.--
The-analysis-was-based-on-several-attributes-for-each-hospital-2-Environment,-Culture,-People,-
Process,-Technology,-and-Sustainability
key-similarities-noted-were:
2A-culture-of-embracing-people-as-their-highest-asset
2-Alignment-of-strategic-planning-process
2-Employ-form
al-process-improvement-approaches
2-Embrace-technology-in-strategy-and-to-create-process-change
2-Engage-clinical/physicians-in-technoogy-decisions
2-utilize-a-m
edical-director-of-inform
ation-technology
2-Adopt-an-integrated-vendor-approach
694
2008A-qualitative-analysis-of-an-electronic-health-record-
(EHR)-im
plementation-in-an-academic-ambulatory-
setting
Inform
atics-in-Primary-Care
32
ambulatory-practice
01
00
0
Case-Study
New-york
EHR
Equilibrium
Several-themes-emerged-from-the-interviews-conducted-during-the-study:--communication,-system-
migration,-teaching-equipment,-support-and-training,-patient-privacy,-efficiency,-financial-
considerations.
696
2008Minim
izing-hybrid-records.-Tips-for-reducing-paper-
documentation-as-new-systems-come-online
Journal-of-AHIM
A/American-Health-
Inform
ation-M
anagement-Association
20
00
00
0News
Montana
EHR
Equilibrium
Moving-from-paper-to-EHR-requires-extra-assistance-to-clinicians,-appropriate-training-and-setting-a-
firm
-deadline-when-paper-will-not-be-used-anym
ore.
989
2008Personal-health-record-use-by-patients-as-perceived-
by-ambulatory-care-physicians-in-Nebraska-and-
South-Dakota:-a-cross-sectional-study
Perspectives-in-Health-Inform
ation-
Management
33
Ambulatory
01
00
0
Cross-Sectional-
Survey
Nebraska-2-
South-
Dakota
PHR
Deep-Structure
In-a-survey-of-955-physicians,-25%-were-unaware-of-what-a-personal-health-record-was.
1001
2008Health-Inform
ation-Technology:-A-Few-Years-of-
Magical-Thinking?
Health-Affairs
51
Naitonal
00
01
0
Opinion
National
Various
Revolution
Authors-state-that-the-focus-on-stimulating-technology-adoption-is-narrow-and-only-serves-to-
automate-something-that-is-not-working.--
"There-are-serious-structural-barriers-to-the-use-of-IT-that-have-nothing-to-do-with-technology.-
Current-legal-and-financial-incentives-provide-little-m
otivation-to-share-inform
ation-across-
institutions,-which-is-critical-to-improving-patient-outcomes-as-well-as-efficiency.-"-pg-w384
Stadards-are-alos-not-the-answ
er-and-experiences-in-other-industries-has-demonstrated-this.--The-
authors-suggest-starting-on-a-m
inim
al-set-of-standards-and-goals-and-letting-the-m
arket-evolve.
117
2009Paper-Versus-Electronic-M
edical-Records:-The-
Effects-of-Access-on-Physicians'-Decisions-to-Use-
Complex-Inform
ation-Technologies*
Decision-Sciences
43
hospital
01
00
0
survey
Unknown
EMR
Revolution
"Results-from-our-study-suggest-that-users-of-complex-technologies-may
adopt-a-path-of-“least-effort”-(Hardy,-1982)-when-deciding-to-use-the-technology
in-question-or-the-paper-version.-When-faced-with-this-choice,-physicians-tended
to-m
inim
ize-their-effort-to-locate-an-available-computer-and-log-into-the-EMR.
They-simply-used-the-paper-chart,-which-was-conveniently-located-near-a-patient’s
room-and-did-not-require-any-authentication-procedures.-The-availability-of-more
up2to2date-inform
ation-in-the-EMR-did-not-seem-to-be-a-sufficient-motivation-to
offset-the-tim
e-and-effort-involved-in-locating-and-logging-into-the-EMR."-pg-230
117
2009Paper-Versus-Electronic-M
edical-Records:-The-
Effects-of-Access-on-Physicians'-Decisions-to-Use-
Complex-Inform
ation-Technologies*
Decision-Sciences
43
hospital
01
00
0
survey
Unknown
EMR
Equilibrium
"an-individuals-decision-to-select-and-use-an-inform
ation-source-(including-electronic-sources)-is-a-
function-of-the-extent-to-which-the-source-is-perceived-as-being-accessible."-pg-218
This-hypothesis-is-based-on-the-"least-effort-m
odel"-which-states-that-accessability-to-a-resource-can-
be-viewed-as-a-cost-to-an-individual.
167
2009People,-Get-Ready
H&HN:-Hospitals-&-Health-Netw
orks
10
National
00
01
0News
National
Various
Revolution
ARRA-represents-a-good-oportunity-for-adopting-HIT-and-improving-care.
168
2009Bon-Secours-Health-System-integrates-Lean-Six-
Sigma-and-Knowledge-Transfer-to-drive-clinical-and-
operational-excellence
Global-Business-&-Organizational-
Excellence
20
hospital
00
10
0
Case-Study-/-
news
Maryland
Various
Equilibrium
Implementation-success-invovles-22-Leasdership-commitment;-Establishing-accountablity;-Training;-
integrating-leadership-and-perform
ance-improvement;-focus-on-cost-of-poort-quality;-invovle-trained-
professionals,-leverage-people-process-and-technology.
169
2009Bound-for-Connectivity
Health-M
anagement-Technology
20
DOH
00
01
0Case-Study-/-
News
New-
mexico
Various
Revolution
Money-and-vision-needed-for-successful-HIT-implementaion-and-organizational-change.--Data-from-
HIT-is-im
portant-to-project-valdation-2-especially-in-a-government-setting.
170
2009Workflow-Automation:-Building-Compliance-into-
Health-Care-Systems
Journal-of-Health-Care-Compliance
10
naitonal
00
10
0news
National
Various
Equilibrium
Workflow-change-is-critical-to-successful-technology-im
plementation.
172
2009Training-Critical-Element-to-HIT-Deploym
ent
Modern-Healthcare
10
Various
00
11
0news
National
Various
Equilibrium
Five-steps-for-im
plementation-and-transition-from-paper-are-22-Engaging-leadership;-communicating-
the-vision;-identifying-stakeholders;-working-with-project-champions-and-Early-Wins.
173
2009Going-All2Digital-is-Easier-Said-Than-Done
Physician-Executive
20
Hospital
00
10
0News
Florida
Various
Equilibrium
physician-resistance-a-key-barrier-to-implementation.--Every-hospital-different,-no-standard-
workflows.
168
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
729
2009Assessing-HIE-stakeholder-readiness-for-consumer-
access:-lessons-learned-from-the-NHIN-trial-
implementations
Journal-of-healthcare-inform
ation-
management:-JHIM
32
hospital
10
00
0
Focus-Group
Indiana
PHR
Deep-Structure
Based-on-interviews-with-CIOs-and-HIT-m
anagers-of-participating-organizations-in-the-Indiana-
Netw
ork-for-Patient-Care,-the-study-found-the-following-issues-related-to-acceptance-and-adoption-of-
PHRs:
12-Providers-remain-wary-of-allowing-patients-to-view-all-of-their-health-care-data
22-providers-remain-concerned-about-health-literacy-issues,-or-the-abiity-to-obtain,-process,-
understand-and-act-on-health-inform
aiton
32-the-adoption-of-PHRs-by-patients-is-likely-to-remain-low-in-the-short-term
42-physical-verification-of-patient-identities-for-PHR-account-subscriptions-may-be-required-to-secure-
buy2in-and-trust-from-provider-organziations.
734
2009Keys-to-engaging-clinicians-in-clinical-IT
Healthcare-Financial-Management
20
Hospital
01
10
0
news
NA
EHR
Equilibrium
Discusses-the-need-to-engage-physicians-in-the-successful-im
plementation-of-HIT.--Existing-barriers-
are-High-cost-of-technology,-physicians-making-the-connection-betw
een-technology-and-improved-
patient-care,-focus-on-bottim
-line-rather-than-patient-care,-and-fragmented-nature-of-healthcare-
delivery.
735
2009The-Evolving-Use-of-a-Clinical-Data-Repository:-
Facilitating-Data-Access-W
ithin-an-Electronic-
Medical-Record
22
Hospital
00
10
0
Case-study
new-York
EHR
Equilibrium
Element-of-inertia-is-comfort-with-existing-system-or-process-which-creates-reistance-to-new-
systems.--In-this-case-study,-access-to-the-old-system-was-not-removed,-resulting-in-its-continued-use.--
To-address-this-a-tab-was-added-to-the-new-system-providing-access-to-the-old-data-form
at.--U
se-of-
the-new-system-subsequently-increased.
736
2009Examining-the-Relationship-betw
een-Clinical-
Decision-Support-and-Perform
ance-M
easurement
32
Hospital
00
10
0
Case-Study
National
CDSS
Revolution
"Perform
ance-m
easures-have-the-potential-to-serve-as-the-impetus-for-a-paradigm-shift-in-how-
providers-operate-in-the-health-care-environment."-pg-224--"The-adoption-of-clinical-reminders-in-
support-of-perform
ane-m
easurement-was-also-described-as-being-transform
ative,-to-the-extent-that-
after-this-paradigm-shift,-other-cahnges-could-be-m
et-more-easily."-pg-224
737
2009Health-care-IT:-supporting-cost-efficiencies-in-tough-
times
Benefits-quarterly
30
Employer-Sponsored-Health-
clinic-or-Plan
11
00
0
News/Opinion
National
Various
Deep-Structure
Author-proposes-that-economics-and-demographics-represent-drivers-of-EMR-adoption.--Economy-is-
brining-to-forfront-the-efficiencies-created-by-EMR-systems-in-running-health-offices-in-a-m
ore-
business-like-m
anner.--
Demographics-2-employees-staying-at-their-current-job-longer.--"This-reality-22-which-has-been-
exacerbated-in-2009-22-is-all-the-m
ore-reason-for-employers-to-invest-in-the-tools,-programs-and-
strategies-that-can-keep-employees-health-and-less-costly-to-care-for,-especially-as-the-average-
worker-longevity-rises-from-three-to-five-years-ordinarily,-to-m
ore-recent-statistics-that-indivate-a-five-
to-ten-year-tenure."-pg-8
738
2009Factors-influencing-acceptance-of-electronic-health-
records-in-hospitals
Perspectives-in-Health-Inform
ation-
Management/AHIM
A,-American-Health-
Inform
ation-M
anagement-Association
33
Hospital
00
10
0
Cross-Sectional-
Survey
Arkansas
EHR
Deep-Structure
Study-evaluates-compunents-of-the-TAM-m
odel-by-measuring-attitudes-of-Perceived-usefullness,-
Perceived-ease-of-use-and-behavioral-intent-betw
een-hospitals-that-adopted-EHR-and-those-that-
have-not.
The-results-indicate-a-significant-doifference-in-these-TAM-components-betw
een-EHR-and-nonEHR-
hospitals.
739
2009A-framework-for-predicting-EHR-adoption-attitudes:-
A-physician-survey
Perspectives-in-Health-Inform
ation-
Management/AHIM
A,-American-Health-
Inform
ation-M
anagement-Association
43
hospital
01
00
0
Cross-Sectional-
Survey
Mississippi
EHR
Deep-Structure
Study-looks-to-examine-attidutes-and-values-that-influence-attitudes-about-EHR-use.--The-study-found-
no-correlation-betw
een-individual-physician-characteristics-(age,-years-of-practice,-specialty-etc.)-and-
EHR-attitudes.
Management-support-was-found-to-have-the-strongest-effect-on-perceived-ease-of-use-and-ease-of-
use-had-the-greatest-effect-on-perceived-usefuless.--Doctor-Patient-Relationship-had-a-negative-
impact-on-perceived-ease-of-use-and-perceived-usefullness.--Physician-autonomy-and-invovlement-in-
EHR-implementaiton-were-found-to-directly-impact-attitudes-toard-EHR.
"Results-from-this-study-highlight-the-need-for-strong-physician-leadership-and-m
anagement-support-
in-the-EHR-selection-and-implementaiton-process."-pg-6
741
2009The-integration-payoff:-3-examples
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
42
hospital
00
10
0
News/Case-StudyNational
Various
Deep-Structure
Article-discusses-changes-taking-place-in-the-deep-structure-of-the-hospital-community.--Based-on-a-
recent-survey,-m
ore-hospitals-are-implementing-physician2hosptial-integration-strategies.--These-
strategies-attempt-to-integrate-previously-independent-pysicians-into-a-m
ore-integrated-helath-
system.--Some-of-the-changes-seen-in-the-survey-are:-an-increase-in-physician-employement;-direct-
compensation-to-physicians-for-additional-services-such-as-ER-on2call-tim
e;-bonus-paym
ents-for-
quality-outcome-m
easures.
"When-discussin-this-question-[alignment-betw
een-physician-and-hospital]-with-the-organziations,-it-
becomes-im
mediately-apparent-that-their-quest-for-greater-integration-is-strategically-focused-on-
ensuring-a-sustainable-system-of-health-are-for-their-commiunities."-pg-68
169
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
742
2009Tensions-and-Paradoxes-in-Electronic-Patient-Record-
Research:-A-Systematic-Literature-Review-Using-the-
Meta2narrative-M
ethod
Milbank-Quarterly
55
Various
01
11
0
Systematic-
Review-(meta2
narative-m
ethod)
NA
EHR
Deep-Structure
The-authors-conduct-a-systematic-review-of-the-literature-on-EHR-to-evaluate-how-EHR(EPR)-
discussed-in-the-literature-and-the-tensions-and-challegnes-expressed-by-researchers.--The-m
ain-
finding-22
"The-findings-suggest-that-EPR-use-will-always-require-human-input-to-recontextualize-knowledge;-
that-even-though-secondary-work-(audit,-research,-billing)-may-be-m
ade-m
ore-efficient-by-the-EPR,-
primary-clinical-work-m
ay-be-m
ade-less-efficient;-that-paper-may-offer-a-unique-degree-of-ecological-
flexibility;-and-that-sm
aller-EPR-systems-may-sometimes-be-m
ore-efficient-and-effective-than-larger-
ones.-W
e-suggest-an-agenda-for-further-research."-pg-729
"Studies-from-both-inside-and-outside-the-health-inform
atics-tradition,-for-example,-are-raising-
questions-about-both-the-scalability-and-the-transferability-of-EPR-systems,-especially-when-such-
systems-are-developed-commercially-rather-than-grown-organically-as-part-of-an-emergent-change-
effort"-pg-771
the-findings-of-the-authors-suggest-that-many-of-the-assumptions-of-EHR-benefits-m
ay-not-be-true:--
"Much-of-the-literature-covered-in-this-review-suggests,-conversely,-that-(1)-the-EPR-m
ay-be-
alternatively-conceptualized-as-an-“itinerary,”“organizer,”-or-“actor”;-(2)-seamless-integration-of-
different-EPR-systems-is-unlikely-because-human-work-will-always-be-needed-to-bridge-the-m
odel2
reality-gap-and-recontextualize-knowledge-for-different-uses;-(3)-while-secondary-work-(audit,-
research,-billing)-may-be-m
ade-m
ore-efficient-by-the-EPR,-primary-clinical-work-is-often-m
ade-less-
743
2009Inform
ation-and-communications-technology-in-US-
health-care:-why-is-adoption-so-slow-and-is-slower-
better?
Journal-of-health-politics,-policy-and-law
51
National-Health
00
01
0
Opinion
National
Various
Deep-Structure
Athors-discuss-the-political-and-economic-reasons-for-a-lack-of-ICT-(inform
aiton-and-communiation-
technology)-implementation-such-as-EHRs.--Several-quotes-follow,-but-the-gist-is-that-the-complexity-
and-m
any-stakeholders-in-the-healthcare-m
arket,-m
ake-the-decision-to-purchase-ICT-risky-and-the-
value-of-waiting-is-often-greater-than-acting.
Some-of-the-specifics-are-as-follows
Netw
ork-effect-and-Positive-feedback--"First-and-foremost,-most-ICT-products-—-from-fax-machines-
to-wordprocessing-programs-to-social2netw
orking-sites-—-exhibit-a-particular-kind-of-externality-
known-as-a-netw
ork-effect-(Katz-and-Shapiro-1985;-Shy-2001;-Shapiro-and-Varian-1999).-A-netw
ork-
effect-occurs-when-the-value-of-a-product-depends-on-its-use-by-other-consumers;-for-example,-the-
more-people-who-use-fax-machines,-the-m
ore-valuable-the-individual-fax-machine-becomes."-pg-
1014
"Netw
ork-externalities-also-give-rise-to-positive-feedback:-the-m
ore-people-who-use-a-netw
ork,-the-
more-valuable-it-is,-and-the-m
ore-people-will-want-to-join-that-netw
ork.--Netw
ork-externalities-and-
positive-feedback-have-several-effects.-First,-in-the-early-stages-of-a-technology-launch,-adoption-
starts-slowly-as-each-consumer-awaits-the-adoption-by-other-consumers,-leading-to-a-point-when-the-
technology-is-sufficiently-valuable.-Second,-while-a-technology-might-be-valuable-if-enough-
consumers-choose-to-buy-it,-it-m
ay-never-get-adopted-if-the-size-of-the-netw
ork-effect-is-“big-
enough.”-Third,-however,-if-the-netw
ork-effect-is-big-enough,-once-adoption-starts,-it-accelerates-and-
rapidly-reaches-saturation-—
-the-so2called-S2shaped-adoption-curve.-Fourth,-because-adopters-of-a-
new-technology-naturally-seek-the-netw
ork-that-they-expect-will-offer-the-broadest-and-m
ost-
valuable-connection,-expectations-of-a-netw
ork-effect-can-lead-to-the-realization-of-that-netw
ork-
effect."-pg-1014
744
2009Electronic-health-records-and-the-board's-
connection
Trustee
10
Hospital
00
10
0news
Unknown
Various
Equilibrium
Trustees-im
portant-to-HIT-adoption.
170
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
746
2009The-sociology-of-change
Journal-of-Medical-Practice-M
anagement
41
Various
00
10
0
Opinion
National
EMR
Deep-Structure
Author-describes-seven-dim
entions-of-culture-that-are-relevant-to-EMR-implementaiton:--Innovation-
and-Risk-Taking;-Attention-to-detail;-outcome-orientation;-people-orientation;-Individual-vs.-Team;-
Aggressiveness;-stability.
"Because-the-large-m
ajority-of-physicians-are-working-in-practices-with-fewer-than-10-doctors,-
implementing-EMRs-has-been-difficult.-The-prevailing-culture-is-Clan,-which-focuses-on-individual-
growth-and-development-as-opposed-to-focusing-on-the-growth-of-the-organization-as-a-whole.-In-
fact,-most-physicians-practicing-in-this-sort-of-environment-struggle-to-understand-why-EMRs-are-
necessary-for-them;-everything-is-just-fine-as-it-is.-"-pg-106
"The-first-step-in-any-change-process-is-the-application-of-heat-such-as-a-problem,-an-opportunity,-a-
changed-circumstance,-and/or-accumulated-excesses-or-deficiencies.-"
748
2009Practitioner-approaches-to-the-integration-of-clinical-
decision-support-system-technology-in-critical-care
Journal-of-nursing-administration
32
Hospital
00
10
0
Case-Study
MidWest
CDSS
Deep-Structure
Barriers-to-change-identified-by-the-study-were-grouped-into-3-themes:---Concern-about-a-lack-of-
medical-staff-involvement;-the-importance-of-preim
plemenation-eduction;-and-concerns-about-
barriers-to-system-use-(poor-technology-and-lack-of-computer-skills).--Pg-466
751
2009Evidence-of-an-emerging-digital-divide-among-
hospitals-that-care-for-the-poor
Health-Affairs
33
Hospital
00
10
0
Cross-Sectional-
Survey
National
EHR
Deep-Structure
Study-looks-to-see-whether-disparities-exist-betw
een-hospitals-with-high-proposion-of-poor-patients-
versus-others.--The-authros-use-the-Disproportionate-Share-Hospital-Index-as-a-proxy-for-patient-mix.--
The-study-found-significant-differences-in-rates-of-electronic-m
edication-lists-and-electronic-discharge-
summaries,-but-no-differences-in-other-functionalities.--W
hen-exm
ining-the-rates-of-adoption-for-a-
basic-or-comprehensive-EHR,-the-differences-were-small-and-not-significant.
