Essays on Meaningful Use of Electronic Health Records in Physicians

Abstract

Meaningful use of electronic health records (EHR), characterized by the use of certified EHR technology to enhance the safety, quality, and efficiency of care, plays a crucial role in optimizing EHR functionalities for facilitating care coordination and health information exchange. Despite the widespread adoption of EHR as a result of the EHR incentive program, a large proportion of physicians continue to struggle with meeting meaningful use criteria. While literature has extensively examined the facilitating conditions and barriers to EHR use, limited research has focused on social influence, a key construct in the technology acceptance model that determines physicians’ intention to use and behavior in utilizing technologies. Given significant fragmentation of the healthcare system, it is important to understand the role of meaningful use in the context of coordination and transitions of care. The lack of empirical evidence in this domain creates a knowledge gap regarding the effectiveness of the EHR incentive program and the meaningful use standards it established.This dissertation comprises three empirical studies that collectively contribute to the understanding of meaningful use of EHR in office-based physicians, providing insights into the challenges and benefits associated with meaningful use and its implementation. The first two chapters delve into the factors that influence physicians’ meaningful use practices. Specifically, the first chapter studies the association between physician relationships and meaningful use performance, and the second chapter seeks to understand whether switching to different EHR vendors hinders physicians’ achievement of meaningful use requirements. The third chapter shifts the focus towards the downstream impact of meaningful use, assessing its association with patient sharing between physicians. Chapter 1 estimates the association of physician network structure with physicians’ performance on meaningful use criteria in 2016. The analysis employs social network analysis techniques and data from the DocGraph HOP Teaming file to construct physician patient-sharing networks at the hospital referral regions level. We calculate a set of measures that characterize the centrality and density of physician networks. We focus on meaningful use criteria that were designed to enhance care efficiency and coordination between physicians. The findings indicate that physicians who were more connected with other physicians or occupied a central position within their networks tended to demonstrate better performance on electronic prescribing and patient electronic access criteria. In contrast, physicians situated within densely interconnected networks were more likely to exhibit poorer performance on these two criteria, suggesting that the isolated local networks may diminish physicians’ perceived usefulness of EHR. These findings contribute to the understanding of the variation in meaningful use across physicians and suggest that future interventions may leverage physician interaction relationships to promote the utilization of EHR functionalities for effective care coordination. Chapter 2 assesses the association of switching EHR vendors with physicians’ meaningful use between 2011 and 2016. We use a difference-in-differences study design to disentangle the heterogeneous effect of vendor switching over time and across physicians who switched vendors at different time points. The findings demonstrate a persistent negative impact of vendors switching on physicians’ meaningful use achievement. Notably, physicians in small practices were particularly vulnerable to the negative effect of vendor switching. These findings speak to the need for ongoing support during vendor switching period and the importance of interoperability across vendors to attain sustained, advanced use of EHR. Chapter 3 investigates the relationship between meaningful use and patient sharing between physicians in stage 2 of the incentive program that aimed to improve care coordination through enhanced exchange and reconciliation of health information. The requirements for health information exchange and patient electronic access may reduce the time and financial costs associated with seeking care from differential physicians, thereby diminishing physicians’ monopoly power and patient sharing with others. We construct a panel of physician pairs who shared patients between 2014 and 2016 and compare the change in the number of patients shared between physician pairs across three groups: neither physician, only one physician, and both physicians achieving meaningful use. We also analyze the moderating effects of physician type and market conditions. The findings indicate a positive association between joint meaningful use achievement and patient sharing, particularly in unaffiliated physicians. The moderating effect of market concentration level highlights the deterrent effect of competitive pressures on patient and information sharing between physicians. These findings supplement existing research on the realized benefits of meaningful use of EHR and highlight the necessity for customized incentives that address competition concerns to encourage patient and information sharing in competitive market environments.