Vinata KulkarniPhD

IMPLEMENTATION OF ELECTRONIC HEALTH RECORDS:
MODELING AND EVALUATING HEALTHCARE INFORMATION SYSTEMS FOR

QUALITY IMPROVEMENTS IN THE U.S.HEALTHCARE INDUSTRY
by
Vinata A. Kulkarni
A Dissertation Presented in Partial Fulfillment

Of the Requirements for the Degree
Doctor of Philosophy
Capella University
October 2006
Vinata Kulkarni, 2006
Abstract
In spite of several innovative measures in the United States (U.S.) healthcare industry, the
industry is not only lagging behind other industries in its technology adoption, but also in
ensuring basic safety and healthcare quality (Landro, 2001). The healthcare information systems
(HIS) can provide financial and qualitative benefits to the healthcare industry (Wickramasinghe,
Fadlalla, Geisler, & Schaffer, 2003). However, the HIS literature review has indicated a lack of
cost-effective HIS model with uniform healthcare information standards and quality measures, in
the U.S. healthcare information technology documentation. The purpose of this study was to
construct and evaluate the Electronic Health Record (EHR)-centric model to monitor a
predefined set of healthcare quality goals. The quantitative research methodology, strategic
contingency theory of organizational management, and economic value-added concepts of HIS
planning have been applied. Secondary survey data from 1999 to 2004, collected by the
American Hospital Association (AHA) annual survey of hospitals and the Dorenfest Integrated
Healthcare Delivery Systems (IHDS), have been used to determine statistical significance of the
proposed critical success factors of healthcare quality in small, medium, and large size healthcare
organizations. The findings have provided a planning structure for healthcare organizations and
new understanding in healthcare information technology management fields, for improving
quality of the healthcare services.
Acknowledgments
I would like to express my sincere thanks to the members of my dissertation committeeDr. Tsun Chow, Dr. Edward Goldberg, and Dr. Sharlene Adams. They provided me a
constructive feedback, valuable suggestions, and have significantly contributed to the completion
of this dissertation. I am grateful to Dr. Tsun Chow, my mentor and the chairman of this
dissertation committee, for his insightful observations, advice and guidance in my research
study. Also, I am indebted to my teachers and colleagues, who made a positive influence on my
educational journey.
Finally, I would like to thank my husband- Arvind, and my children- son
Vainatey and daughter Anvita, for their patience and full support throughout my doctoral studies.
I also thank my son Vainatey, for his assistance in proofreading and editing my dissertation
document.
iii
Table of Contents
Acknowledgments
iii
List of Tables
vii
List of Figures
xi
CHAPTER 1: INTRODUCTION
Introduction to the Problem
Background of the Study
Statement of the Problem
Purpose of the Study
Rationale
Research Questions
Significance of the Study
Definition of the Terms
Nature of the Study
12
Assumptions and Limitations
13
Organization of the Remainder of the Study
15
CHAPTER 2: LITERATURE REVIEW
17
The U.S. Healthcare Systems Background
iv
17
Review of the U.S. Healthcare Information Systems
18
Electronic Health Record through Healthcare Information Systems for Managed

Healthcare Delivery and Quality
22
Theoretical Development and Information Systems Models for Healthcare Information

Systems' Integrity and Quality
25
Healthcare Information Systems and Electronic Health Record Modeling
30
Summary of the Literature Review
36
CHAPTER 3: METHODOLOGY
38
Research Design with the Conceptual Model
39
Measurement of the Variables
49
Validity of the Secondary Survey Data Instrument
60
Hypothesis Testing
61
Log Transformed Linear and Logistic Regression Model
65
Possible Research Study Implications and Recommendations
69
CHAPTER 4: DATA COLLECTION AND ANALYSIS
72
Data Descriptives
73
Hypothesis Testing of Healthcare Quality Profiles
81
Hypothesis Testing of Critical Success Factors' Profiles
84
Log Transformed Linear and Logistic Regression Models
89
Summary of the Predictive and Significant Variables