Barriers-including-inadequate-capitol-and-lack-of-future-support-were-statistically-higher-for-high-DSH-
hospitals.
753
2009Inform
ation-technology-im
plementation-in-a-rural-
hospital:-a-cautionary-tale
Journal-of-healthcare-
management/American-College-of-
Healthcare-Executives
22
hopsital
00
10
0
Case-Study
Unknown
Various
Equilibrium
Issues-related-to-implementation-were:-a-lack-of-clinical-leadership,-staff-skeptisim,-turnover-in-the-
executive-team,-an-aggressive-schedule,-vendor-whose-producst-were-not-ready-on-tim
e.
Study-also-examined-changes-in-quality-as-measured-by-error-rates.--The-findings-showed-an-increase-
in-errors-at-the-implementation-of-HIT-systems.
755
2009The-relationship-betw
een-local-hospital-IT-
capabilities-and-physician-EMR-adoption
Journal-of-Medical-Systems
33
hospital-2-physician
01
10
0
Cross-Sectional-
Survey
Florida
EMR
Revolution
Study-evaluates-whether-policy-of-removing-Stark-law-prohibitions-for-hospitals-providing-physician-
with-EHRs-is-an-effective-policy-to-increase-adoption.
"A-key-finding-of-our-Florida-county2based-analysis-is-that-IT-investments-by-hospitals-in-2003-were-
associated-with-physician-adoption-of-EMR-systems-in-2005.-Specifically,-physicians-in-m
arkets-where-
hospitals-had-m
ore-robust-clinical-IT-capabilities-were-significantly-more-likely-to-adopt-EMR-systems-
even-after-controlling-for-other-market-and-physician-characteristics-that-influence-adoption."-pg-333
759
2009Stimulus-bill-im
plementation:-expanding-m
eaningful-
use-of-health-IT
41
00
01
0
Opinion
National
Various
Revolution
Discusses-the-recent-HITEC-Act-provisions-and-potential-barriers-that-remain-to-successful-
transform
ation-of-care.--The-article-describes-changes-in-environmental-factors-that-will-significantly-
effect-HITEC-22-future-health-reform
-legilsation-including-changes-in-paym
ent-strategies-which-will-
reward-apprpraite-changes-in-quality-and-efficiency.
760
2009Overcoming-barriers-to-the-implementation-of-a-
pharm
acy-bar-code-scanning-system-for-medication-
dispensing:-a-case-study
Journal-of-the-American-M
edical-
Inform
atics-Association
32
Hospital
00
10
0
Case-Study
massachuse
tts
Rx-Bar-Code
Deep-Structure
the-authors-identify-three-barriers-to-implementation-of-a-Rx-Bar-coding-system-in-a-large-hospital.--
The-three-barriers-are-Process-(training-and-process-flow-changes),-Resistance-(communication,-
feeling-overw
helm
ed-and-negative-perceptions)-and-Technology-(software,-hardware-and-the-role-of-
the-vendor-during-implementation)
761
2009The-clinical-decision-support-consortium
Stud-Health-Technol-Inform
31
Hospital
00
10
0Opinion
unknown
CDSS
Deep-Structure
highlights-several-significant-barriers-to-adtoption-of-CDSS.--Of-note-is-the-difficulty-translating-clinical-
guidelines-into-computable-form
.
764
2009Testing-some-m
ajor-determ
inants-for-hospital-
innovation-success
International-Journal-of-Health-Care-
Quality-Assurance
33
Hospital
00
10
0
Cross-Sectional-
Survey
National
NA
Revolution
The-authors-hypothesize-that-innovation-m
anagement-correlates-with-successful-innovation.--In-a-
survey-of-233-hospitals,-the-study-authors-find-that-clear-evidence-exists-regarding-the-importance-of-
competative-intelligence,-strategic-leadership,-managmeent-of-technology-and-specific-
characteristics-of-a-hospitals-change-process-to-the-ssuccess-of-business-innovation-regarding-
products,-business-processes,-organization-structure-and-organization-culture."--pg-464
the-six-elements-m
easured-were-Implementing-change,-competitive-intelligence,-transactional-
leasdership,-charism
atic-leadership,-manbagment-of-technology-and-change-process-features.--
Competative-leadership-showed-the-highest-incremental-change-in-innovation-success.
765
2009Dilemmas,-tetralemmas,-reim
agining-the-electronic-
health-record
Advances-in-Nursing-Science
31
00
00
0
Opinion
EHR
Deep-Structure
Authors-note-a-significant-barrier-to-adoption-for-nursing-is-the-lack-of-nursing-documentation-
standards-that-would-allow-for-a-m
eaningful-documentation-of-the-nursing-actions,-problems-and-
diagnosis-with-regard-to-patient-care.
766
2009GE-program-could-boost-EMR-adoption
Healthcare-Benchmarks-&-Quality-
Improvement
10
Hospital
00
10
0news
Revolution
GE-offering-interest-free-loans-to-hospitals-wishing-to-implement-GE's-EHR-system/software.
171
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
774
2009Strategies-for-ensuring-an-IT-project-delivers-value
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
21
Hospital
00
10
0
Opinion
Unknown
Various
Equilibrium
Succesful-im
plenmentation-involves-22-development-of-a-sound-project-plan,-assignment-of-effective-
sponsors,-capabile-project-m
angement,-m
anagement-of-value-delivery-including-accountablility-and-
measures.
"In-today's-ecominic-climate,-healthcare-organizations-simply-cannot-tolerate-suboptimal-value-from-
an-IT-investment."-pg-31
777
2009Does-it-compute?
Modern-Healthcare
10
00
10
0news
Various
Revolution
"At-the-heart-of-any-organization-are-people.--W
ell2implemented-technology-aligned-with-business-
goals-and-improved-outcomes-will-have-a-good-impoact-on-the-people-invovled,"-pg-10
778
2009A-proclamation-for-change:-transform
ing-the-
hospital-patient-care-environment
Journal-of-nursing-administration
21
01
00
0
Oppinion
National
Various
Revolution
Authors-outline-the-"Proclomation-for-Change"-which-identifies-several-needs-to-effectively-
transform
-the-hospital-patient-care-environment-to-provide-m
ore-direct-patient-care-versus-
documentation.--The-elements-of-the-proclomation-are:-Patient2centered-design;-Systemwide,-
integrated-technology;-Seamless-workplace-environments;-and-vendor-partnerships.
779
2009Im
minent-adopters-of-electronic-health-records-in-
ambulatory-care
Inform
atics-in-Primary-Care
33
physician
00
00
0
Cross-Sectional-
Survey
Massachuse
tts
EHR
Deep-Structure
Survey-of-ambulatory-care-physicians-in-the-state-of-massachusetts.--Focus-was-on-differences-
betw
een-those-clinicians-that-were-imminent-adoptors-of-EHR-versus-those-that-currently-use-EHRs-
and-those-that-don't.--
Imminent-adopters-were-yonger-than-non2users-but-older-than-users.--Greater-experience-with-
technology-correlated-with-likelihood-of-being-an-imminent-adoptor.--Imminent-adoptors-were-m
ore-
likely-to-be-invovled-in-quality-improvement-activities.--
Imminent-adoptors-were-less-likey-to-own-their-practices-and-m
ore-likely-to-have-financial-incentives-
to-adopt-EHR.---"Since-non2users-are-m
ore-often-owners,-it-m
ay-be-that-they-hesitate-to-adopt-EHRs-
becase-they-have-a-higher-financial-stake-in-the-adoption-of-HIT."-pg-13
Authors-note-that-financial-benefits-continue-to-be-the-greatest-barrier-to-adoption.--M
ake-
comparisons-to-UK-program-of-incentives.
786
2009Resistance-is-futile:-but-it-is-slowing-the-pace-of-EHR-
adoption-nonetheless
Journal-of-the-American-M
edical-
Inform
atics-Association
53
Physicians
01
00
0
Model-
Development-/-
Cross-Sectional
national
EHR
Revolution
Authors-recalculate-the-tim
e-horizon-for-EHR-diffusion-using-updated-data-through-2007.--The-
projection-is-based-on-the-technology-diffusion-theory-of-Rogers-as-operationalized-by-Bass.--Bass-
developed-a-m
athematical-model-that-predict-the-uptake-of-consumer-products-based-on-the-
influence-of-exsternal-and-internal-factors.
The-diffusion-is-slower-based-on-this-new-data:
"For-the-period-2001–2007-the-external-coefficient-of-influence-increased-to-0.0083-indicating-that-
factors-such-as-policy-pressure,-EHR-vendors'-m
arketing-efforts-and-public-discourse-were-playing-a-
larger-role-than-in-the-earlier-time-frame.
Compared-to-other-medical-technologies-that-diffused-rapidly,-such-as-ultrasound-imaging-(Q-=-
0.510,-c.f.-the-current-study's-result-Q-=-0.1038)-and-m
ammography-(Q-=-0.738,-c.f.-the-current-
study's-result-p-=-0.0083),-the-internal-influence-coefficients-for-EHR-use-is-relatively-low.-To-rapidly-
accelerate-a-technology's-diffusion-it-is-essential-to-increase-the-internal-or-social-contagion-factors-
that-influence-adoption-decisions.-Otherw
ise,-EHR-adoption-rates-among-small-practices-will-remain-
relatively-low-and-tim
e-horizons-for-complete-adoption-will-remain-distant.-"-pg-2772278
The-authors-speciulate-that-uncertqainty-is-the-key-factor-in-the-delayed-difussion-of-EHRs.--
"While-the-m
andates-for-CMS-will-eventually-move-m
edical-practice-towards-adoption,-the-
uncertainty-created-by-both-the-economic-realities-and-political-landscape-m
ay-be-doing-m
ore-to-
787
2009Im
proving-doctor2patient-communication:-
examining-innovative-m
odalities-vis2a2vis-effective-
patient2centric-care-m
anagement-technology
Journal-of-Medical-Systems
21
Physician
11
00
0
Opinion
Uknown
Various
Equilibrium
Authors-examine-the-transform
aiton-to-patient2centered-care.--HIT-is-iintroduced-as-a-tool-for-
improving-communication-betw
een-practitioner-and-patient.--H
IT-in-this-instance-is-a-enhancer-of-
patient-care-in-the-incremental-im
provement-of-care-to-a-new-patient2centered-m
odel.
172
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
788
2009Im
plementing-a-Pharm
acy-System:-Facilitators-and-
Barriers
Journal-of-Medical-Systems
22
Hospital
00
10
0
Case-Study
Georgia
CPOE
Equilibrium
Authors-describe-the-implementation-of-a-Pharm
acy-system-at-a-large-pediatric-hospital-in-Atlanta.--
Interviews-were-conducted-pre2post-implementation-and-examined-anticipated-and-actual-problems-
during-implementation.
Key-barriers-to-adption-reported-were-Adjustmenet-to-new-work-process,-usabilty-of-drug-file,-and-
poor-communication-and-feedback.--
The-m
ost-significant-facilitator-to-a-sucessful-im
plementation-was-the-extensive-traning-and-
education-perform
ed-pre2implementation-including-the-training-of-"super2users"-and-2427-phone-
suport.
The-authors-also-note-that-the-ability-to-continue-to-support-an-HIT-system-after-focus-turns-to-the-
next-system-to-be-implemented-is-critical-for-maintaining-buy2in-and-acceptance.
792
2009Im
plementation-of-an-Electronic-Documentation-
System-Using-M
icrosystem-and-Quality-
Improvement-Concepts
Advances-in-Neonatal-Care
32
Hospital
00
10
0
Case-Study
Michigan
EMR
Equilibrium
Following-an-initial-failure-in-implemnenting-EHR-within-the-neonatal-unit,-the-authors-describe-the-
process-used-to-successfully-im
plement-the-EMR-system-the-second-tim
e.--The-hsopital-adopted-a-
"microsystem-concept"-to-structure-the-next-implementation.--M
icrosystem-concept-includes-6-steps-
2-organize,-assess,-diagnose,-treat,-followup,-case-study.
Using-this-m
ethod,-the-staff-identified-5-areas-of-focus-for-im
plementation-22-unit-culture,-time-for-
traininng,-education,-equipment-and-access-and-technical-support.
793
2009A-competitive-edge.-Whether-for-profit-or-not,-CIOs-
are-under-pressure-to-m
ake-sure-every-IT-dollar-
yields-concrete-benefits
Healthcare-inform
atics:-the-business-
magazine-for-inform
ation-and-
communication-systems
21
Hopsital
00
10
0
News
National
Various
Deep-Structure
"And-its-for-profit-business-m
odel,-Eckes-says,-translates-into-a-greater-willingness-to-invest-in-
technology,-facilities-and-other-areas.--For-one-thing,-such-investments-reap-large-m
arketing-
rewards."-pg-20--***contradicts-findings-from-surveys-that-state-for2profit-have-lower-adoption-of-
technology-due-to-low-ROI.
"The-word-the-CIO-needs-to-focus-on,-rather-than-the-term
-ROI,-is-value,-'I-challenge-the-concept-of-
'ROI'-off-the-bat,'-he-says,-'because-it's-the-classic-term
-that-everybody-uses,-bit-they-limit-it-pretty-
much-to-the-costs-of-invements.--I-like-to-talk-about-'VOI',-the-value-of-investment,'-he-says.-Pg-23
795
2009Toward-a-21st2century-health-care-system:-
recommendations-for-health-care-reform
Annals-of-internal-medicine
31
00
01
0
Opinion
National
Various
Equilibrium
Article-highlights-findings-from-the-FRESH2Thinking-project-which-brought-several-health-leaders-
together-to-discuss-recommendations-to-fix-US-helathcare.--The-8-recommendations-are:
1----Replace-the-current-fee2for2service-paym
ent-system-with-a-paym
ent-system-that-encourages-and-
rewards-innovation-in-the-efficient-delivery-of-quality-care.-The-new-paym
ent-system-should-invest-in-
the-development-of-outcome-m
easures-to-guide-paym
ent.
2----Establish-a-securely-funded,-independent-agency-to-sponsor-and-evaluate-research-on-the-
comparative-effectiveness-of-drugs,-devices,-and-other-medical-interventions.
3----Sim
plify-and-rationalize-federal-and-state-laws-and-regulations-to-facilitate-organizational-
innovation,-support-care-coordination,-and-streamline-financial-and-administrative-functions.
4----Develop-a-health-inform
ation-technology-infrastructure-with-national-standards-of-
interoperability-to-promote-data-exchange.
5----Create-a-national-health-database-with-the-participation-of-all-payers,-delivery-systems,-and-
others-who-own-health-care-data.-Agree-on-m
ethods-to-m
ake-de2identified-inform
ation-from-this-
database-on-clinical-interventions,-patient-outcomes,-and-costs-available-to-researchers.
796
2009How-to-successfully-select-and-implement-electronic-
health-records-(EHR)-in-small-ambulatory-practice-
settings
BMC-M
edical-Inform
atics-and-Decision-
Making
31
Small-Practice
00
00
0
Opinion
National
EHR
Deep-Structure
Barriers-to-change-in-the-small-practice-environmented-noted-by-the-authors-include:--Price-of-EHR-
products,-appliations-are-not-standardized,-EHRs-are-m
ore-difficult-to-use-than-paper,-
implementation-reduces-productivity-and-disturbs-workflow,-EHR-benefits-accrue-to-others-(society-
and-payers).
173
Appe
ndix(C(–(Cod
ed(Article(Details
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Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
797
2009Patterns-and-changes-in-prescriber-attitudes-toward-
PDA-prescription2assistive-technology
International-Journal-of-Medical-
Inform
atics
33
Hospital
01
00
0
Pre2post-
interview
Unknown
PDA-eRx
Deep-Structure
Authors-apply-the-theories-of-diffusion-of-innovation-and-TAM-to-assess-attitudes-toward-PDA-
technology-in-a-hospital-setting.
The-study-found-that:
"•----Early-adopting-physicians-are-younger-and-are-junior-in-experience-and-status-than-later-
adopting-physicians.-Early-adopting-physicians-are-m
ore-likely-to-be-aware-of-and-own-news-
technologies-than-later-adopting-physicians.
•----Early-adopting-physicians-hold-significantly-more-positive-attitudes-and-beliefs-about-PDA-ease-of-
use-and-utility-in-clinical-settings,-and-are-m
ore-favorably-inclined-towards-adopting-the-PDA-for-
clinical-use.
•----The-top-barrier-to-PDA-adoption-among-early-adopters-is-cost,-while-for-later-adopters-it-is-
training.
•----The-ultim
ate-utilization-of-the-PDA-for-Rx,-even-after-experience-with-the-innovation,-continues-
to-be-influenced-by-the-clinician's-personality,-with-Eas-utilizing-the-PDA-for-Rx-more-frequently-than-
Las.-Interestingly,-post2intervention,-Eas-focus-on-the-PDA's-ease-of-use-while-LA's-focus-on-its-utility-
as-a-prescribing-tool."-pg-338
800
2009Organizational-factors-associated-with-the-use-of-
inform
ation-systems-in-nursing-homes
Health-Care-M
anagement-Review
33
nursing-home
00
10
0
Cross-Sectional-
Survey
National
Various
Deep-Structure
In-a-study-of-nursing-homes,-researchers-found-that-affiliation-or-membership-in-a-change-were-
significantly-more-likely-to-use-all-types-of-IS.--Non2profit-nursing-homes-were-m
ore-likely-to-use-IS.
"Findings-of-this-projecct-support-the-notion-of-Iss-being-a-strategic--decision.--This-if-the-resources-
are-avaialbe-and-the-nursing-home-cdan-m
ake-the-investment,-the-outcome-m
ay-eventually-and-
perhaps-utilm
ately-lead-to-both-better-resident-care-and-improved-perform
ance."-pg-148
801
2009Knowledge-m
anagement-as-a-m
ediator-for-the-
efficacy-of-transform
ational-leadership-and-quality-
management-initiatives-in-US-health-care
Health-Care-M
anagement-Review
33
Hospital
00
10
0
Cross-Sectional-
Survey
National
Knowledge-M
angementRevolution
Authors-propose-and-test-a-m
odel-of-organizational-perform
ance-based-on-elements-of-
transform
aitonal-leadership-and-quality-m
angaement.--The-study-finds-that-Transform
ational-
leadership-impact-ogranizational-perform
ance-via-knowledge-responsiveness-and-that-qulaity-
management-directly-impacts-operational-perform
ance-as-well-as-indirectly-impacts-perform
ance-
thorugh-knowledge-reposnsiveness.--
Knowledge-reposnsiveness-referrs-to-the-way-the-organization-utilizes-various-types-of-knowldege,-
such-as-how-an-oganization-could-use-cstomer-knowledge-to-improve-customer-statisfaction.
Model-shown-on-pages-133-and-137
802
2009Financial-incentives,-quality-improvement-programs,-
and-the-adoption-of-clinical-inform
ation-technology
Medical-care
33
physician
01
00
0
survey/cross-
sectional
national
Various
Revolution
Authors-looked-to-detrerm
ine-the-effect-of-incentives-and-quality-improvement-efforts-on-HIT-
adoption.--The-authors-found-that-"The-evaluation-of-physician-organizations-by-insurers-and-other-
outside-entities-for-piurposes-of-public-reporting-and-pay-for-perform
ance-stiumulate-imform
ation-
technology-adoption-when-they-are-focused-specifically-on-inform
ation-tecnology-but-not,-aparently,-
when-they-are-focuesd-on-m
easures-of-quality."-pg-415
however,-based-on-a-self2m
easure-of-commitment-to-quality,-there-is-a-strong-association-betw
een-
commitment-to-quality-and-CIT-adoption.
803
2009Managing-the-complexity-of-a-systemwide-
electronic-m
edical-record-design-and-
implementation:-lessons-for-nurse-leaders
Nursing-Administration-Quarterly
42
Hospital
00
10
0
Case-Study
National
Various
Revolution
Authors-propose-a-m
odel-for-transform
ation-that-includes-the-inputs-of-culture,-EBP,-technology-and-
rapid-cycle-work-redesign.--The-authors-define-their-healthcare-system-as-a-Complex-Adaptive-
System-and-identify-3-principles-which-are-critical-to-transform
ation-within-a-CAS-22-Self2organization-
(encourage-a-certain-level-of-diversity-within-the-organization),-Comfort-with-a-certain-level-of-"noise,-
creativity-and-exploration-that-is-necessary-for-learning,-changing-and-adapting."-pg-111-and-
Effective-structures-that-support-self2organziation-and-interaction-within-the-system.
805
2009Priority-setting-for-technology-adoption-at-a-hospital-
level:-Relevant-issues-from-the-literature
Health-Policy
44
Hospital
00
10
0
Literature-Review
Various
Revolution
Authors-propose-a-m
odel-"Reference-Framework"-for-technology-adoption-within-hospitals.--The-
frame-work-considers-the-intersection-of-the-ability-of-new-technology-to-create-"value"-and-
"sustainability.--V
alue-is-discussed-in-term
s-of-Social-Value,-Economic-Value-and-Knowledge.--
Sustainability-is-described-in-term
s-of-financial,-organizational,-technological,-resource-and-context.--
See-Figure-1-page-85.
806
2009Clinical-transform
ation:-under-pressure-to-alter-the-
cost/quality-paradigm,-hospital-organizations-are-
turning-to-IT
Healthcare-inform
atics:-the-business-
magazine-for-inform
ation-and-
communication-systems
30
hospital
00
00
0
News
national
Various
Revolution
Discusses-the-important-of-ROI-when-discussing-clinical-transform
ation.--"It's-become-extremely-
important-to-ensure-in-any-clinical-transform
ation-initiative-that-we-can-track-the-return-on-
investment-and-can-validate-the-return-on-investment."--pg-24
808
2009Which-physicians-have-access-to-electronic-
prescribing-and-which-ones-end-up-using-it?
Health-Policy
43
Physician
01
00
0
Cross-Sectional-/-
Survey
National
eRx
Revolution
"Physicians-practicing-in-a-group/staff-m
odel-HMO-setting-had-the-highest-acess-to-e2prescription-IT-
while-physicians-in-solo/two-physician-practices-had-the-lowest-access-to-this-technology.--"-pg-293
Authors-propose-that-these-results-stem-the-from-the-vertical-integration-and-economies-of-scale-
experienced-in-an-HMO-environment-versus-a-solo/two-persoin-pycian-practice.
174
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ndix(C(–(Cod
ed(Article(Details
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5)Rigor(
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stry/Settin
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Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
809
2009Redesigning-care-processes-using-an-electronic-
health-record:-a-system's-experience
Joint-Commission-Journal-on-Quality-and-
Patient-Safety
22
hospital
00
10
0
Case-Study
National
Various
Equilibrium
AT-a-large-health-system-(44-hospitals-and-379-outpatient-facilities),-im
plementation-of-HIT-involved-
a-focus-on-"patient2centered"-work-flows-and-process-redesign.--Clinitian-invovlement-in-the-
development-and-implemenation-was-key-to-the-success-of-im
plementation.--Also-authors-believe-
the-patient2centered-focus-avoided-post-implementation-redesigns-and-changes.
810
2009Electronic-health-records:-Use,-barriers-and-
satisfaction-among-physicians-who-care-for-black-
and-Hispanic-patients
Journal-of-Evaluation-in-Clinical-Practice
43
Physician
01
00
0
Cross-Sectional-
Survey
Massachuse
tts
EHR
Revolution
Authors-examine-the-effect-of-practice-m
inority-population-on-EHR-adoption.--"We-examined-
whether-practices-in-M
assachusettts-with-large2m
inority-populations-had-lower-levels-of-EHR-
adoption-or-faced-different-or-greater-barriers-to-EHR-adoption-than-practices-with-fewer-moinority-
patients,-and-found-essentially-no-relationship."-pg-161--"We-further-found-no-appreciable-
differences-in-the-perceived-varriers-to-adoption-of-benefits-of-EHR-systems-among-m
inority-
servicing-phsicians.--Pg-163
811
2009Physician-adoption-of-personal-digital-assistants-
(PDA):-testing-its-determ
inants-within-a-structural-
equation-m
odel
Journal-of-health-communication
43
hospital
01
00
0
Pre2post-
implementation-2-
Survey
New-York
PDA
Revolution
Authors-empirically-test-a-m
odel-of-technology-acceptance-and-use.--The-prpoposed-m
odel-is-a-
combination-of-Rogers'-diffusion-of-innovation-m
odel-and-the-TAM.--Based-on-the-results-of-the-
study,-age-and-position-in-the-hospital-significantly-influence-the-preadtopn-beliefs-about-PDAs.--The-
particular-practice-specialty-did-not.--Younder-and-less-tim
e-at-the-hospital-(resident-vs.-attending)-
indicated-higher-expectations-for-technology.
Physicians-who-owned-m
ore-technology-held-positive-view-about-usability-of-PDA.--Their-overall-
model-explained-55%-of-the-variance-in-actual-PDA-use-at-the-end-of-the-study.
814
2009Technology-will-have-m
ajor-im
pact-on-shaping-
future-EDs,-say-the-experts
ED-M
anagement
10
ED
01
00
0News
Deleware
Various
Deep-Structure
Resistance-from-doctors-to-technology-that-puts-you-"farther-away-from-the-patient."
816
2009Health-inform
ation-technology22results-from-a-
roundtable-discussion
Journal-of-managed-care-pharm
acy:-JM
CP
31
Clinician
01
00
0
Opinion
National
EHR-and-eRx
Deep-Structure
Article-discusses-the-various-benefits-and-barriers-to-EHR-and-e2prescribing-systems.--Contributing-
factor-to-low-adoption-cited-by-the-authors-include-"paucity-of-data-supporting-imporoved-patient-
outcomes,-privacy-concerns,-lack-of-a-national-standard-platform
-for-im
form
ation-exchange,-legal-
concerns-and-high-systems-costs."
Of-note-was-mention-of-a-2008-piece-of-legislation-2-M
edicare-improvements-for-Patients-and-
Providers-Act-(MIPPA)-of-2008.--This-law-provided-2%-incentive-payemnt-for-using-eprescribing-and-a-
penalty-of-122%-in-2012-for-lack-of-use-of-e2Prescribing.
817
2009Remote-patient-management:-technology2enabled-
innovation-and-evolving-business-m
odels-for-chronic-
disease-care
Health-Affairs
31
Various
01
11
0
Opinion
Various
Remote-Patient-
Management
Deep-Structure
Authors-discuss-the-benefits-and-first-m
over-experiences-of-Remote-Patient-Management-(RPM)-
technologies-in-vcarious-settings.--Specifically,-the-authors-look-at-RPM-and-how-it-can-benefit-
chronic-care.
Key-to-the-success-of-RPM-technology-are-the-Emerging-business-m
odels-that-can-support-RPM.--
Supportive-m
odels-where-saving-from-reduced-hospital-stays-and-ED-visits-inlcude-the-VHA,-
Integraed-provider-based-health-plans-and-home-care-agencies.--IDS-can-experience-a-lost-revenue-
from-reductions-in-visits-and-health-plans-themselves-have-largely-relied-on-contradtors-to-identify-
apporpiate-uses-of-RPM-technologies.
818
2009Perspectives-from-nurse-leaders-and-chief-
inform
ation-officers-on-health-inform
ation-
technology-im
plementation
Hospital-Topics
32
Hospital
00
10
0
semi2structured-
interviews
Pennsylvani
a
Various
Equilibrium
Change-m
anagement-is-critically-required-to-effectuate-successful-HIT-implementation.
--"If--m
anagers-implement-HIT-without--1-establishing-a-sence-of-urgency,-2)-a-computer-literate-end2
user-coalition;-(3)-a-communicated-vision-of-the-rewards-of-HIT-implementation,-buy2in-throughout-
the-hispotal-and-stroties-about-the-short2term
-success-of-consolodation,-and-(4)-institutionalized-HIT-
approaches-to-obtaining-clinical-and-business-inform
ation-for-decision-m
aking,-the-leaders-are-
setting-up-their-m
anagement-team-and-clinical-end-users-for-a-long,-energy2absorbing,-inefficient-
process-that-can-lead-to-loss-of-employee-commiutm
ent-and-descreased-return-on-investment"-pg-8
175
Appe
ndix(C(–(Cod
ed(Article(Details
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Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
819
2009Building-capacity-for-a-transform
ation-initiative:-
system-redesign-at-Denver-Health
Health-Care-M
anagement-Review
52
Integrated-Delivery-System
00
10
0
Case-Study
Colorado
Various
Revolution
key-takeaway-from-case-study-is-the-importance-of-extrenal-factors-and-experiences-to-the-success-
and/or-driver-for-transform
ational-change.--The-authors-note-four-sources-that-contribute-to-
successful-transform
atoin:
"First-are-external-conditions-(m
arkets,-technologies,-and-regulation)-creating-pressures-for-radical-
change.-Support-for-transform
ational-objectives-and-programs-by-powerful-external-stakeholders-
(e.g.,-owners-and-legislators)-and-supportive-external-netw
orks-are-additional-external-facilitators.-
Second,-transform
ation-initiatives-typically-require-a-set-of-shared-beliefs-and-values.-These-include-a-
shared-perceived-need-for-change,-a-m
otivating-vision-for-transform
ation,-staff-commitment-to-the-
core-values-of-the-initiative,-and-a-culture-of-mutual-trust.-Third-are-organizational-and-leadership-
factors-aiding-change-implementation,-including-clear-change-goals-and-priorities-and-a-workable-
change-strategy;-m
anagement-systems-for-coordinating-change-activities,-m
easuring-progress-
toward-objectives,-assuring-accountability,-and-m
anaging-human-resources;-facilitative-processes-
(e.g.,-m
ultilevel-leadership-and-change-champions,-rich-communication,-and-teamwork);-and-an-
inform
ation-system-capable-of-sustaining-quality-improvement-and-learning.-Fourth-are-change-
management-processes-capable-of-supporting-implementation-of-organizational,-technical,-and-
cultural-changes-(e.g.,-training,-user-involvement-in-decisions,-and-follow2up-and-constructive-
feedback-on-improvement-efforts)"-pg-44
"the-DH-case-shows-how-institutional-and-task-environments-combine-to-create-pressure-and-
opportunities-for-transform
ation.-DH-was-subject-to-severe-m
arket-and-financial-pressure.-Instability-
in-its-institutional-field-created-opportunities-for-organizational-innovation-in-response-to-this-
pressure.-Innovation-involved-importing-and-adapting-techniques-and-ideas-from-other-fields-(Scott-
et-al.,-2000)."-pg-51
820
2009Community2wide-implementation-of-health-
inform
ation-technology:-the-M
assachusetts-eHealth-
Collaborative-experience
Journal-of-the-American-M
edical-
Inform
atics-Association
42
Physician
01
01
0
Case-Study
Massachuse
tts
EHR
Revolution
Case-study-of-the-M
ass-eHealth-collaborative-that-im
plemented-several-EHR-systems-across-three-
counties-in-the-state.--Some-the-the-factors-identified-as-essential:
Strong-financial-backing-from-payor-community-(BX-put-up-$50-m
illion),-intensive-practice-support,-
commitment-to-collective-action,-clear-goals,-leadership-from-the-physician-community,-
governmental-support-and-a-community-based-focus.--
Barriers-included:-inadequate-standards-for-dta-representation-and-vocabulary,-concerns-about-
vendor-instability-and-system-obsolesence,-systemm-lim
itations,-privacy-and-security-issues,-
contracting-demans-and-practice-inertia-(resistaance-to-change)
821
2009Use-of-Electronic-Health-Records-in-U.S.-Hopistals
New-England-Journal-of-Medicine
33
Hospital
00
10
0
Survey-Cross-
Sectional
National
Various
Deep-Structure
Survey-showed-a-very-low-adoption-rate-of-HIT-in-hospitals.--1.5%-have-a-comprehensive-electronic-
records-system-and-7.6%-have-a-basic-system.--Barriers-to-change-were-reported-to-be-222-inadequate-
capitol-for-purchase,-concern-about-maintenance-costs,-reistsane-on-the-part-of-physicians,-and-lack-
of-availabliity-of-staff-with-adequate-expertise-in-inform
ation-technology.--Further-the-results-showed-
that-larger-institutions-were-m
ore-likely-to-have-electronic-records-systems,-but-that-this-difference-
was-not-large-and-dim
ished-when-part-of-a-m
ultivariate-analysis.
821
2009Use-of-Electronic-Health-Records-in-U.S.-Hopistals
New-England-Journal-of-Medicine
33
Hospital
00
10
0Survey-Cross-
Sectional
National
Various
Revolution
Policy-recommendations--noted-by-the-authors-include-rewarding-hospitals-for-using-HIT,-and-
harm
onizing-technology-standards.
993
2009A-critical-review-of-the-research-literature-on-Six-
Sigma,-Lean-and-StuderGroup's-Hardwiring-
Excellence-in-the-United-States:-the-need-to-
demonstrate-and-communicate-the-effectiveness-of-
transform
ation-strategies-in-healthcare
Implementation-Science
54
National-System
00
01
0
Systematic-
Review
Naitonal
Various
Revolution
Authors-present-a-m
odel-of-transform
ation-based-on-the-need-to-transform
-BOTH-culture-and-practic-
within-an-oganization-to-achieve-SUSATAINABLE-transform
atoin.--M
odel-in-Table-1
998
2009Paper-Versus-Electronic-M
edical-Records:-The-
Effects-of-Access-on-Physicians'-Decisions-to-Use-
Complex-Inform
ation-Technologies
Decision-Sciences
43
Hospital
01
00
0
Cross-Sectional-
Survey
Southesat
EHR
Revolution
"The-m
ain-premise-of-the-study-is,-when-faced-with-a-decision-betw
een-alternate-IT-systems,-
individual-users-tend-to-select-and-m
ake-use-of-the-technology-or-system-that-is-m
ost-readily-
accessible.-"-pg-213
Accessabliity-a-key-issue-for-acceptance-and-usability.
"We-show-that-in-the-context-of-user-interaction-with-such-a-complex-technology,-accessibility-needs-
to-be-easier-if-the-technology-is-to-be-considered-for-adoption-and-use."-pg-229
"Logical-accessibility-had-a-direct-effect-on-EMR-usage-intentions,-while-physical-access-did-not.-It-
appears-that-physicians-in-this-study-were-concerned-with-issues-related-to-m
ultiple-logins-into-the-
EMR-m
ore-so-than-the-physical-access-to-EMR.-"-pg-230
176
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ndix(C(–(Cod
ed(Article(Details
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Title
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(0>5)
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stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
174
2010The-Digital-Transform
ation-of-Healthcare:-Current-
Status-and-the-Road-Ahead
Inform
ation-Systems-Research
51
natoinal-System
11
11
1
opinion
national
Various
Equilibrium
Authors-describe-a-research-agenda-to-advance-HIT-and-HIT-Transform
ation.--Figure-1-provides-an-
outline-of-major-research-themes-in-HIT.
Priorities-for-research-include-22-HIT-design,-im
plementation-and-m
eaningful-use;-measurement-and-
quantification-of-HIT-payoff-and-impact;-and-Extending-the-traditional-realm
-of-HIT.
The-patient-perspective-is-noted-as-im
portant-to-future-research.--"In-m
uch-the-same-way-as-
consumer-technologies-have-altered-how-individuals-communicate,-consunmer-HIT-tools-such-sa-
PHRs-are-poised-to-alter-patient-engagement-with-their-healthcare."-pg-803
177
2010Working-on-IT
Modern-Healthcare
40
National-System
00
01
0Opinion
national
Various
Deep-Structure
Education-is-a-key-component-of-deep-structure-and-stands-as-a-potential-barrier-to-broad-HIT-
impleenetation-and-use.
178
2010Beyond-Innovation
Inform
ationweek
20
Hospital
00
10
0News
Pensylvania
Various
Equilibrium
Pittsburgh-university-Hospital-looks-at-commertialization-of-its-IT-systems.--Commercializaztion-
represents-a-validation-of-the-transform
aiton-taking-place-at-the-m
edical-center.
700
2010Using-technology-to-prevent-adverse-drug-events-in-
the-intensive-care-unit
Critical-care-m
edicine
21
hospital
00
10
0Opinion
National
Various
Deep-Structure
Discusses-benefits-of-various-Rx-technologies-in-an-ICU-setting.--M
ain-take-away-is-that-the-ICU-
setting-is-complex.
701
2010Baby-steps.-Lessons-learned-by-leaders-of-one-of-the-
nation's-leading-children's-hospitals-on-the-
complexities-of-IT-rollouts-in-the-pediatric-setting
Healthcare-inform
atics:-the-business-
magazine-for-inform
ation-and-
communication-systems
20
hospital
00
10
0
News
Massachuse
tts
Various
Deep-Structure
Complexity-extends-to-patient-level,-i.e.-pediatrics-vs.-adult.
703
2010Service2oriented-architecture-in-public-health
Journal-of-healthcare-inform
ation-
management:-JHIM
22
Public-Health
00
01
0
Case-Study
New-York,-
Rhode-
Island
Various
Equilibrium
Little-relevence-to-PE.--Equilibrium-component-is-supported-by-SOA-in-that-SOA-is-a-m
ethodology-to-
reuse-and-leverage-existing-technologies-for-new-purposes.
704
2010Physician-buy2in-for-EMRs
Journal-of-healthcare-inform
ation-
management:-JHIM
21
Various
01
00
0Opinion
national
Various
Revolution
Physician-chanpions-are-critical-to-EHR-implementaion-success-and-change-in-general.--A
uthors-
discuss-characteristics-of-a-good-clinician-champion.
705
2010Strategy-and-governance-for-successful-
implementation-of-an-enterprise2w
ide-ambulatory-
EMR
Journal-of-healthcare-inform
ation-
management:-JHIM
22
Health-System
00
10
0
Case-Study
new-York
EHR
Equilibrium
Case-study-for-pilot-project-to-implemenet-EHR-in-a-large-Health-system-in-NYC.--Key-lessons-from-the-
case-study-that-contribute-to-incremental-change-are-know-the-software-solution,-understand-
stakeholders,-leverage-partnerships-(in-this-case-NYC-experience-with-eCW),-respect-the-culture,-
maintain-project-champanions.
706
2010A-Health-Center-Controlled-Netw
ork's-Experience-in-
Ambulatory-Care-EHR-Implementation
J-Healthc-Inf-Manag
22
community-health-center
00
10
0
case-study
New-York
EHR
Equilibrium
Discusses-the-basic-process-of-im
plementting-an-EHR-in-a-community-health-center.--Keys-to-success-
were;-leadership-and-m
entorship-during-implemetation.--Authors-note-the-benefits-of-being-part-of-a-
netw
ork-of-community-health-centers.