CHAPTER 5: RESULTS, RECOMMENDATIONS, AND CONCLUSIONS
Results
104
115
116
Practical Implications
118
Limitations
120
Recommendations for Further Study
121
Conclusions
123
REFERENCES
126
APPENDIXES
140
A. Definition and Description of the Data Variables
140
B. Output from Statistical Package for Social Sciences-Graduate Pack

Version 13.0
144
vi
List of Tables
Table 1: Consolidated Balanced Scorecard and Critical Success Factors Analysis
45
Table 2: Secondary Survey Responses By Bed Size
77
Table 3: Healthcare Quality Descriptives for Small, Medium and Large Integrated Healthcare
Delivery Systems
78
Table 4: Descriptives of Electronic Health Record Centric Critical Success Factors of Healthcare
Quality
79
Table 5: Analysis of Variance for Quality Profile Healthcare Information Systems Annual
Operating Cost per bed
83
Table 6: Discriminant Analysis for Quality Profile Health Insurance Portability and
Accountability Act (HIPAA) Compliance
84
Table 7: Analysis of Variance for Electronic Health Record Centric Critical Success Factors of
Healthcare Quality
86
Table 8: Discriminant Analysis for Electronic Health Record Centric Critical Success Factors87
Table 9: Canonical Discriminant Functions for Electronic Health Record Centric Critical Success
Factors
88
Table 10: Log Transformed Linear Regression Model Summary
94
Table 11: Log Transformed Linear Regression Model for Small Size Integrated
Healthcare Delivery Systems Organizations
95
Table 12: Log Transformed Linear Regression Model for Medium Size Integrated
96
Table 13: Log Transformed Linear Regression Model for Large Size Integrated
97
Table 14: Logistic Regression Model Summary for Small Size Integrated Healthcare Delivery
Systems Organizations
vii
100
Table 15: Logistic Regression Model Summary for Medium Size Integrated Healthcare Delivery
101
Table 16: Logistic Regression Coefficients Summary for Large Size Integrated
102
Table 16a: Logistic Regression Model Summary for Large Size Integrated Healthcare Delivery
103
Table 17: Summary of Predictive and Significant Factors of Healthcare Information Systems
(HIS) Annual Operating Cost per Bed
105
Table 18: Summary of Predictive and Significant Factors of Health Insurance Portability and
106
Table B1: Dependent Variable: Healthcare Information Systems (HIS) Annual Operating Cost
per Staffed Bed (1999-2003)
144
Table B2: Dependent Variable: Health Insurance Portability and Accountability Act (HIPAA)
Compliance (2002-2003)
144
Table B3: Dependent/Explanatory Variables: Descriptive Statistics
145
Table B4: Test of Homogeneity of Variances
147
Table B5: Discriminant Analysis: Health Insurance Portability and Accountability Act (HIPAA)
Compliance
149
Table B6: Discriminant Analysis: Physicians' Usage of Healthcare Information Systems
150
Table B7: Discriminant Analysis: Affiliation Status
151
Table B8: Discriminant Analysis: Strategic Usage of Healthcare Information Systems
152
Table B9: Discriminant Analysis: Healthcare Information Systems Connectivity
153
Table B10: Discriminant Analysis: Electronic Health Record Supporting Technology