707
2010An-implementation-case-study.-Implementation-of-
the-Indian-Health-Service's-Resource-and-Patient-
Management-System-Electronic-Health-Record-in-
the-ambulatory-care-setting-at-the-Phoenix-Indian-
Medical-Center
Journal-of-healthcare-inform
ation-
management:-JHIM
22
Medical-Cener-2-Indian-Health-
Service
00
10
0
case-study
Arizona
EHR
Equilibrium
Discusses-im
plementation-process-at-a-single-indian-health-center-in-Arizona.--Planning-and-the-step2
wise-implementation-process-were-noted-to-be-keys-to-the-successful-im
plementation-of-the-EHR-
system.
708
2010Keys-to-a-successful-and-sustainable-telemedicine-
program
International-Journal-of-Technology-
Assessment-in-Health-Care
23
Telemedicine
00
10
0
cross-sectional-
survey
National
Telehealth
Deep-Structure
Didn't-really-deal-with-HIT-implementation,-acquisition,-but-did-address-characteristics-of-susccessful-
telehealth-businesses-which-can-be-extrapolated-to-HIT-gerneally.
"programs-that-have-a-high-level-of-creativity,-organizational-support,-having-and-following-a-
business-plan,-dveloping-a-form
ally-defined-program-and-understanding-how-financial-support-
4effets-the-prgeam"-are-characteristics-of-a-successsful-telehealth-program.-Pg-215
709
2010Transform
ing-m
edicine-via-digital-innovation
Science-Translational-Medicine
31
Various
10
00
0
Opinion
national
Wireless
Revolution
The-rapid-growth-of-wireless-devices-has-the-potential-to-push-m
edicine-to-new-areas-of-treatm
ent-
and-relationships.--The-advent-of-devices-which-can-m
onitor-many-physiological-functions-and-be-
transm
itted-to-a-phone-has-the-ability-to-pull-patients-into-the-direct-m
onitoring-of-their-care-for-
many-chronic-diseases.
710
2010Who'll-Run-Your-IT?
Hospitals-&-Health-Netw
orks
40
Hospital
00
10
0
Opinion
national
Various
Deep-Structure
Ideintifies-the-resource-problem-associated-with-the-Deep-sTructure-which-represents-a-huge-barrier-
to-transform
ation-and-change.-"The-power-to-ramp-up-EHRs-will-only-intensify-the-competition-fo-an-
already-inadeqate-supply-of-qualitied-tech-workers."-pg-22
711
2010What-have-we-learned-about-interventions-to-
reduce-m
edical-errors?
Annual-review-of-public-health
24
Various
01
10
0
Literture-Review
National
Various
Equilibrium
Authors-review-the-evidence-around-systems-that-reduce-m
edical-error-from-people-systems-and-
culture-change-to-HIT.--Authors-state-that-regardless-of-what-is-implemented,-new-problems-will-turn-
up,-"The-law-of-unintended-consequances-predicts-that-new-solutions-will-create-new-safety-
problems."-pg-491
712
2010Clinical-Tech-Trends-2010.-Trend:-HITECH
Healthcare-inform
atics:-the-business-
magazine-for-inform
ation-and-
communication-systems
40
Hospital
00
10
0
News/Opinion
National
Various
Deep-Structure
The-allocation-of-resources-including-m
oney-will-be-toward-m
eandingful-use-at-the-expense-of-other-
IT-projects.
713
2010Physicians-at-the-CFO's-door:-what's-your-response-
to-requests-for-new-technology?
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
40
Hospital
00
10
0
news/Opinion
National
Various
Deep-Structure
Author-discusses-the-need-for-evaluating-cost/technology-decisions-similar-to-cost-evaluations-of-
new-treatm
ents.--For-technology-you-have-the-same-quesitons-22-W
hat-are-the-costs,-what-are-the-
benefits-in-term
s-of-health,-quality,-public-good,-etc.
716
2010Transform
ing-to-a-computerized-system-for-nursing-
care:-organizational-success-within-M
agnet-idealism
Computers-Inform
atics-Nursing
21
Hospital
00
10
0
Case-Study
Florida
Various
Equilibrium
Little-relevence-to-PE.--Article-discusses-structure-and-process-used-to-implement-new-HIT-within-
Miami-hospital.--M
agnet-status-of-hospital-was-noted-to-help-in-implementation-in-that-the-
organization-was-structured-to-address-quality,-efficiency-and-transform
aiton.
717
2010Carrots-and-sticks-for-EHR-implementation
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
30
Mixed
01
10
0
News/Opinion
national
EHR
Deep-Structure
Author-analyzes-whether-hospitals-and-physician-offices-should-attempt-to-m
eet-the-m
eaningful-use-
deadlines.--A
uthor-notes-several-concerns-about-incentives-such-as-CMS-capability-to-receive-quality-
measures-and-other-reporting-of-meaningful-use.---Costs-and-ROI-are-the-key-decision-factors-as-well-
as-capability-of-the-practice-or-hospital-to-take-on-implementation.
Also-uncertainty-about-existing-systems-to-m
eet-meaningful-use-criteria.
177
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
720
2010Social,-organizational,-and-contextual-characteristics-
of-clinical-decision-support-systems-for-intensive-
insulin-therapy:-a-literature-review-and-case-study
International-Journal-of-Medical-
Inform
atics
32
Hospital
00
10
0
Case-Study
Tennessee
CDSS
Equilibrium
Authors-provide-a-case-study-of-Vanderbuilt-univ-hospitals-implementaiton-of-a-CDSS-to-support-
Intensive-insulin-therapy.--
Authors-highlight-complexity-of-HIT-implementation-and-social-differences-which-can-effect-how-a-
tool-is-used.
"The-interaction-of-hardware,-clinical-inform
ation-systems,-clinical-decision-support-m
odules,-blood-
glucose-devices,-and-clinicians-is-complex,-tim
e-consuming,-and-susceptible-to-error,-yet-most-
evaluations-of-computer2based-IIT-take-it-for-granted.-"-pg-39
"Computer2based-intensive-insulin-therapy-requires-substantial-organizational-change-and-
introduces-additional-complexity-with-unintended-consequences-including-error"-pg-40
"The-same-computer2based-intensive-insulin-therapy-protocol-used-in-two-hospitals,-or-tw
o-units-in-
the-same-hospital,-m
ight-produce-variability-in-social-processes-and-clinical-perform
ance.-"-pg-39
721
2010Toward-the-development-of-national-telehealth-
services:-the-role-of-Veterans-Health-Administration-
and-future-directions-for-research
TELEMEDICINE-and-e2HEALTH
31
IDS
11
10
0
Opinion
National
TeleHealth
Deep-Structure
Authors-note-the-benefits-of-an-integreated-delivery-system-(such-as-the-VA)-for-im
plementing-
technologies-such-as-telehealth:--these-include,-the-universal-use-of-standardized-EMRs,-practitioners-
as-part-of-the-VA-don't-need-to-worry-about-cross2state-licensure,-capitated-paym
ent-system.--
Patients-used-to-technology.
722
2010Can-you-feel-IT-coming?-Though-adoption-of-
anesthesiology-inform
ation-systems-is-still-low,-their-
use-is-rising,-and-will-continue-as-ARRA-approaches
Healthcare-inform
atics:-the-business-
magazine-for-inform
ation-and-
communication-systems
30
Hospital
01
00
0
Opinion/N
ews
anesthesia
Deep-Structure
Offers-a-unique-opinion-for-an-anesthesialogist-perspective.--Complexity-of-the-OR-is-cited-as-a-
barrier-to-adtopion-of-HIT.
"Record2keping-often-represents-a-significant-distraction-from-m
ore-immeidate-patient-care-needs.--
'When-you-take-it-to-the-OR,-you're-looking-at-vitals,'-says-Hess.--'There-are-all-these-variables-in-play-
and-the-person-is-cut-open-and-you're-trying-to-keep-them-from-bleeding-to-death'"-pg-14
723
2010The-technology-acceptance-m
odel:-its-past-and-its-
future-in-health-care
Journal-of-biomedical-inform
atics
44
Mixed
01
10
0
Literature-Review
Various
Deep-Structure
Authors-perform
-a-literature-review-of-the-ability-of-the-TAM-m
odel-to-explain-HIT-acceptance.--
"There-is-strong-evidence-to-conclude-that-the-perceived-usefulness-of-an-IT-will-have-some-impact-
on-whether-clinicians-accept-and-subsequently-use-a-health-IT.-Whether-the-IT-is-perceived-to-be-
easy-to-use-m
ay-not-be-as-likely-to-affect-acceptance,-but-it-does-appear-to-correlate-with-usefulness,-
perhaps-reflecting-the-notion-that-IT-that-is-difficult-to-use-cannot-possibly-be-perceived-as-useful-
[40].-The-implication-is-that-design,-training,-and-inform
ational-sessions-must-focus-on-ensuring-that-
health-IT-is-(or,-at-least,-is-perceived-to-be)-capable-of-im
proving-important-outcomes-and-is-not-
difficult-to-use.-"-pg-166
Critisism
-of-TAM22
"Indeed,-some-scholars-have-criticized-TAM-research-for-adding-variables-haphazardly,-leading-to-a-
progressively-less-coherent-theory."-pg-167
"Among-m
oderating-or-contextual-factors,-one-worth-exploring-m
ay-be-the-voluntariness-of-health-IT-
use-[46,-50,-102,-110].-Another-is-the-stage-of-the-health-IT;-some-studies-reviewed-here-studied-
prototypes-[96],-trial-systems-[107],-or-to2be2implemented-systems-[108],-whereas-others-studied-
implemented-systems-that-had-been-around-for-different-lengths-of-times.-"-pg-167
725
2010Funding-the-unfundable:-mechanisms-for-managing-
uncertainty-in-decisions-on-the-introduction-of-new-
and-innovative-technologies-into-healthcare-systems
Pharm
acoeconomics
24
Naitonal
01
00
0
Systematic-
Review
National
Various
Deep-Structure
Authors-examine-the-m
echanisms-by-which-technologies-(namely-thereputic)-are-approved-for-use.--
They-state-that-"traditionally,-m
uch-of-the-risk-associated-with-outcomes-of-coverage-decisions-has-
been-borne-by-the-payer-(e.g.-governments,-insurers,-etc.)"-pg-1142115
Relative-to-PE-in-that-revolution-periods-are-partially-defined-by-uncertainty-22-some-of-which-is-what-
will-be-covered.--A-significant-barrier-to-HIT-adoption-is-who-will-pay-and-whether-payors-who-control-
reim
bursement-decisions-and-benefit-from-HIT-implementation,-should-include-HIT-in-their-
reim
bursment-deicisions.--This-includes-US.
726
2010Medical-librarians-supporting-inform
ation-systems-
project-lifecycles-toward-improved-patient-safety
J-Healthc-Inf-Manag
31
Mixed
00
10
0
Opinion/N
ews
National
Various
Equilibrium
Adds-to-argument-that-the-m
ore-parties-invovled-in-all-aspects-of-HIT-implementation-the-better.
"Medical-librarians-are-already-part-of-many-healthcare-organizations-and-can-be-embedded-into-
project-m
anagement-and-health-inform
ation-system-lifecycle-teams-to-work-towards-system-success-
for-healthcare-workers,-patients-and-the-institution."-pg-53
178
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
727
2010Making-m
usic-out-of-noise.-The-Sentara-Healthcare-
Experience-Implementing-e2Care
Journal-of-healthcare-inform
ation-
management:-JHIM
32
hospital
00
10
0
Case-Study
Virginia-2-
North-
Carolina
Various
Equilibrium
Basic-discussion-of-im
plementaiton-activities-at-a-large-integrated-delivery-system.--Success-of-the-
project-was-based-on-the-use-of-"optimization"
"Successful-organizations-seek-continuous-im
provement-via-optimization.
Optimization-entails-overcoming-implementation-issues-to-ensure-continued-benefit-realization.-
Optimization-at-Sentara-has-the-following-goals:-1.)-establish-an-optimization-dashboard-to-track-
expected-ROI-as-to-validate-that-the-hospital-and-physician-practices-are-m
aking-their-business-cases;-
2.)-identify-the-optimization-project-selection-criteria;-3.)-select,-initiate-and-complete-three-to-five-
optimization-projects-per-quarter;-4.)-establish-a-baseline-of-system-functionality,-set-goals-and-track-
utilization;-and-5.)-establish-a-baseline-for-the-customer-experience,-set-goals-and-track-progress."-pg-
50
728
2010So-m
uch-to-do,-so-little-tim
e.-To-accomplish-the-
mandatory-initiatives-of-ARRA,-healthcare-
organizations-will-require-significant-and-thoughtful-
planning,-prioritization-and-execution
Journal-of-healthcare-inform
ation-
management:-JHIM
31
mixed
00
01
0
new/O
pinion
National
Various
Deep-Structure
Article-list-the-various-criteria-for-meeting-the-HITEC-requirements-under-ARRA.--STRUCTURE-now-a-
critical-component-of-im
plementation-and-deep-structure-in-order-to-m
eet-meaningful-use-
targets/requirements.
These-criteria-include:--Functionality,-affordability,-scalability-and-integration,-connectivity,-physicial-
limitations.
730
2010Top-EHR-challenges-in-light-of-the-stimulus.-Enabling-
effective-interdisciplinary,-intradisciplinary-and-cross2
setting-communication
Journal-of-healthcare-inform
ation-
management:-JHIM
31
Various
01
11
0
Opinion
National
Various
Deep-Structure
Deep-strcuture-of-our-current-health-care-system-is-episodic-and-not-patient-centered.--In-addition,-
the-m
eaningful-use-criteria-are-focused-on-accredidation-and-not-necesarialy-patient-care-2-"The-
initial-goal-of-the-2011-definition-of-meaningful-use-is-capturing-and-sharing-healthcare-data,-which-
would-be-m
eaningful-for-accreditation,-reim
bursement-and-healthcare-policy-m
ore-than-it-is-focused-
on-what-would-be-m
eaningful-for-patients-and-the-clinicians-who-care-for-them."-pg-18
"In-addition,-attention-m
ust-be-paid-to-weaknesses-in-the-current-healthcare-system-to-prevent-
codifying-them-in-health-IT.-Our-current-system-is-focused-on-episodic-care,-rather-than-
patientcentric,-and-has-been-weak-in-care-coordination.-While-encoding-all-current-data-in-episodic-
care-could-help,-it-does-not-coordinate-the-care."-pg-23
731
2010The-relationship-betw
een-physician-practice-
characteristics-and-physician-adoption-of-electronic-
health-records
Health-Care-M
anagement-Review
33
outpatient
01
00
0
Cross-Sectional-
Survey
Nebraska-
and-South-
Dakota
EHR
Deep-Structure
Study-applies-theiry-of-"resource-dependency"-to-m
ake-assumptions-on-physician-behaviour-with-
regard-to-EHR-adoption.--The-resource-dependency-theory-suggests-that-physicians-will-manage-their-
practices-in-a-way-that-reduces-their-dependency-on-others.--"This-framework-hypothesizes-that-
physicians-will-decide-to-adopt-EHR-systems-when-it-is-advantageous-to-do-so-and-not-to-adopt-when-
it-increases-external-dependencies."-pg-56
Through-a-survey,-all-5-hypotheses-were-shown-to-be-statistically-significant-2-physician-with-internal-
HIT-support-m
ore-likely-to-adopt-EHR;-physician-who-own-his-or-her-HIT-systems-more-likely-to-adopt-
EHR;-physicians-with-an-ownership-stake-in-his-or-her-practice-less-likely-to-adopt-EHR;-physicians-
who-are-part-of-a-larger-helath-care-system-are-m
ore-likely-to-adopt-EHR;-and-prm
ary-care-physicians-
are-m
ore-likely-to-adopt-EHR
733
2010Health-inform
ation-technology:-fallacies-and-sober-
realities
Journal-of-the-American-M
edical-
Inform
atics-Association
51
Mixed
01
11
0
opinion
national
Various
Deep-Structure
The-deeps-tructure-of-the-healthcare-is-notably-"human"-and-complex.--The-author-highlights-that-
HIT-m
ust-take-into-account-this-human-element-in-the-design-and-implementation-of-HIT.---Botttom-
line,-we-are-not-good-at-designing-HIT-yet.
"we-cannot-yet-design-and-deploy-complex-software-systems-that-are-on-tim
e,-within-budget,-m
eet-
the-specified-requirements,-satisfy-their-users,-are-reliable-(bug-free-and-available),-m
aintainable,-
and-safe.23-24-Edsger-Dijskstra,-a-recognized-leader-in-software-engineering,-lamented-that:"…
-most-
of-our-systems-are-m
uch-m
ore-complicated-than-can-be-considered-healthy,-and-are-too-m
essy-and-
chaotic-to-be-used-in-comfort-and-confidence.-The-average-customer-of-the-computing-industry-has-
been-served-so-poorly-that-he-expects-his-system-to-crash-all-the-tim
e,-and-we-witness-a-m
assive-
worldwide-distribution-of-bug2ridden-software-for-which-we-should-be-deeply-ashamed.23"-pg-617
Believe-FDA-oversight-is-a-good-thing-for-HIT-technology.--M
uch-of-the-article-discusses-the-falacies-of-
current-HIT-design,-noting-that-humans-alone-do-not-make-error,-no-do-computers-alone-m
ake-errors-
"Thus,-bad-outcomes-are-the-result-of-the-interactions-among-systems-components-including-the-
people,-tools-and-technologies,-physical-environment,-workplace-culture,-and-the-organizational,-
state,-and-federal-policies-which-govern-work.-Poor-HIT-outcomes-do-not-result-from-isolated-acts-of-
individuals,-but-from-interactions-of-multiple-latent-and-triggering-factors-in-a-field-of-practice."-pg-
618
Healthcare-is-complex-and-NOT-LINEAR.--"However,-as-a-complex-sociotechnical-system,-many-parts-
of-healthcare-delivery-are-m
essy-and-non2linear…
.HIT-designs-often-assume-a-rationalized-m
odel-of-
healthcare-delivery.-Templates-walk-clinicians-through-a-prescribed-set-of-questions-even-though-the-
questions-and/or-their-order-may-not-be-relevant-for-a-particular-patient-at-that-time."-pg-619
179
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
776
2010Strategic,-political,-and-cultural-aspects-of-IT-
implementation:-im
proving-the-efficacy-of-an-IT-
system-in-a-large-hospital
Journal-of-healthcare-
management/American-College-of-
Healthcare-Executives
32
hospital
00
10
0
Case-Study
Massachuse
tts
Patient-Management
Deep-Structure
In-a-case-study-of-the-implementation-of-a-Patient-management-system,-the-authors-found-that-
political-issues-were-a-m
jor-stumbling-block-to-implemention-of-the-IT-system.--The-intersts-of-
mangaers-were-different-from-those-of-the-systems-users.--Cultural-values-were-also-not-alligned.
"Our-analysis-found-that-the-obstacles-to-this-IT-implementation-involved-(1)-problems-in-strategic-
design,-including-a-lack-of-linking-and-alignment-mechanisms,-(2)-a-disparity-in-the-political-interests-
of-management-versus-line-staff,-and-(3)-significant-differences-in-the-culteral-meanings-of-the-KMD-
in-the-two-subcultures."-pg-202
822
2010Community2Driven-Standards2Based-Electronic-
Laboratory-Data2Sharing-Netw
orks
Public-Health-Reports
31
Public-Health
00
01
0
Opinion
National
HIE
Revolution
Focuses-on-the-Public-Health-Laboratories.--A
uthors-state-that-public-health-requires-standards-in-an-
increasingly-complex-environment:
"Because-the-engine-for-a-successful-open2innovation-effort-is-the-community,-any-change-in-the-
environment-that-compromises-the-stability-and-efficiency-of-the-community2based-collaboration-
represents-a-significant-threat.-In-the-public-health-domain,-several-common-challenges-are-notable."-
pg-45
Sustainability-2-"There-is-significant-historical-precedent-for-short2term
-program-perspectives-where-
momentum-gained-early-on-subsequently-stalls-and-leads-to-premature-term
ination-of-program-
support."-pg-54
Community-2-"The-m
aintenance-of-a-large,-complex-collaborative-requires-a-long2term
-commitment-
on-the-part-of-many-stakeholders."-pg-54
Governance-and-competition-2-"To-ensure-robust-and-efficient-community-collaboration,-there-m
ust-
be-effective-m
echanisms-in-place-to-m
aintain-strong-program-stewardship.-While-some-form
s-of-
competition-m
ay-fracture-the-community-and-have-a-detrim
ental-im
pact-on-netw
ork-output,-it-may-
be-nonetheless-reasonable,-for-example,-to-assess-program-effectiveness-on-a-regular-basis-and-even-
to-consider-competitive-bids-on-a-five2year-cycle-to-m
anage-the-open2innovation-community."-pg-56
824
2010Sustained-Participatory-Design-and-Implementation-
of-ITHC
Inform
ation-Technology-in-Health-Care:-
Socio2Technical-Approaches-2010.-From-
Safe-Systems-to-Patient-Safety
11
00
10
0
Opinion
National
Various
Equilibrium
Discusses-the-benefts-of-participatory-design-which-stresses-the-involvement-of-participants-in-
software-design,-terative-prototyping,-and-improvizational-change.
825
2010Changing-around-ICTs-innovations-is-usually-complex-
and-on2going-but-to-study-it-is-fundamental-to-
understand-what-happens-when-people,-
organizations,-institutions-and-technology-come-
together.
Studies-in-health-technology-and-
inform
atics
31
Various
01
10
0
Opinion
National
Various
Revolution
Atricle-discusses-how-to-look-at-change-differently.--Change-should-be-though-of-in-sociotechnical-
term
s.--
"Changing-around-ICTs-innovations-is-usually-complex-and-on2going-but-to-study-it-is-fundamental-to-
understand-what-happens-when-people,-organizations,-institutions-and-technology-come-together."-
Pg-?
The-social-aspects-os-the-socio-technical-framework-is-framed-as-"Thus-we-need-to-investigate-what-
people-understand-about-technology-(perceptions,-hopes,-fears)-and-what-they-do-in-their-daily-
practices-with-technology-(uses-and-practice).-In-doing-so,-we-understand-adoption-but-also-
rejection,-‘non-use’,-‘misuse’-and-resistance-of-technology,-not-as-failure-or-negative-consequence-
but-as-alternative-enactments-upon-technology…
.-Second,-we-need-to-capture-not-only-what-people-
say-they-do-versus-what-they-are-doing-but-to-reconcile-states-of-being-(being-a-doctor,-being-a-
computer,-being-a-patient)-and-practices-of-doing-(making-a-diagnosis)….-Cho-et-al.-[17]-explain-how-
the-adoption-of-a-health-inform
ation-system-in-a-hospital-conditioned-redistribution-of-professional-
responsibility-and-(re2)division-of-labour-as-people-attempted-to-inscribe-their-interests-into-the-
technology."-pg-?
Core-recommendation-is-2-"This-paper-makes-a-familiar-argument-but-with-a-twist;-we-should-study-
the-processes-of-‘sociotechnical-changing’-and-m
ove-away-from-static-pre-and-post-implementation-
‘impacts’-or-notions-of-discrete-change-that-dominate-studies-in-healthcare"-pg-?
180
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
826
2010Hospital-IT-adoption-strategies-associated-with-
implementation-success:-Im
plications-for-achieving-
meaningful-use
Journal-of-Healthcare-M
anagement
31
hospital/system
00
10
0
Opinion
national
Various
Equilibrium
Discuss-implementation-strategies-to-m
eet-meaningful-use-requirements.--Three-strategies-are-
reviewed-(Single2vendor,-Best-of-Breed-and-Best-of-Suite).
"There-is-no-one2size2fits2all-strategy.-The-single2vendor-strategy-is-likely-to-gain-m
arket-share-as-
mergers-and-acquisitions-continue-to-consolidate-the-HIT-vendor-sector-and-a-few-dominant-players-
expand-their-application-footprint.-Further,-the-sheer-complexity-of-managing-HIT-systems-with-
numerous-applications-will-serve-as-an-impetus-for-hospitals,-especially-relatively-small-ones-that-are-
not-part-of-a-larger-system,-to-adopt-single2vendor-solutions.-On-the-other-hand,-firm
s-pursuing-BoS-
strategies-with-clearly-differentiated-capabilities,-greater-flexibility,-and-m
ore-rapid-implementation-
schedules-will-continue-to-play-a-significant-role-in-the-hospital-HIT-m
arket."-pg-8
827
2010Millennial-transform
ation-for-primary-care
Military-m
edicine
51
health-system
10
01
0
Opinion
National
Various
Deep-Structure
Deep-structure-is-changing-as-the-values-and-experiences-of-future-generations-have-m
ore-influence-
on-healthcare.--
The-m
illenium-generation-is-influecing-the-practice-of-medicine-thorugh-changes-in-22-knowledge-
acquisition,-social-netw
orks-and-personal-empowerm
ent-(see-book-I-bought-on-this-by-Harvard-guy).--
Ultim
ately-these-forces-will-change-the-deep-strcuture.
830
2010Technological-viewpoints-(frames)-about-electronic-
prescribing-in-physician-practices
Journal-of-the-American-M
edical-
Inform
atics-Association
32
Ambulatory
01
00
0
Focus-Group-2-
Case-Study
Not-Stated
eRx
Revolution
Authors-examine-the-acceptance,-perceptions-and-use-of-technology-in-term
s-of-"technological-
frames".--Three-frames-are-identified-2-Positive,-Neutral-and-Negative.--Frames-represent-cognitive-
structures-thorugh-which-users-m
ake-sense-of-the-role-of-technology.
The-authors-conclude-that:
"Our-investigation-shows-that-technological-frames-provide-a-basis-for-understanding-why-some-
practices-adopt-eRx-rapidly-while-others-continue-to-resist-or-delay-adoption.-When-decision-m
akers-
have-no-frame-on-which-to-base-adoption-and-use-decisions-(eg,-they-have-little-knowledge-of-the-
technology-and-no-experience-with-its-use),-they-will-delay-or-defer-the-adoption-decision-until-they-
are-able-to-acquire-knowledge-about-the-system.8-W
hen-forced-to-adopt-a-technology-by-external-
mandate,-users-m
ay-actively-resist-the-technology,-m
isuse-it,-or-otherw
ise-not-utilize-it-in-the-m
anner-
intended-by-its-designers.-Thus,-the-gains-realized-from-technology-use-are-likely-to-be-m
inim
al.--
Creating-an-organizational-culture-that-is-positively-framed-m
ay-be-a-precursor-to-m
eaningful-use.-"-
pg-430
831
2010Change-m
anagement-for-effective-quality-
improvement:-A-primer
American-Journal-of-Medical-Quality
31
Various
01
10
0
Opinion
National
Various
Equilibrium
Change-m
anagement-is-escential-for-im
proveing-quality-and-acceptance-of-change.
"Developing-technology,-the-changing-needs-of-patients,-and-economic-pressures-are-among-the-
many-factors-that-contribute-to-the-need-for-health-organizations-to-continually-modify-their-
practices.3-Quality-improvement-(QI)-of-current-processes-is-central-to-these-efforts.-To-best-m
anage-
the-introduction-of-change-to-a-health-organization-via-QI,-it-is-crucial-to-focus-on-people-and-
relationships-as-a-part-of-change."-pg-268
"According-to-a-survey-of-93-companies,-the-3-m
ost-frequent-problems-that-affect-change-
implementation-include-a-longer-than-planned-tim
e-frame-to-complete-the-change-process;-major-
unanticipated-problems;-and-ineffective-coordination-of-activities.6-Other-obstacles-that-im
pede-
change-include-resistance-from-employees,-lack-of-adequate-communication,-an-attempt-to-change-
everything-at-once,-and-halfhearted-m
anagement-commitment."-pg-268
"The-success-of-change-efforts-is-critical-to-improve-quality-of-care.-Adoption-of-change-m
anagement-
practices-increases-the-odds-of-success-because-focus-is-placed-on-the-people-in-the-organization-
who-m
ake-things-happen.-As-physician-executives-set-about-im
plementing-change,-it-is-also-
important-to-note-that-change-is-more-readily-accepted-when-it-is-viewed-as-a-state-of-being-rather-
than-a-onetime-event."-pg-272
181
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
832
2010Computerized-physician-order-entry:-lessons-
learned-from-the-trenches
Neonatal-Netw
ork:-The-Journal-of-
Neonatal-Nursing
32
Hospital
00
10
0
Case-Study
Unknown
CPOE
Equilibrium
Authors-review-the-process-used-to-implement-a-CPOE-system-as-part-of-a-pilot-at-a-hospital.
Lessons-learned-were-reported-to-be:
"Key-unit2based-care-providers-who-actively-participate-in-planning-and-implementation-are-
essential.
2.-A-physician-champion,-critical-for-oversight-and-support,-does-not-necessarily-need-to-be-involved-
in-the-detail-of-building-the-order-sets.
3.-Some-paper-orders-do-not-translate-well-to-computer-documentation-(feeding-orders,-TPN).
4.-Order-sets-should-m
atch-the-work-processes-in-the-unit.
5.-Meeting-in-person-with-the-builders,-who-can-immediately-m
ake-revisions-on-the-computer,-is-the-
most-efficient-and-effective-use-of-everyone’s-tim
e-(e2m
ail-is-easily-m
isinterpreted).
6.-Use-the-practice-domain-to-place-“real-orders”-to-work-out-the-kinks.
7.-W-W
hen-reviewing-order-sets,-make-very-sure-that-all-the-functionality-or-step-by-step-sequencing-
that-is-needed-to-complete-the-order-actually-works-and-that-all-the-order-details-are-correct.
8.-Make-screen-shots-of-all-order-sets-as-revisions-are-m
ade,-because-items-can-be-lost-or-changed-
during-the-production-phase.
9.-Self2paced-training-guides-with-realistic-practice-scenarios-help-staff-m
ake-the-transition-at-their-
833
2010Sustainable-rural-telehealth-innovation:-a-public-
health-case-study
Health-services-research
32
public-Health-system
00
01
0
Case-Study
Georgia
Telehealth
Revolution
Authors--describe-(using-puctuated-equilibrium)-within-a-case-study-how-a-telehealth-project-m
oved-
from-a-federally-funded-pilot-to-a-sustainable-service-within-the-system.
Keys-were-exsamining-tele2health-from-a-business-vantage-point-and-a-valuable-tool-for-meeting-the-
public-health-m
ission-of-the-district.--Tele2health-eventually-became-sustainable-by-replacing-prior-
face2to2face-encounters-with-tele2health-solutions-reducing-travel-and-other-costs.
834
2010Even-when-Physicians-Adoppt-E2prescribing,-Use-of-
Advanced-Features-Lags
23
Physician
01
00
0
Cross-Sectional-
Survey
National
eRx
Deep-Structure
Summarizes-results-of-the-HSC-2008-health-Tracking-Physician-Survey.--Found-that-while-m
any-
doctors-had-capabilities-for-eRx,-it-was-not-being-used-to-its-fullest-extent-despite-incentives-from-
MIPPA-and-ARRA.
835
2010Barriers-to-cross22institutional-health-inform
ation-
exchange:-a-literature-review
Journal-of-healthcare-inform
ation-
management:-JHIM
44
National
00
01
0
Literature-ReviewNational
HIE
Deep-Structure
Systematic-Review-of-the-Literature-on-barriers-to-adoption-of-HIE.--"Upon-review,-the-m
ajor-barriers-
to-HIT-interoperability-included:-need-for-standards-(particularly-reference-term
inology-standards),-
security/privacy-concerns,-economic-loss-to-competitors-and-complex-and-federated-systems-(w
hich-
require-costly-interfaces)."-pg-24
"While-some-independent-standards-exist,-global-standards-in-HIT-have-not-yet-been-implemented-or-
national-im
plementation-guidelines-do-not-yet-exist.-Klein-argues-that-lack-of-standards-leads-to-
fragmented-patient-inform
ation-that-limits-the-development-of-medical-knowledge-and-can-lead-to-
medical-errors-and-inefficiency."-pg-24
"For-instance,-it-is-difficult-to-determ
ine-where-exactly-the-boundaries-on-standardization-should-be-
established.-Should-they-be-m
andated-at-the-data-collection-point,-so-that-each-clinician-collects-data-
in-the-same-way;-at-the-practice-level—
allowing-for-customization-according-to-specialty;-at-the-
institutional-level;-at-the-regional-sphere;-or-at-the-national-sphere?"-pg-24
837
2010Electronic-m
edical-record-systems-in-critical-access-
hospitals:-leadership-perspectives-on-anticipated-
and-realized-benefits
Perspectives-in-Health-Inform
ation-
Management/AHIM
A,-American-Health-
Inform
ation-M
anagement-Association
42
Hospital
00
10
0
Case-Study/Focus-
Group
Iowa
EHR
Equilibrium
expected-benefits-of-EMRs-are-not-yet-aligned-with-realized-benefits.--Thus,-a-group-of-sm
all-rural-
hospitals-have-invested-considerable-tim
e,-money-and-hyuman-resources-in-implementing-EMRs-
based-on-high-hopes-but-have-very-little-empirical-evidence-of-bneefits-resulting-from-the-commercal-
systems-they-have-installed."--pg-8
838
2010EHR-acceptance-factors-in-ambulatory-care:-a-survey-
of-physician-perceptions
Perspectives-in-Health-Inform
ation-
Management/AHIM
A,-American-Health-
Inform
ation-M
anagement-Association
33
Hospital
01
00
0
Cross-Sectxional-
Survey
Mississippi
EHR
Deep-Structure
Authors-examine-the-sociaotechnical-factors-that-might-represent-the-antecedents-of-EHR-adoption.
"None-of-the-phsician-characteristics-in-this-study-correlated-with-any-of-the-other-model-variables.--
These-findings-could-be-reflective-of-a-homogenous-sample-and-are-consistent-with-findings-
observed-in-several-prior-studies."-pg-4
To-explain-the-high-failure-rate-of-EHR-implementations-the-authors-state-that-based-on-the-results-
"it-can-not-be-assumed-that-physicians-of-a-particular-age,-clinical-specialty,-affiliation-
(faculty/resident)m-or-computer-skill-elvel-will-be-m
ore-or-less-resistant-than-other-physicians."-pg-6
182
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
839
2010The-effects-of-innovation-factors-on-smartphone-
adoption-among-nurses-in-community-hospitals
Perspectives-in-Health-Inform
ation-
Management/AHIM
A,-American-Health-
Inform
ation-M
anagement-Association
33
Hopsital
01
00
0
Cross-Sectional
SouthEast
SmartPhone
Revolution
In-a-survey-of-nurses-using-new-smartphone-technology,-researchers-found-that-job-relevance-was-a-
significant-innovation-characteristic.--"If-a-nurse-believed-a-smartphone-assisted-with-improving-
patient-care,-he-or-she-would-m
ore-readily-adopt-a-amartphone."-pg-6
the-study-also-found-no-significance-from-personal-characteristics-such-as-demographics-pr-
experience.
841
2010'M
eaningful-use'hoists-hospital-IT-to-next-level
Hospitals-&-health-netw
orks/AHA
10
Hospital
00
10
0news
National
Various
Equilibrium
Article-talks-about-the-organizational-changes-that-can-be-m
ade-to-support-m
eaningful-use-and-that-
meaningful-use-is-a-first-step-in-imporoving-quality-and-outcomes.--Incremental-approach.
845
2010Transform
ing-nursing-workflow,-part-1:-the-chaotic-
nature-of-nurse-activities
Journal-of-nursing-administration
12
Hospital
01
00
0
Case-Study-/-
Work2tim
e-
analisys
Kansas
Various
Equilibrium
Authors-m
inim
ally-discuss-any-of-the-three-components-of-PE.--Focus-of-study-is-on-changes-in-work-
flows.
Do-discuss-Lean-design-and-concept-of-continuous-im
porvement-of-workflows.
846
2010Clinical-decision-support:-progress-and-opportunitiesJournal-of-the-American-M
edical-
Inform
atics-Association
31
national
00
01
0
Opinion
National
CDSS
Revolution
the-authors-report-on-the-progress-of-suggestions-made-to-facilitate-adoption-of-CDSS.
"Three-years-ago,-as-part-of-an-overall-framework-for-CDS-advancement-in-the-USA,-a-group-of-
experts-identified-a-set-of-tasks-to-help-support-broader-use-of-these-tools.-Significant-progress-has-
been-m
ade-in-m
ost-of-the-areas-described,-but-much-work-is-still-needed.-Demonstration-projects-in-
CDS-have-been-funded-and-are-under-way.-The-healthcare-quality-community-increasingly-recognizes-
the-role-of-HIT-and-supports-greater-use-of-CDS.-Commercial-entities,-federal-organizations,-non2
profit-groups-and-academic-organizations-are-all-contributing-approaches-to-help-disseminate-
important-knowledge-about-CDS-deploym
ent.-Incentives-for-provider-adoption-of-these-tools-are-on-
the-rise.-We-believe-that-continued-progress-in-this-area-would-be-greatly-facilitated-by-four-key-
activities:-(1)-the-designation-of-a-single-entity-to-coordinate-CDS-development-and-deploym
ent;-(2)-
the-development-and-use-of-techniques-to-m
easure-the-use-of-CDS-tools;-(3)-continued-research-
funding-for-CDS;-and-(4)-the-development-of-an-updated-critical-path.-"-pg-490
847
2010The-Internet-and-the-physician2patient-relationship
Clinical-Orthopaedics-and-Related-
Research
31
Various
11
00
0
Opinion
National
Internet
Deep-Structure
"The-healthcare-industry-continues-to-lag-behind-other-industries-that-have-been-transform
ed-by-the-
Internet.-Numerous-industries-including-travel,-real-estate,-retail-sales,-and-banking-have-m
igrated-
both-comprehensive-inform
ation-resources-and-transactions-to-the-Internet-in-order-to-improve-
efficiency-and-customer-satisfaction.-That-same-process-is-occurring-now-in-the-healthcare-industry.-
Credible-and-comprehensive-Inform
ation-resources-are-beginning-to-m
ature.-Transactions-are-still-in-
their-infancy,-reflecting-a-continued-concern-about-privacy-and-security."-pg-2566
"The-current-approach-dominating-the-healthcare-transaction-today-is-to-physically-present-oneself-
to-the-system-to-complete-nearly-all-of-the-tasks-associated-with-understanding-“what-to-do”-and-
“how-to-do-it.”-This-is-inefficient-for-both-patient-and-provider-and-needlessly-expensive."-pg-2569
"One-of-the-m
ain-reasons-health-care-has-been-slow-to-embrace-the-Internet-revolution-is-about-the-
risk-of-transactions,-not-inform
ation-components.-"-pg-2569
848
2010Reducing-disparities-in-health-care-quality:-the-role-
of-health-it-in-underresourced-settings
Medical-Care-Research-and-Review
22
Hospital-(Safety-Net)
00
10
0
Focus-Group
national
Various
Deep-Structure
Healthcare-in-underserved-populations-can-be-assited-by-HIT.--However,-HIT-should-not-be-
considered-the-solution,-but-rather-an-enabler-for-addressing-disparities-in-healthcare.
Utilizing-HIT-in-underserved-populations-will-also-include-the-social-context-of-where-care-is-
provided,-and-how-HIT-integrates-with-potentially-new-healthcare-delivery-options-and-contexts.