Application Status
154
Table B11: Discriminant Analysis: Utilization of Patient Safety Software Applications
155
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Table B12: Discriminant Analysis: Status of Clinical data security issues
156
Table B13: Small Bed Size Model Summary
157
Table B14: Small Bed Size Model Summary After Removing Factors Information Systems Staff
and Information Systems Servers
159
Table B15: Medium Bed Size Model Summary
161
Table B16: Large Bed Size Model Summary
163
Table B17: Large Bed Size Model Summary After Removing Information Systems Staff and
Information Systems Servers
163
Table B18: Large Bed Size Model Summary Using Stepwise Regression/Backward
Regression
165
Table B19: Small Bed Size: Health Insurance Portability and Accountability Act (HIPAA)
Compliance Model Summary
167
Table B20: Small Bed Size Health Insurance Portability and Accountability Act (HIPAA)
Compliance Model: Standardized Canonical Discriminant Function Coefficients 168
Table B21: Small Bed Size Health Insurance Portability and Accountability Act (HIPAA)
Compliance Model Summary Using Block One Backward Stepwise (Conditional)
Method
169
Table B22: Medium Bed Size Health Insurance Portability and Accountability Act (HIPAA)
170
Compliance Model Using Block One and Backward Stepwise Likelihood Ratio
Method
171
Compliance Model if Terms Removed
175
Compliance Model: Standardized Canonical Discriminant Function
Coefficients
ix
177
Table B26: Large Bed Size Health Insurance Portability and Accountability Act (HIPAA)
178
Compliance Model Summary with Block One Backward Stepwise Likelihood Ratio
Method
179
Compliance Model if Terms Removed
180
Compliance Model: Standardized Canonical Discriminant Function
Coefficients
183
List of Figures
Figure 1: Electronic Health Record-centric building blocks of healthcare integration
42
Figure 2: The conceptual model of Electronic Health Record-centric healthcare quality
48
Figure 3: The number of beds and hospitals for American Hospital Association- registered
hospitals
73
Figure 4: The bed size category and patients' admissions for American Hospital Associationregistered hospitals
74
Figure 5: The Out patients' visits & full time equivalent personnel for American Hospital
Association- registered hospitals.
75
Figure 6: Total expenses and revenue for American Hospital Association- registered
hospitals
76
Figure 7: Normal approximation of log transformed healthcare information systems annual