854
2010Critical-access:-the-need-to-connect.-Connecting-
midsize-hospitals-to-rural-critical-access-hospitals-is-
important-to-the-growth-of-both22but-there-are-
things-larger-hospitals-need-to-know
Healthcare-inform
atics:-the-business-
magazine-for-inform
ation-and-
communication-systems
30
hospitals-2-Critical-Access
00
10
0
News/Opinion
National
EHR
Deep-Structure
Deep-structure-of-the-environments-for-sm
all-rural-critical-access-hospitals-is-quite-different-from-
larger-hospitals.--"I've-seen-several-of-our-larger-hospitals-try-and-put-their-EMRs-into-a-small-hospital-
and-it-has-not-worked-out-well."-pg-25
856
2010Transform
ing-nursing-workflow,-part-2:-the-impact-
of-technology-on-nurse-activities
Journal-of-nursing-administration
33
Hospital
01
00
0
Pre2Post-
Workflow-Study
Unknown
Medication-
documentation
Equilibrium
During-periods-of-equilibrium,-incremental-changes,-such-as-the-new-m
edication-system-studied-
here,-had-m
inim
al-to-no-effect-on-nursing-activities,-i.e.-they-are-absorbed-by-the-organization.--
The-effects-in-this-case-were-m
easured-based-on-observations-of-29-specific-nursing-activities-
develop-by-Cronell.
857
2010A-progress-report-on-electronic-health-records-in-US-
hospitals
Health-Affairs
53
hospital
00
10
0
Cross-Sectional-
Survey
National
EHR
Deep-Structure
Main-finding-is-the-digitial-divide-emerging-betw
een-urban-and-rural-hospitals-2-rural-sm
all-hospitals-
have-a-m
uch-lower-adoptoin-rate-of-EHRs-and-other-technologies.--A
RRA-m
ay-in-fact-serve-to-widen-
this-gap-if-the-larger-urban-hospitals-reeive-the-bulk-of-the-incentive-paym
ents-and-are-able-to-
expand-their-HIT-activities.--
"While-adoption-rate-increased-m
odestly-[in-2009]-sm
aller,-rural-and-public-hospitals-fell-furher-
behind-their-counterparts.--By-2009,-very-few-hospitals-could-m
eet-the-final-stage-1-rules-for-
meaningful-use."-pg-1957
183
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
859
2010Project-HealthDesign:-Rethinking-the-power-and-
potential-of-personal-health-records
Journal-of-biomedical-inform
atics
32
home
10
00
0
Case-Study
Various
PHR
Revolution
Based-on-a-study-on-the-development-of-PHR-applications-sponsored-by-RWJF,-the-authors-state-that-
"the-m
ost-important-lesson-that-emerged-was-that-user-demand-for-personal-health-applications-
revealed-a-greater-need-for-day2to2day-data-(observations-of-dalily-living,-ODLs)-than-for-the-
relatively-static-clinical-data."-pg-S4
860
2010Smart-leadership!-Finding-the-right-mix-of-minds-to-
manage-the-future
Hospitals-&-health-netw
orks/AHA
30
Hospital
00
00
0
news
national
Various
Revolution
Changes-in-deep-structure-needed-to-effectuate-transform
ation-required-by-ACA-and-ARRA.--Shifting-
risk-is-a-large-part-of-these-changes.--M
oving-from-fee2based-to-perform
ance-based-m
eans-hospitals-
take-on-m
ore-risk.--Authors-state-that-this-transform
aitn-will-require-new-leaders-that-are-focused-on-
managing-this-risk,-controlling-costs,-and-including-all-levels-of-the-organization-in-m
anagemetn-and-
planning.
863
2010Developing-and-validating-a-m
odel-to-predict-the-
success-of-an-IHCS-implementation:-the-Readiness-
for-Im
plementation-M
odel
Journal-of-the-American-M
edical-
Inform
atics-Association
44
Various
10
10
0
Longitudinal-
Study-Validating-
model
National
IHCS-(PHR)
Equilibrium
Authors-test-a-m
odel-developed-in-previous-work-to-predict-the-success-of-the-implementation-of-a-
Interactie-Health-Communication-System-(IHCS)-with-patients.--The-m
odel-contains-sevel-factors-with-
42-individual-elements-that-are-used-to-predeict-organizational-readiness-for-im
plementation-and-
success.-Pg-709/Table-1
Of-the-sevel-organizational-factors,-organizational-motivation-and-m
eeting-user-needs-were-the-m
ost-
important-predictors.--This-was-shown-in-a-factor-analysis-of-the-various-elements.--Promotion-was-
found-to-be-relatively-less-influential.--
Study-finding-validated-the-RIM
-model-developed-by-the-authors.
864
2010For-hospitals-and-m
eaningful-use,-context-is-
everything
Hospitals-and-health-netw
orks
30
Hospital
01
10
1
News
National
Various
Deep-Structure
"Perheps-the-biggest-concern-at-the-m
oment-for-providers-is-whether-vendors-have-the-produc-and-
staff-in-place-to-m
eet-what's-likely-to-be-a-dramatic-increase-in-demand"-pg-21
Demand-and-vendar-capabilities-are-issues-in-the-current-deep-structure.
865
2010Avoiding-the-trap-in-the-HITECH-Act's-incentive-
timeframe-for-im
plementing-the-EHR
Journal-of-Health-Care-Finance
20
Hospitaql
00
10
0
News/opinion
National
EHR
Equilibrium
Hospitals-should-not-be-rushed-into-implementing-an-EHR.--"a-rushed-implementation-is-unlikely-to-
result-in-the-acquisition-of-a-system-that-will-stisfy-its-intended-users."-pg-97
Authors-provide-a-structured-process-that-should-be-followed-for-successful-im
plementation.
867
2010The-impact-of-electronic-m
edical-record-systems-on-
outpatient-workflows:-A-longitudinal-evaluation-of-
its-workflow-effects
International-Journal-of-Medical-
Inform
atics
44
outpatient-clinic
00
00
0
Mixed
Buffalo
EMR
Deep-Structure
Authors-study-the-effect-on-attitudes-and-perceptions-about-EHR-and-the-later-satisfaction-with-the-
systems.--Three-findings-are-of-note:
12-"Physician-expectations-from-the-EMR-were-best-predicted-by-their-attitudes-tw
oards-health-IT-
rather-than-a-tesk2technology-fit."-pg-787
22-"physicians-were-less-than-satisfied-with-the-new-EMR.--In-the-present-study,-physicians'-
satisfaction-levels-were-lower-across-the-board-on-all-the-workflow-areas-of-im
pact-of-the-new-EMR.--
…-This-suggests-that-the-decision-regarding-the-usefulness-of-the-EMR-is-made-very-early-within-the-
first-few-m
onths-of-use-of-the-EMR."-pg-787
32-"The-affects-of-leaning,-however,-accounted-for-less-than-10%-of-the-variance-in-satisfaction-levels-
across-the-various-workflow-impact-areas."-pg-787
868
2010A-comparison-of-the-adoption-of-electronic-health-
records-in-North-Carolina-and-South-Carolina-HIV-
systems
Southern-M
edical-Journal
33
Health-System
01
01
0
Comparative-
case-Study
North-
Carolina-2-
South-
carolina
EHR
Revolution
Results-of-the-caparative-case-study-of-statewide-adoption-of-EHR-show-the-need-for-state-
promotion-in-the-form
-of-policies-and-m
andates-as-well-as-a-state-chanmpion-to-propmote-standards-
and-adoption.
"State-and-federal-policies-clearly-have-a-significant-effect-on-the-adoption-of-EHRs.-In-both-of-the-
case-studies,-each-State-Health-Department-promoted-the-use-of-EHRs;-however,-a-significant-
difference-was-the-form
al-adoption-of-the-EHR-by-the-SC-State-Health-Department-to-standardize-
and-collect-statewide-data.-Medical-and-ancillary-providers-considering-adoption-of-an-EHR-should-
consider-whether-there-is-significant-policy-support-from-policymakers-and/or-funders-for-the-
implementation-and-sustainability-of-an-electronic-health-record,-and-it-may-be-necessary-to-
investigate-form
al-policy-support-for-the-EHR-at-local,-state,-and-federal-levels.
Results-from-the-study-also-suggest-that-a-dedicated-champion-at-the-state-health-department-plays-
a-key-role-in-the-m
ulti2institutional,-cross2sectoral-adoption-of-an-EHR."-pg-1117
872
20107-strategies-for-im
proving-HITECH-readiness
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
30
Hospital
00
10
0
News/opinion
National
EHR
Revolution
Policy-driving-a-change-in-deep-structure-that-will-result-in-organizational,-structural-and-strategy-
changes-at-the-individual-organizational-level.--"…demonstation-of-meaningful-use-of-EHRs-by-
healthcare-organziations-has-become-larger-than-qualifying-for-stim
ulus-dollars."-pg-90
874
2010Health-inform
ation-technology:-integration-of-
clinical-workflow-into-m
eaningful-use-of-electronic-
health-records
Perspectives-in-Health-Inform
ation-
Management/AHIM
A,-American-Health-
Inform
ation-M
anagement-Association
21
Ambulatory
01
00
0
Opinion
National
EHR
Deep-Structure
Authors-emphasize-the-changing-environment-for-physicians.--In-escense-the-deep-structure-of-the-
environment-has-changed-with-the-ephasis-placed-on-it-by-meaningful-use.--This-will-require-a-change-
in-physician-workflows.
184
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
876
2010The-regional-extension-center-program:-helping-
physicians-meaningfully-use-health-inform
ation-
technology
Annals-of-internal-medicine
41
Various
01
00
0
News/Opinion
National
EHR
Revolution
RECs-represent-siginifcant-policy-to-alter-deep-strcuture-of-the-current-healthcare-environment.--
RECs-will-faciliate-this-change-through-direct-assistance-to-individual-phsysicans.--A
ssistance-will-be-in-
the-form
-of-training,-selection-of-vendors,-assistance-during-implementaiton,-etc.
Modeled-after-Mass-eHealth-and-PCIP-program-in-NYC.
877
2010Kaiser-Perm
anente's-Perform
ance-Improvement-
System,-Part-1:-From-Benchmarking-to-Executing-on-
Strategic-Priorities
Joint-Commission-Journal-on-Quality-and-
Patient-Safety
42
IDS-2-Kaiser
00
10
0
Case-Study
National
Various
Equilibrium
Good-detailed-description-of-efforts-undertaken-by-Kaiser-to-implement-perform
ance-improvement-
system-throughout-their-netw
ork.--Process-improvement-represents-an-incremental-change-
methdology-that-is-typical-of-equilibrium-period.--
Case-study-outlines-typical-process-for-im
plementation-of-such-a-perform
ance-improvement-
program.
Components-of-the-PI-program-includedx-six-areas-of-focus:--Leadership,-System-approach-to-
improvement,-m
easurement-capability,-learning-organziation,-im
provement-capability-and-culture-2-
priorities,-benchmarking,-cimmunication-and-M
EASUREMENT!!
880
2010More-than-just-a-question-of-technology:-Factors-
related-to-hospitals'-adoption-and-implementation-
of-health-inform
ation-exchange
International-Journal-of-Medical-
Inform
atics
53
hospitals
00
10
0
Cross-Sectional-
Survey
National
HIE
Deep-Structure
TOE-Framework-used-2-Technology-Organziation-and-Environmental-contexts.--The-framework-is-used-
to-develop-m
easures-and-variables-for-the-adoption-and-implementaiton-of-HIE.
Technological-Context:
"However,-once-controlled-for-other-factors,-the-presence-of-a-certified-EHR-was-not-associated-with-
adoption-or-im
plementation."-pg-801
Organizational-Context
"for-profit-hospitals-were-significantly-less-likely-to-adopt-HIE-than-not2for2profit-and-public-hsopitals,-
which-only-serves-to-support-assertions-that-HIE-is-perceoived-as-a-financially-undesirable-
proposition."-pg-802
Envronmental-context
"these-results-sugggest-competition-m
ay-be-a-continual-hindrance-even-in-light-of-near-mandatory-
EHR-adoption."
882
2010What-you-heed-to-know-about-meaningful-use
Hospitals-&-health-netw
orks/AHA
20
Hospital
00
10
0News
National
EHR
Revolution
Outlines-requirements-of-meaningful-use.--Attempt-by-Legislation-to-influence-deep-structure-of-the-
environment.
883
2010'No-physician-left-behind'is-an-IT-priority-for-
hospitals
Hospitals-&-health-netw
orks/AHA
20
hospital
01
00
0News
national
EHR
Revolution
Be-sure-to-include-physicians-at-all-levels-of-im
plementaiton-of-EHR.
885
2010The-influence-of-context-on-quality-improvement-
success-in-health-care:-a-systematic-review-of-the-
literature
Milbank-Quarterly
35
Various
00
01
0
Systematic-
Review
Internation
al
Various
Deep-Structure
Systematic-review-of-the-literature-examinng-contextual-areas-that-im
pact-the-success-of-HIT-QI-
efforts.--Findings-include:-competition,-leadership,-culture-supportive-of-QI,-capacity,-physician-
leadership.--All-were-shown-to-influence-QI-success.
Noted-at-very-early-stage-and-m
ore-research-needed.--Findings-did-m
atch-results-from-QI-in-other-
industries-and-theories.
"Competition-was-the-m
ost-consistently-studied-environmental-contextual-factor."-pg-508
886
2010EHR-adoption-among-doctors-who-treat-the-elderly
Journal-of-Evaluation-in-Clinical-Practice
33
Outpatient
01
00
0Cross-Sectional-
Survey
Florida
EHR
Revolution
In-an-examination-of-the-elderly-population,-High-Volume-Elderly-clinicians-were-less-likely-to-have-an-
EHR-than-their-counterparts.
185
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
887
2010Evaluating-the-impact-of-investments-in-inform
ation-
technology-on-structural-inertia-in-health-
organizations
US-Arm
y-Medical-Department-journal
51
Various
00
10
0
Opinion-/-m
odel-
development
National
Various
Equilibrium
Author-applies-the-theory-of-Population-ecology-and-structural-inertia-to-the-relationship-betw
een-an-
organizations-HIT-investment-and-business-failure.--The-population-ecology-framework-shares-many-
features-of-Complex-Adaptive-Systems-in-that-population-ecology-looks-at-an-oganizations-ability-to-
adapt-to-their-environment-and-the-capacity-to-adapt-(structural-inertia).--
The-framework-predicts-that-technology-will-im
pact-a-m
arket-in-3-ways-12-alters-industry-strcutures;-
22-supports-cost-and-differentiation;-and-32-spawns-new-businesses.--Pg-61
In-the-case-of-IT-in-healthcare-"Two-clear-themes-have-emerged-from-a-review-[of]-the-literature-
involving-the-helathcare-IM/IT-experience:-there-is-a-general-underutilization-of-IM
/IT-capailities-
accrosss-the-m
arket,-and-IM/IT-complexity-is-possitively-associated-with-business-failure."-pg-61
889
2010Nursing-and-technology:-a-love/hate-relationship
Nursing-economic$
41
Nursing
01
10
0
Opinion
National
Various
Equilibrium
IT-and-Quality-improvement-do-not-always-m
ix-well,-especially-with-nursing.--"we-cannot-'force'-the-
technology-adoption-into-workflow-or-the-transform
ation-of-care,-particularly-if-these-are-not-
inherent-to-the-technology-and-process-being-implemented."-pg-405
"The-basic-principle-here-is-that-technology-does-not-stand-on-its-own,-but-that-it-is-used-by-people-
as-they-are-perform
ing-a-process,-and-that-getting-these-three-elements-aligned-is-essential-to-
ensuring-project-success-and-a-system-that-supports-optimized-workflow."-pg-405
"We-m
ust-consider-letting-the-quality-improvement-process-drive-and-define-when-and-how-
technology-is-used,-running-our-projects-as-practice-changes-and-not-IT-implementations,-with-
nursing-sponsors-owning-the-projects-and-leading-the-charge.-This-m
ay-be-just-what-we-need-to-turn-
the-love/hate-relationship-with-technology-into-a-true-m
arriage"-pg-4072408
890
2010Uniting-the-tribes-of-health-system-improvement
American-Journal-of-Managed-Care
41
National-Setting
00
01
0
Opinion
national
Various
Revolution
Authors-stress-the-importance-of-not-looking-at-HIT-as-a-singular-solution.--Transform
ation-of-
healthcare-will-require-a-combination-of-interventions-which-in-addtion-to-HIT-include:-quality-
improvement-(i.e.-Lean-and-other-continuous-quality-improvements);-paym
ent-reform
;-and-
consumer-or-patient-engagement.
891
2010HITECH-Lays-the-Foundation-for-More-Ambitious-
Outcomes2Based-Reim
bursement
The-American-journal-of-managed-care
51
National-System
00
01
0
opinion
National
Various
Revolution
The-combination-of-HITEC-and-ACA-has-fundamentally-changed-the-environment-of-healthcare-
delivery.--HITEC-focused-attention-on-the-use-of-HIT-and-ACA-focused-attention-on-how-HIT-will-
measure,-change-and-organize-care-going-forw
ard.
"The-recently-passed-healthcare-reform
-legislation-known-as-the-Patient-Protection-and-Affordable-
Care-Act-(PPACA)-underscored-the-federal-government’s-interest-in-new-care-delivery-m
odels-such-as-
accountable-care-organizations-(ACOs)-and-new-reim
bursement-approaches-such-as-episode-and-
bundle-paym
ents-that-address-the-cost-and-quality-imbalance-by-significantly-im
proving-the-
efficiency,-quality,-and-coordination-of-care-delivery."-pg-SP20
"In-effect,-HITECH-has-perm
anently-shifted-our-focus-from-adoption-of-HIT-to-its-use."-pg-SP19
"Therefore,-one-really-ought-to-assume-that-HITECH-is-fundamentally-laying-the-foundation-for-
paym
ent-and-structural-reform
,-which-assumes-widespread-m
eaningful-use-of-interoperable-EHRs."-
pg-SP20
"These-changes-may-be-m
ore-significant-to-the-industry-and-to-healthcare-inform
ation-technology-
than-the-m
eaningful-use-regulation-itself."-SP-21
"At-the-end-of-the-day,-if-you-do-not-know-whether-you-are-m
aking-or-losing-m
oney-on-a-particular-
892
2010Congressional-intent-for-the-HITECH-Act
Am-J-M
anag-Care
31
National
00
01
0Opinion
National
Various
Revolution
Overview-of-HITEC-provisions-from-the-point-of-view-of-congressman-stark.--Stark-suggests-that-
HITEC-addresses-the-cost-bvarrier-to-doctors-and-hospitals-adopting-HIT.
186
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
893
2010Smart-health-community:-the-hidden-value-of-health-
inform
ation-exchange
Am-J-M
anag-Care
51
National
10
01
0
Opinion
National
Various
Revolution
The-authors-state-that-the-opportunity-to-transform
-healthcare-is-"constrained-by-the-prevaling-
patient2healthcare-pradigm-in-the-US-healthcare-sector…
-the-emerging-consumer2community-
paradigm,-we-argue,-is-a-better-means-by-which-to-assess-the-opportunities-created-by-a-new-health-
inform
ation-infrastructure."-pg-1
Comparison-is-made-to-automobiles-22-"By-shifting-the-frame-of-innovation-from-the-production-line-
to-swcheduling-based-on-customer-demand,-Toyota-changed-the-shape-and-structure-of-the-auto-
industry-forever.--It-did-not-take-long-for-the-rest-of-the-industry-to-follow-suit.--Those-who-could-not,-
perished."-pg-3
"The-adoption-of-health-inform
ation-technology-will-create-efficiencies-(w
ithin-the-current-fram),-but-
it-m
ust-also-be-leveraged-to-create-new-m
arkets-and-business-m
odels-if-we-are-to-capture-full-value-
from-the-opportiunity."-pg-3
Barrier-is-still-the-customer-22-"The-lack-of-service-adoption-by-consumers-is-cause-for-concern-among-
HIT-enthusiats.--Public-and-private-sector-leaders-recognize-patient-engagement-as-a-critical-enabler-
for-quality-of-care."-pg-4
894
2010Increasing-consumerism
-in-healthcare-through-
intelligent-inform
ation-technology
The-American-journal-of-managed-care
51
national
10
01
0
Opinion
National
Various
Revolution
Authors-stress-the-role-of-the-patient/consumer-in-the-development-of-new-technology-and-
realization-of-value-from-HIT.--"the-opportnity-to-partner-with-patients-to-deliver-better,-m
ore-cost2
effective-care-deserves-greater-prioritization."--pg-8
"The-value-to-the-consumer-often-is-lost-in-the-desire-to-have-sophisticated-and-innovative-
technology."-pg-5
"Consumers-have-a-spectrum-of-health-needs…
.-Yet-many-innovations-trageted-to-consumers-focus-
on-particular-parts-of-this-spectrum-in-issolation….-Electronic-helath-records-tend-to-share-
inform
ation-effectively-among-providers,-but-often-are-isolated-from-patients."-pg-5
895
2010Physician-ePortfolio:-the-m
issing-piece-for-linking-
perform
ance-with-improvement
The-American-journal-of-managed-care
41
Clinician
01
00
0
Opinion
National
Various
Equilibrium
Authors-argue-for-the-need-to-change-the-m
indset-of-physician-learning-to-one-of-continuous-
imprvement-from-that-of-asssessment-and-examination.--"These-new-requirements-reflect-a-
fundamental-change-in-philosophy-in-the-'house-of-medicne'-from-a-focus-on-cognitive-learning-and-
assessment-through-CME-and-written-examination-to-ongoing-assessment,-loifelong-learning,-and-
improvement-in-practice."-pg-223
896
2010Achieving-m
eaningful-use:-a-health-system-
perspective
Am-J-M
anag-Care
32
Health-System
00
10
0
Case-Study
Massachuse
tts
EHR
Revolution
Discusses-the-implementation-and-diffusion-of-EHR-within-the-Partners-Healthcare-system-in-Boston.--
The-authros-note-several-factors-that-facilitated-the-cahnge:--"PCHI-had-learned-that-in-order-to-be-
successful-in-changing-physician-behavior,-the-desired-change-had-to-be-clinically-relevent-and-
meaningful-to-patients."-pg-4
"These-lessons-include-providing-high2quality-products,-creating-financial-incentives-that-are-aligned-
with-the-cost-of-im
plementation,-and-offereing-servces-and-support-to-assist-with-the-m
igration."-pg-
5
899
2010Electronic-health-inform
ation-in-use:-Characteristics-
that-support-employee-workflow-and-patient-care
Health-Inform
atics-Journal
22
IDS-(VA)
01
01
0
Focus-Group
Unknown
EHR
Equilibrium
Atricle-discusses-various-elements-following-EHR-imlementation-that-im
pact-patient-safety-either-
from-persistent-use-of-paper-or-limitationos-of-EHR-itself.
Based-on-interviews-with-20-pratitioners,-4-domains-that-support-healthcare-workflow-were-
identified:--Trustworthy-and-reliable;-Effectively-displayed;-Ubiquitous;-and-Adaptable-to-workflow.
"
990
2010Stratifying-Computer-Literacy:-A-Competency-
Measurement-Strategy
Computers,-Inform
atics,-Nursing
31
Nursing
01
00
0
Opinion
National
EHR
Deep-Structure
Computer-literacy-is-a-key-element-of-the-deep-structure-of-the-environment-and-impacts-the-ability-
to-implement-successfully-an-EHR-or-other-HIT-system.--
"…measurement-of-computer-literacy-for-CIS-users-is-an-imperative-strategy-for-the-ultim
ate-
adoption-of-the-(local)-EMR"-pg-291
182
2011Tablets,-mobile-apps-transform
-pharm
acy
Drug-Store-News
30
Pharm
acy
11
00
0News
Natoinal
Pharm
acy
Equilibrium
Within-the-Pharm
acy-sector-new-technologies-are-focusing-on-"enhancing-the-expeirence-of-the-
customer."-pg-38
184
2011Clinician-Adoption-of-Technology
Physician-Executive
20
national
00
01
0news
national
Various
Equilibrium
Measures-for-successful-im
plementation-of-HIT-m
ust-be-m
eaningful-and-include-outcomes-and-other-
quality-m
easures.--M
easures-of-usage-and-adoption-are-not-enough.
187
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
185
2011That's-nice,-but-what-does-IT-do?-Evaluating-the-
impact-of-bar-coded-m
edication-administration-by-
measuring-changes-in-the-process-of-care
International-Journal-of-Industrial-
Ergonomics
33
hospital
00
10
0
Pre2Post-
experiment
National
Bar-Code
Equilibrium
The-implementation-of-new-technology-transform
s-through-an-alteration-of-the-W
rok-process-and-
work-system.--The-results-of-the-study-showed-"evidence-of-the-process-transform
ations-that-came-
about-from-a-hospital-work-system-that-was-changed-considerable-by-the-ointroduction-of-BCMA-
[Bar-code-m
edical-administration].--Process-changes-were-not-uniform
ly-desirable…"-pg-378
human-factors-m
odel-framework.
187
2011Today's-monolithic-EMRs-delay-hope-for-the-
'learning-health-system'
Managed-Healthcare-Executive
50
national
00
01
1
news
National
EHR
Deep-Structure
By-pushing-EHR-adoption,-the-federal-HITEC-plan-m
ay-be-building-a-larger-obstacle-to-inform
ation-
exchange-and-a-fully-integrated-learning-health-system.
"The-Federal-Strategic-Plan-indicates-that-the-inform
ation-exchange-function-central-to-realizing-the-
benefits-of-EHRs-does-not-exist-today-because-there-is-no-interoperable-infrastructure-to-support-it.-
However,-in-the-plan,-requirements-for-interoperability-and-health-inform
ation-exchange-are-kicked-
down-the-road-for-the-later-stages-of-meaningful-use.-"-pg-27
"Rick-Kneipper,-chief-strategy-officer-of-health-IT-company-Anthelio,-says-the-PCAST-[President's-
Council-of-Advisors-on-Science-and-Technology]-warning-that-federal-funding-to-stimulate-EHR-
adoption-during-early-stages-of-meaningful-use-could-exacerbate-the-problem-of-incompatible-legacy-
systems.-"-pg-28
"Perpetuating-the-current-breed-of-EHRs—
those-proprietary-applications-based-on-workflow-of-the-
traditional-paper-records—
is-likely-to-happen-under-meaningful-use,-given-ONC's-current-direction.-
That-means-some-EHR-systems-will-require-m
ajor-retooling-to-provide-the-broad-spectrum-of-
inform
ation-and-interoperability-envisioned-within-a-comprehensive-health-IT-framework.-"-pg-28
"Greenspun-says-the-EHR-problem-boils-down-to-the-hardest-nut-to-crack:-the-underlying-
architecture,-or-getting-providers-to-change-how-they've-been-doing-things-for-the-last-century-"-pg-
28
188
2011Leading-from-the-Future:-Leadership-M
akes-a-
Difference-During-Electronic-Health-Record-
Implementation
Frontiers-of-Health-Services-Management
31
Hospital
00
10
0
opinion
national
Various
Equilibrium
Implementation-success-requries-a-clear-VISION-and-integration-into-workflows.--Leadership,-
selecting-the-right-projects-and-approparpiite-project-m
angement-and-planning-help-m
ake-this-
happen.
192
2011Dynamic-Capabilities-in-Home-Health:-IT2Enabled-
Transform
ation-of-Post2Acute-Care
Journal-of-the-Association-for-Inform
ation-
Systems
32
Home-Health-Care
00
10
0
Csae-Study
Georgia
Various
Equilibrium
Case-involves-the-use-of-HIT-to-improve-cost-quality-and-access-of-a-large-home-care-institution-
during-a-period-of-finacial-and-regulatory-turm
oil-and-uncertanty.
Moved-from-transactrion-to-event2driven-focus.
193
2011Computing-Power-Is-Transform
ing-Health-
Care‚Äö?Ѭ?At-Long-Last
Forbes.com
10
national
00
01
0news
National
Various
Revolution
Changing-demographics-will-increase-the-use-and-confort-with-technology.
200
2011Electronic-M
edical-Records-and-Physician-
Productivity:-Evidence-from-Panel-Data-Analysis
34
Outpatient-Clinics-at-Academic-
Hospital
01
00
0
Observational-
(Pre2post-
comparison)
Western-USEMR-System
Deep-Structure
Physician-productivity-following-EMR-implementation-varies-by-specialty.--"IM
s-[internal-medicine]-
exceeded-their-pre2EMR-level,-but-the-prodcutivity-levels-for-Peds-and-FPs-still-lag-behind-their-pre2
EMR-implementation-productivities-…-the-productivity-gap-betw
een-Ims-and-the-other-tw
o-
specialties-appears-to-increase-after-EMR-implementation."-pg-12
No-relation-to-gender-or-experience-was-found.--Productivity-measured-in-term
s-of-WRVU-(Relative-
Value-Units)
901
2011Clinical-decision-support-in-small-community-
practice-settings:-a-case-study
Journal-of-the-American-M
edical-
Inform
atics-Association
22
IPA
01
10
0
Case-Study
Oregon
EHR
Equilibrium
Authors-review-a-successful-EHR-implementation-across-a-large-IPA-in-Oregon.--The-study-identified-
three-overriding-factors-for-the-success-of-the-EHR-implementation:
1-2-Agreement-by-all-physicians-and-clinics-to-join-together-and-agree-on-an-EHR-implementation-and-
a-single-vendor
22-Central-location-of-the-software-which-is-accessed-remotely-by-each-physian-and-practice.
32-EHR-provides-a-wealth-of-data-for-im
proving-community-health-and-practice.
903
2011Surviving-OR-Computerization
AORN
32
hospital
00
10
0
case-study
West-
Virginia
EHR-/-OR
Equilibrium
Case-study-of-an-Full-OR-system-at-a-W
est-Virginia-health-System.--Very-ditailed-descxription-of-the-
process-the-OR-team-went-through-including-site-visits,-work-flow-m
apping,-technolgy-acquisition,-
etc.--Key-findings-included-the-buy-in-of-staff-m
emebers,-the-m
apping-of-work-flows-prior-to-
implementation,-training-and-paying-for-additional-RN-staff-to-provide-24/7-support,-and-the-
allocation-of-sufficient-resources-in-the-form
-of-time,-money-and-people-thorughout-im
plementatio.
904
2011Phased-implementation-of-electronic-health-records-
through-an-office-of-clinical-transform
ation
Journal-of-the-American-M
edical-
Inform
atics-Association
22
Hospital
00
10
0
Case-Study
Virginia
EHR
Equilibrium
Authors-review-organizational-changes-made-to-improve-EHR-adoption-following-a-failed-prior-
implementation-effort.--Creation-of-an-Office-of-Clinical-Transform
aiton-was-used-to-facilitate-
adoption-with-positive-results.
188
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
905
2011From-promise-to-reality:-achieving-the-value-of-an-
EHR
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
20
Hospital
00
10
0
Opinion
National
EHR
Revolution
Discusses-the-basic-benfeits-if-EHR-systems-to-a-hospitals-revenue-cylce.--Physician-and-RN-
champions-are-important-to-success.
908
2011Being-m
indful-of-change:-a-technique-to-reduce-
stress-amid-change
Journal-of-AHIM
A/American-Health-
Inform
ation-M
anagement-Association
21
01
10
0Opinion
National
Various
Equilibrium
change-invovles-stress-and-stress-needs-to-be-m
anaged-22-Authors-discuss-M
indfulness-Based-Stress-
Reduction-(MBSR)-to-alleviate-stress-during-IT-change.
911
2011Staying-Afloat-in-a-Sea-of-Digital-Waves
Journal-of-Nursing-Administration
31
00
01
0
Opinion
National
Various
Deep-Structure
healthcare-is-complex-and-involves-many-unpredictable-behaviours-and-activities.--Introduction-of-
HIT-m
ust-take-into-account-the-complexity-of-healthcare.--"As-ssytems-gro-m
ore-complex,-staragies-
to-successfully-introcduce-technology-and-design-new-workflows-must-take-into-account-the-
increasingly-unpredictable-m
nature-of-health-systems-today."--pg-53
913
2011Innovation-in-Indian-healthcare:-using-health-
inform
ation-technology-to-achieve-health-equity-for-
American-Indian-and-Alaska-Native-populations
Perspectives-in-Health-Inform
ation-
Management/AHIM
A,-American-Health-
Inform
ation-M
anagement-Association
21
Indian-Health-Service-/-IDS
00
01
0
Opinion
Naitonal
EHR-and-telehealth
Deep-Structure
Notes-barriers-to-EHR-adoption-center-around-a-lack-of-standards-among-EHR-systems-and-in-
particular-betw
een-EHRs-and-telehealth-systems-which-are-used-within-the-indian-health-servcie.
915
2011A-partnership-m
odel-for-im
plementing-electronic-
health-records-in-resource2lim
ited-primary-care-
settings:-experiences-from-two-nurse2m
anaged-
health-centers
Journal-of-the-American-M
edical-
Inform
atics-Association
33
Health-Centers
01
10
0
comparative-
Case-Study
California-
and-
Michigan
EHR
Equilibrium
Data-integration-key-to-implementation.--M
easurements-of-change-helpful-to-stakeholders-and-
support-buy2in.--Specifics-of-community-healthcare-needs-requires-increased-customization-of-EHR.--
Lack-of-resources-significantly-constraining.--Healthcare-complex-and-unpredictable.--M
any-of-the-
barriers-experiences-were-not-anticipated-by-the-planners.
916
2011Not-so-fast:-IOM-report-warns-of-danger-in-rushing-
IT-training,-as-providers,-vendors-push-for-keeping-
safety-reporting-voluntary
Modern-healthcare
34
hospital
01
10
0
Opinion-(IOM)
National
Various
Equilibrium
Errors-and-dangers-from-EHR-implementations-come-largely-from-the-ways-providers-use-IT-and-do-
not-reset-solely-on-vendors.--Cite-the-Seattle-Pittsburgh-case-of-tw
o-insititutions-im
plementating-the-
same-system-with-different-results.
"'The-m
ore-your-organization-has-knowledge-about-the-details-of-that-system,-the-fewr-mistakes-that-
will-result-from-their-use-of-it,'-Tang-said."--pg-3
918
2011Meaningful-use-of-electronic-prescribing-in-5-
exemplar-primary-care-practices
The-Annals-of-Family-Medicine
33
Primary-Care
01
00
0
Comparative-
Case-Study
Unknown
eRx
Equilibrium
Implementation-success-depends-on-Planning,-im
plementation-and-Use.--The-study-found:
"We-found-that-successful-adoption-of-e2prescribing-required-substantial-investments-of-planning-
time-and-the-ongoing-transform
ation-of-work-processes.-Specifically,-it-required-that-practices-(1)-
have-at-least-1-practice-m
ember-able-to-articulate-the-importance-of-e2prescribing-within-the-process-
of-clinical-care-delivery;-(2)-develop-communication-strategies-for-introducing-and-orienting-patients-
and-pharm
acies-to-e2prescribing-processes;-(3)-have-access-to-technical-support-throughout-the-
implementation-process-capable-of-responding-to-problems-before-user-frustration-impeded-
adoption-success;-and-(4)-focus-on-transform
ing-work-processes-to-effectively-incorporate-e2
prescribing.-"-pg-396
"Our-findings-suggest-that-the-RECs-will-serve-an-important-role-in-fostering-adoption-of-health-IT-in-
that-all-of-the-successful-practices-we-observed-had-strong-external-assistance-for-making-the-
transition-to-e2prescribing."-pg-396
919
2011Seeking-the-United-State-of-HIEs2Connecting-
Inform
ation-Exchange-Efforts-Is-ONC's-Next-
Challenge
Journal-of-the-American-Health-
Inform
ation-M
anagement-Association
31
National-System
00
01
0
Opinion
National
HIE
Revolution
ONC-is-loosing-focus-on-HIE-due-to-Priorities-of-Stage-1-m
eaningful-use-not-emphasizing-HIE.--Direct-
program-is-taking-priority-as-it-m
eets-the-basic-needs-of-HIE.--
Value-of-HIE-is-a-hard-sell.-"The-value-of-HIE-can-be-a-harder-sell-than-EHR-implementation,-too."-pg-
29
920
20117-for-11.-Health-inform
ation-m
anagement-and-
technology-stories-to-watch-in-2011
Journal-of-AHIM
A/American-Health-
Inform
ation-M
anagement-Association
21
Various
01
11
0
Opinion
National
Various
Revolution
Author-highlights-priorities-for-policy,-providers-and-pratictioners-in-2011:
Meaningful-use;-regional-extention-centers;-ICD210;-HIE;-Health-IT-workforce;-Provacy-and-security;-
Quality-m
easures.
922
2011Meaningful-use-in-radiology
Journal-of-the-American-College-of-
Radiology
11
Radiology
01
00
0Opiniopn
National
EHR
Revolution
Discusses-elements-of-meansginful-use-as-they-might-apply-to-radiology-and-suggest-strategies-for-
radoiologist-to-take-to-obtain-incentive-paym
ents.--Little-relevence-to-this-study.
925
2011A-re2conceptualization-of-access-for-21st-century-
healthcare
Journal-of-General-Internal-Medicine
51
Practitioner
11
01
0
Opinion
national
e2health
Revolution
Authors-describe-the-changes-in-deep-structure-needed-to-achieve-transform
ation-in-healthcare.--
They-state-the-need-to-rethink-the-definision-and-understanding-of-"Access-to-care"--Access-can-no-
longer-be-m
easured-as-simply-a-face-to-face-encounter-and-"percieved"-access-m
ay-infact-be-m
ore-
important,-i.e.-ability-to-email-m
ay-increase-a-patients-perceived-access-to-their-physician-and-
therefore-there-perceived-quality-of-care.
"Perceived-access-is-no-less-valid-than-actual-access-and-m
ay-be-a-stronger-predictor-of-utilization-
than-actual-access.-"-pg-S641
"As-innovations-in-e2health-technologies-transform
-the-way-healthcare-is-delivered,-digital-
communications-betw
een-patients-and-their-providers,-peers-and-computerized-health-applications-
have-the-potential-to-drastically-im
prove-access-to-m
any-types-of-healthcare-services.-"-pg-S645
Propose-a-m
odel/conceptualization-of-access-specific-to-the-VA-system.
189
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
926
2011Emerging-Perspectives-on-Transform
ing-the-
Healthcare-System:-Redesign-Strategies-and-a-Call-
for-Needed-Research
Medical-Care
51
Various
01
11
0
Opinion
National
Various
Revolution
Athors-discuss-a-series-of-strategies-needed-to-transform
-health-care:--Complex-adaptive-systems-
framework;-fosterin-organizational-redesign;-appropriate-perform
ance-m
easures;-continuous-
learning-organziations;-integrating-health-inform
ation-and-communication-technologies.
927
2011The-brave,-new-world-of-HIEs
Healthcare-financial-management:-journal-
of-the-Healthcare-Financial-Management-
Association
30
Various
00
01
1
Opinion
National
HIE
Deep-Structure
HIE-success-has-several-barriers-22-IT-Governance-concerns-related-to-privacy,-security,-and-patient-
consent;-The-financial-viability-and-sustainability-of-HIT;-Data-standards-confusion;-Uncertainty-
created-by-the-ARRA.
""I-think-the-stimulus-money-is-a-really-sm
art-thing-to-do,-but-giving-the-states-$4-m
illion-to-$30-
million-to-plan-a-state2based-netw
ork-will-lead-to-an-absolute-disaster.-The-people-the-states-are-
inviting-to-the-table-don't-have-enough-training-to-figure-out-what-they-should-do.-It-is-like-the-owner-
of-a-car-dealership-trying-to-design-tires."-pg-48
"Said-one-concerned-buyer:-"There-is-no-good-sustainable-business-m
odel-for-HIEs.-W
ithout-a-vision-
for-HIE-development,-and-without-direction,-every-HIE-is-headed-in-a-different-direction.-For-a-
provider,-that-means-we-have-to-throw-out-a-lot-of-HI-Es-in-which-we-have-no-confidence-that-the-HIE-
will-be-able-to-sustain-itself."-pg-48
933
2011Inform
atics2Enabled-Behavioral-Medicine-in-
Oncology
The-Cancer-Journal
21
Practitiioner
01
00
0
Opinion
national
EHR-/-PHR
Equilibrium
Authors-discuss-the-benefits-of-Inform
atics-in-the-treatm
ent-of-Cancer.--G
ood-charts-of-Inform
atics-
systems-role-in-various-areas-of-cancer-care-such-as-prevention,-diagnosis-and-end-of-life.--
Note-that-as-the-shortage-for-primary-care-will-require-greater-attention-and-focus-on-inform
atics-
solutions-for-self2care.
934
2011How-CEOs-drive-the-clinical-transform
ation-and-
inform
ation-technology-agenda
Frontiers-of-health-services-management
21
hospital
00
10
0
Opinion
Maine
Various
Equilibrium
CEOs-as-leaders-have-the-sole-responsibility-to-influence-and-lead-change.--CEOs-should-be-
accountable-in-three-primary-areas-of-influence:-organizational,-resourcing,-and-m
essaging.--The-CEO-
must-be-able-to-communicate-and-justify-the-value-of-HIT-investments-and-lead-by-example.
938
2011Community2Based-Health-Inform
ation-Technology-
Alliances:-Potential-Predictors-of-Early-Sustainability2
Page-2
Am-J-M
anag-Care
33
HIE/RHIO
00
01
0
Cross-Sectional-
Survey
New-York
HIE
Deep-Structure
Study-examined-factors-that-predicted-additional-funding-for-HIE-in-new-York-Sate.--The-study-found-
that-organizations-led-by-health-inform
ation-organizations-(RHIOs)-were-six-tim
es-more-likely-to-
receive-addtiional-funding-than-organizations-led-by-healthcare-organizations-(hospital,-IPA).
939
2011Introduction-of-an-electronic-m
edical-record-system-
into-physician-practice-offices:-why-is-it-so#%!-&2ing-
hard-for-everybody?22Part-III
The-Journal-of-medical-practice-
management:-M
PM
20
practitioner
01
00
0
Opinion
national
EHR
Equilibrium
To-reduce-physician-resistance-and-increase-acceptance-and-success-of-EHR-implementatoin,-5-
pieces-of-advice-are-offered-by-the-authors:-im
prove-communication-with-physicians-and-better-
prepare-them-for-emr-im
plementation;-educate-professionals-about-the-nature-of-medical-work;-
execute-work-process-changes-simultaneous-with-EMR-implementation;-attent-to-authority-
amibguities;-m
anage-the-level-of-stress-throughout-the-implementation.
"Below-the-appearance-of-the-physician-practice-lies-a-hidden-complexity.-Over-the-years,-this-has-
precipitated-a-distributed-authority-within-the-profession-wherein-each-physician-has-the-authority-
to-determ
ine-how-he-or-she-will-provide-care-and-also-the-authority-to-direct-his-or-her-support-staff.-
This-wide-variation-in-physician-practice-leads-to-an-equally-wide-variation-in-results,-an-outcome-
that-will-be-difficult-to-accept-in-a-reform
ed-healthcare-environment.-"-pg-39
942
2011E2patient-Connectivity-and-the-Near-Term
-Future
Journal-of-General-Internal-Medicine
41
Home-Care
01
01
0
Opinion
National
connected-health-2-
remote-health
Revolution
While-only-an-opinion-piece,-the-authors-describve-the-coming-need-to-change-the-norm
-from-face-
to-face-to-m
ore-remote-m
edicine.--Age,-increasing-chronic-care-needs,-and-growing-population-put-
greater-demans-on-an-old-delivery-structure.
"Sim
ple-m
ath-suggests-that-if-we-are-lim
ited-to-face-to-face-encounters-in-specific-locations,-we-will-
not-be-able-to-m
et-the-demand-for-services."-pg-S636
946
2011Computerized-physician-order-entry-in-the-critical-
care-environment:-a-review-of-current-literature
Journal-of-Intensive-Care-M
edicine
31
Hospital
00
10
0
Opinion
National
CPOE
Deep-Structure
ICU-represents-a-unique-environment-for-CPOE-implemenation.--This-uniqueness-has-the-effect,-
without-recognition-or-customization,-to-increase-the-failure-of-CPOE-implementation,-increase-
unintended-consequences-and-increase-resistance.
Workflow-is-a-key-to-success-of-CPOE-implemenation.
190
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
948
2011An-Early-Status-Report-on-the-Beacon-Communities’-
Plans-for-Transform
ation-via-Health-Inform
ation-
Technology
Health-Affairs
31
Beacon-Communities
00
01
0
Opinion
National
Various
Revolution
Community-invovlement-critical-to-HIT-transform
ation.--Cultural-differences-thorughout-US.
"The-features-of-the-Beacon-Communities-will-help-the-country-prepare-for-new-m
odels-of-care-
delivery,-such-as-accountable-care-organizations-and-patient2centered-m
edical-homes,-and-for-new-
paym
ent-methods-for-providers,-such-as-bundled-paym
ents,-that-are-included-in-the-Affordable-Care-
Act-of-2010.-"-pg-782
"If-Beacon-Communities-are-to-achieve-their-health-care-improvement-objectives,-they-must-use-an-
implementation-framework-that-allows-them-to-learn-from-early-results-and-to-refine-interventions-
over-time.-…-a-culture-of-innovation-and-learning-focused-on-concrete-health-improvement-goals,-
with-the-idea-that-leaders-of-individual-communities-will-be-able-to-rapidly-collect-data-about-their-
interventions,-m
ake-changes-to-improve-those-interventions,-and-disseminate-inform
ation-about-
their-experiences.-"-pg-786
950
2011Florida-Doctors-Seeing-M
edicaid-Patients-Show-
Broad-Interest-In-Federal-Incentives-For-Adopting-
Electronic-Health-Records
Health-Affairs
33
Ambulatory
01
00
0
Cross-Sectional-
Survey
Florida
EHR
Revolution
In-a-survey-of-Florida-Physicans,-66.4%-stated-their-intereest-in-applying-for-HITEC-funding.--The-
intention-to-seek-funding,-based-on-a-m
ultivariate-m
odel,-was-assocaited-with-higher-volumes-of-
medicaid-and-m
edicare-patients,-practice-size,-ownership-interest-and-knowledge-of-HIT.--
The-authors-note-that-RECs-will-play-an-important-role-in-facilitating-the-change-to-m
eaningful-use.
951
2011Environmental-factors-and-health-inform
ation-
technology-management-strategy
Health-Care-M
anagement-Review
53
Hospital
00
10
0
Cross-Sectional
Naitonal
Various
Deep-Structure
Study-examines-the-environmental-characteristics-and-their-impact-on-HIT-strategies-within-
hospitals.--Specificically-three-strategies-are-examined-in-relation-to-environmental-factors-related-to-
munificence-(avaialbility-of-resources)-and-complexity-(ability-to-project-the-future).--
Researchers-found-that-single-vendor-strategies-tended-to-be-in-m
arkets-with-lower-incomes,-lower-
rates-of-physician-specialists,-smaller-changes-in-historic-unemploym
ent-22-in-other-words-stable-
environments-with-fewer-resources.--Environments-with-higher-munifisence-were-less-likely-to-adopt-
single-vendor-strategies.--
Due-to-the-findings-of-environmental-im
pacts,-the-authors-suggest-that-the-current-focus-on-
meaningfule-use-fail-to-recognize-the-effects-of-the-environment.--"Thus,-incentive-programs-focusing-
exclusively-on-financial-aspects-that-fail-to-consider-environmental-factors-m
ay-ultim
ately-attenuage-
the-intented-impacts-of-such-policies."-pg-282
953
2011Experts-in-Short-Supply
Trustee:-the-journal-for-hospital-governing-
boards
30
Hospital
00
11
0
Opinion
National
Various
Deep-Structure
Staffing-shortage-in-clinical-IT-professioners-an-issue-of-the-environment.--"In-a-poll-of-health-care-
CIOs-last-fall,-more-than-70%-said-their-organziations-had-inadequate-IT-staff-to-implement-the-
clinical-software-that's-critical-to-raising-the-level-of-their-computer-systems-to-m
eet-government-
expectations."-pg-13
954
2011Addressing-the-business-of-discharge:-Building-a-
case-for-an-electronic-discharge-summary
Journal-of-Hospital-Medicine
32
Hospital
00
00
0
Case-Study
California-
(UCSF)
EMR
Equilibrium
Addresses-the-need-for-a-business-case-that-takes-into-account-both-quantitative-and-qualitative-
measures.--Q
uanititative-m
easures-include:-cost-avoidance,-cost-savings,-revenue-generation-and-
costs-associated-with-personnel,-infrastructure,-maintenance-and-training,-and-revenue-loss.--
Qualitative-m
easures-include:-provider-satisfaction,-quality-improvement,-reputation,-staff-efficiency,-
accuracy-of-data-and-redundancy-in-data.
955
2011Factors-affecting-home-care-patients'-acceptance-of-
a-web2based-interactive-self2m
anagement-
technology
Journal-of-the-American-M
edical-
Inform
atics-Association
35
Hospital
10
00
0
RCT
Unknown
CHIT-(Consumer-health-
inform
ation-
technologies)
Revolution
Examines-the-elements-that-effect-a-patients-acceptance-and-use-of-technology.--A
pply-the-
framework-of-UTAUT-(Unified-theory-of-Acceptance-and-use-of-Technology).--Study-supported-prior-
findings-about-the-m
odel-in-that-it-explained-~-69$%-of-the-varience-in-behavioural-intention.--The-
model-had-the-following-components-2-perform
ance-expectancy,-effort-expectancy,-social-influence,-
and-facilitating-conditions.--
"The-amount-of-variance-in-perceived-effective-use-accounted-for-by-perceived-usefulness,-
healthcare-knowledge,-and-behavioral-intention-was-68.5%.-Perceived-ease-of-use-and-subjective-
norm
-explained-48%-of-the-total-variance-in-perceived-usefulness.-"-pg-55
"ur-results-suggest-that,-first-and-foremost,-in-order-to-increase-the-likelihood-that-patients-will-
experience-the-potential-benefits-of-CHITs,-the-technology-must-be-designed-such-that-system-
applications-are-in-consonance-with-patients'-needs.-This-is-of-course-easier-said-than-done,-but-the-
results-have-design-and-development-im
plications.-Based-on-the-items-measuring-usefulness,-the-
data-have-suggested-that-CHITs-that-are-designed-to-support-disease-m
anagement-must-improve-
patients'-ability-to-m
anage-their-disease,-save-them-tim
e-m
anaging-their-disease,-and-m
ake-them-
more-effective-at-managing-their-disease.-Achieving-these-goals-will-likely-require-cognitive-analyses,-
such-as-cognitive-work-and-task-analyses,15-76–78-followed-by-careful-attention-to-human-factors-
engineering79-and-cognitive-engineering-principles-for-designing-automation-to-support-cognitive-
work-(eg,-managing-a-disease)."-pg-57
191
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
958
2011A-conceptual-framework-for-achieving-balance-
betw
een-innovation-and-resilience-in-optimizing-
emergency-department-operations
The-Health-Care-M
anager
33
Hospital
00
10
0
Literture-Review
National
Various
Revolution
Tecnology-represents-only-one-component-of-innovation-and-change.--A-systems-view-is-required-to-
achieve-"a-balanced-strategy.--A
-systems-analysis-is-called-for-attaining-a-thourough-understnanding-
of-collaborating-and-competing-components-ahtat-are-centrol-to-efforts-geared-towrds-attaining-
efficacy-verss-those-focused-on-m
ainingn-risk-readiness."-pg-357--Balance-betw
een-efficiency-and-risk-
and-tecnology-only-one-component-or-tool-to-accomplish-thes-objectives.
960
2011Consumer-attitudes-toward-personal-health-records-
in-a-beacon-community
The-American-journal-of-managed-care
33
Community
10
00
0
Cross-Secctional-
Survey
New-york
PHR
Deep-Structure
Inidividuals-are-m
ore-likely-to-accept-PHR-at-higher-incomes-and-with-access-to-Internet-and-prior-
experience-looking-up-health-inform
ation-on-internet.
"Our-study,-among-the-first-to-identify-factors-associated-with-potential-use-of-PHRs,-found-that-a-
large-proportion-of-consumers-want-a-comprehensive-PHR-that-enables-them-to-do-a-range-of-
activities-to-m
anage-their-individual-and-family-healthcare-needs.-However,-a-number-of-barriers-
related-to-the-digital-divide,-including-Internet-access-and-experience,-as-well-as-privacy-and-security-
concerns,-m
ay-limit-adoption.-"-pg-e1112e112
962
2011Mobile-Technology:-Implementing-a-W
eb2Based-
Home-M
onitoring-System-within-an-Academic-
Health-Care-Netw
ork:-Barriers-and-Facilitators-to-
Innovation-Diffusion
Journal-of-diabetes-science-and-
technology
42
Health-System-(Partners)
00
10
0
Case-Study
Massachuse
tts
TeleHealth
Revolution
Researchers-used-the-diffusion-of-innovation-theory-to-evalute-the-acceptance-and-use-of-a-remote-
monitoring-dabetes-system-at-Partners-health.
Key-finding-was-that-the-practieces-that-were-able-to-incoirporte-the-system-into-their-workflows-had-
a-higher-rate-of-acceptance-and-use-and-outcomes.--The-authors-also-found-that-pratice-champiods-
were-essential-to-transition-from-early-adoptor-to-early-majority.--This-required-a-demonstration-of-
ongoing-value-by-the-practice-champions.
In-general,-the-intration-of-the-program-followed-the-principles-of-Rogers-DIT.
964
2011Ramping-up:-Healthcare-IT-leaders-begin-the-serious-
work-of-preparing-for-the-transition-to-ICD210
Healthcare-inform
atics:-the-business-
magazine-for-inform
ation-and-
communication-systems
10
Hospital
00
10
0
Opinion
National
ICD210
Equilibrium
ICD-represents-a-change-in-standards-and-requires-significant-planning,-resources-and-tim
e.
965
2011Use-of-Health-Inform
ation-to-Improve-Care
NC-M
ed-J
22
Beacon-community
00
01
0Case-Study
north-
carolina
Various
Revolution
Study-describes-activities-to-prepare-for-im
plementation-of-Beacon-community-inititative.--Key-
activity-noted-by-authors-is-the-development-of-measures-to-demonstrate-success-of-the-project.
972
2011Testing-the-Technology-Acceptance-M
odel:-HIV-case-
managers'-intention-to-use-a-continuity-of-care-
record-with-context2specific-links
Inform
atics-for-Health-and-Social-Care
33
Health-System
01
00
0
Cross-Sectional-/-
Survey
New-York
EHR/CCD
Authors-validate-the-TAM-m
odel-within-a-gourp-of-HIV-case-m
anagers.
978
2011Adoption-of-anesthesia-inform
ation-m
anagement-
systems-by-US-anesthesiologists
Journal-of-clinical-monitoring-and-
computing
33
Practitioner
01
00
0
Cross-Sectional-
Survey
national
EHR-/-AIM
SDeep-Structure
Anesthesiologists-share-certain-barriers-to-EHR/AIM
S-adoption-(cost,-size-of-practice,-etc.)-but-are-
unique-in-their-specific-needs-and-the-current-provisions-of-HITEC-have-placed-Anesthesiologists-in-a-
difficult-position.
"many-of-the-m
eaninful-use-requirements-do-not-applue-to-anesthesia-practice."-pg-134--
American-Society-of-Anesthesiology-is-looking-for-exemption-from-m
eaningful-use-penalties-or-
meaningful-use-criteria-that-match-specifics-of-practice-ans-setting.
979
2011Explaining-physicians'-use-of-EMR-systems-and-
perform
ance-in-the-shakedown-phase
Journal-of-the-American-M
edical-
Inform
atics-Association
53
Various
11
00
0
Cross-Sectional-
Survey
Unknown
EHR
Deep-Structure
The-authors-propose-and-test-a-m
odel-of-EMR-use-by-physicians.--The-resulting-m
odel-based-on-
testing-accounts-for-40%-of-the-vairance-in-physician-EMR-system-use.--The-m
odel-proposes:--"…-a-
holistic-m
odel-(figure-1)-to-explain-physicians'-use-of-EMR-systems-and-consequent-perform
ance-
impacts-during-the-shakedown-phase-of-the-system-implementation.-We-consider-how-physician's-
EMR-system-use-is-affected-by-the-following-three-sets-of-factors:-individual-(physician-
characteristics),-system-(physicians'-perceptions-of-the-new-EMR-system),-and-interactions-among-
physicians-(the-social-influence-of-other-physicians-on-EMR-system-use).-W
e-also-expect-EMR-system-
use-to-affect-physician-perform
ance.-"-pg-125
980
2011Biomedical-inform
atics:-changing-what-physicians-
need-to-know-and-how-they-learn
Academic-M
edicine
21
Education-2-Practitioner
01
00
0
Opinion
national
Various
Revolution
changes-in-education-required-to-take-full-adavatage-of-HIT-and-what-it-can-add-to-"expert-based"-
medicine.
"We-believe-biomedical-inform
atics-has-become-a-foundational-science-essential-to-the-
improvement-of-health-and-the-deliery-of-hoigh2quality-patient-care.--The-future-expert-will-not-be-
able-to-know-everythng-necessary-to-m
ake-the-best-decisions."-pg-432
192
Appe
ndix(C(–(Cod
ed(Article(Details
Data ID
Publication(
Year
Title
Journa
lRe
levance((0>
5)Rigor(
(0>5)
Indu
stry/Settin
g
Patients
Practitioner
Hospital
National
Vendor
Design
Locatio
nTechno
logy
Punctuated
(Eq
uilib
rium(
Compo
nent
Notes
981
2011Disrupting-Incrementalism
-in-Health-Care-InnovationAnnals-of-surgery
51
national
11
11
1
opinion
National
Various
Revolution
healthcare-behaves-differently-than-other-markets.--Healthcare-is-driven-by-incremental-innovation-
versus-incremental-innovation-due-to-insurance-rules,-gold-standard,-decisions-not-being-m
ade-on-
cost.
"This-discussion-reveals-that-outside-the-setting-of-health-care,-incremental-innovations-are,-at-best,-
sustaining-to-a-business,-and-that-large-organizations-are-best-positioned-to-exploit-them.-In-contrast,-
small-companies-and-groups-of-individual-entrepreneurs-are-m
ore-likely-to-succeed-if-they-pursue-
market-disruptions.-"-pg-203
Difficult-for-helathcare-to-compete-on-price-first-(low2end-disruption)-because-of-need-to-be-at-least-
as-good-as-gold-standard-and-reim
bursement-rules.
"Stated-another-way,-in-m
ost-cases-it-is-not-acceptable-to-develop-a-lower-quality-health-product-and-
simply-accept-lower-margins-to-m
ake-up-for-it.-Moreover,-it-is-difficult-to-challenge-nonconsumption-
and-develop-a-new-value-chain,-as-the-consumers-in-health-care-(patients,-doctors,-providers,-and-
insurers)-are-well2defined-and-their-roles-are-well-established.-Most-importantly,-existing-regulatory-
and-reim
bursement-systems-are-designed-to-evaluate-innovations-relative-to-an-established-“gold”-
standard,-which-again-favors-incrementalism
-over-disruptiveness,-as-defined-in-non2health-care-
sectors.-"-pg-205
194
2012Healthcare-Sector-Is-Finally-Ripe-for-Change
Channel-Insider
10
National
01
10
0News
National
Various
Equilibrium
Cloud-computing-will-allow-smaller-organization-with-less-financial-resources-to-adopt-HIT.
193