operating cost per bed for small bed size healthcare organizations.
93
xi
CHAPTER 1. INTRODUCTION
Introduction to the Problem
The healthcare industry is an economically and socially significant portion of the United
States (U.S.) industry sector. The industry represents a fifth of the U.S. economy and carries
social significance due to its ongoing focus on quality of the services. However, the healthcare
industry is not only lagging behind other industries in its technology adoption, it is also behind
other high risk industries in ensuring basic safety and healthcare quality (Landro, 2001). While
the U.S. healthcare "absorbs more than $1.7 trillion per year--twice the Organization for
Economic Cooperation and Development (OECD), average-premature mortality in the country is
much higher than OECD averages" (Hillestad, Bigelow, Bower & Girosi, 2005, p. 1103).
The Institute of Medicine (IOM) committee on quality healthcare in America has taken
initiative steps on healthcare quality since 2000 (Sokol & Molzen, 2002). The IOM committee
presented a series of quality reports identifying gaps in healthcare quality in areas including
healthcare information systems (HIS) and patient safety (Swan, Lang & McGinley, 2004). As per
the IOM report, errors in the healthcare industry are due to failures in organizational systems and
various organizational factors. The IOM and the Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO) are trying to implement error-reducing processes. In a series
of reports, IOM recommended implementing an electronic health record program (EHR) to
achieve effective coordination of clinical services and in turn to improve healthcare quality
(IOM, 2001, 2003b). At present, when several healthcare practitioners treat a patient, they often
do not have complete information about the medicines prescribed or details about their patient's
illnesses. Most medical records are still stored on a paper, which makes it difficult to properly
coordinate care and provide detail information to the consumers about healthcare costs or quality
and to make informed decisions about their care (Hillestad, et al., 2005).
Healthcare literature indicates the existence of some healthcare errors due to scribbled
writing in medical records and prescriptions that resulted in administration of a drug for which
the patient had a known allergy. Lesar, Ben, and Henry (1997) pointed that if healthcare
providers have timely information about their patients and the prescribed medication with the use
of computerized systems and EHR, many of these errors could be avoided. Another important
current issue observed is that segments of the healthcare industry and individual providers have
adopted technology at different rates and a gap is widening between the most wired and the
least wired providers (Solovy, 2000). According to Hillestad et al. (2005, p. 1104), "the U.S.
trails a number of other countries in the use of EHR. Only 15-20 % of the U.S. physicians'
offices and 20-25 % of hospitals have adopted such systems." Thus, in spite of several innovative
measures in the U.S. healthcare industry, there are still many barriers in EHR implementation
that include high costs, a lack of certification and standardization of IT tools, and an inadequate
HIS infrastructure. HIS cost reduction and improvement in quality of services are two important
issues of the U.S. healthcare industry while implementing EHR.
Background of the Study
As per GAO Report (2004, para.1), from 1992 to 2002, the U.S. healthcare spending
"increased from $827 billion to about $1.6 trillion and it is expected to nearly double to $3.1
trillion in the subsequent decade." The Peirce (2004) analysis of cost and wages indicated a rapid
increase in medical costs compared to that in wages, which is a threat to the global
competitiveness of the United States. Although the United States leads the world in per capita
medical spending, life expectancy of people in the U.S. is approximately same as Cuba's and
significantly behind nations such as France, New Zealand, Spain, and Singapore (Peirce, 2004).
High healthcare costs, errors in medical data recording systems, administrative inefficiencies,
and lack of system coordination are some of the concerning issues of the U.S. healthcare
industry. According to the estimates made by the IOM, there are some 44,000 losses of human
life in the U.S. hospitals each year, and there are more losses of life due to medical mistakes than
from highway accidents, breast cancer, or AIDS each year (Tickner, 1999). According to the
IOM report, the total national cost for adverse events is estimated to be between $37.6 and $50
billion. Also, at present, the application of health information technology (HIT) to clinical
records is quite slow.
Thus, at present, an integration of HIT into the nation's healthcare system seems quite
inadequate (White House Statement, 2004). There is variation in the healthcare quality within
and across communities, hospitals, practitioners, patients, delivery systems, geographic areas,
and health problems. Researchers have demonstrated that even for the same groups, healthcare
quality performance varies considerably at different times and situations, which makes it difficult
to develop programs to improve healthcare quality based on the current knowledge. Teisberg,
Porter, and Brown (1994, p. 131) suggested innovation as "the fundamental driver of continuous
quality improvement and cost reduction." Thus, considering the seriousness of medical errors
and the technology potential to decrease medical errors, the healthcare industry needs a specific
guideline for reducing cost and improving quality of the healthcare.
Many accreditation agencies, state governments, business coalitions, and U.S.

government agencies are proposing solutions to decrease the medication errors. The Agency for
Healthcare Research and Quality (AHRQ) designed the national healthcare disparity report
(NHDR) and national healthcare quality report (NHQR) to provide policy makers with snapshots
of disparities and quality of healthcare in the U.S. (Moy, Dayton, & Clancy, 2005). One of the
objectives of the IOM Report was to establish a national goal of reducing the number of medical
errors by 50% over 5 years (Kohn, Corrigan, & Donaldson, 2000). To accomplish this goal and
to reduce the medical mistakes, the healthcare advisers have created a four-tiered framework.
The framework includes establishing a national focus to create leadership, research, tools, and
protocols to enhance the knowledge base about safety; identifying and learning from medical
errors through mandatory and voluntary reporting systems; raising standards and expectations for
improvements in safety through the actions of oversight organizations, group purchasers, and
professional groups; and implementing safe practices at the delivery level.
On January 27, 2005, the U.S President took an important step in the nation's health IT
plan by signing the electronic prescribing (e-prescribing) proposed regulation by the Centers for
Medicare and Medicaid Services (CMS) at the Department of Health and Human Services
(HHS). Also, recently the U.S. President signed the new Patient Safety and Quality Improvement
Act (White House, 2005) with an objective to create an incentive for healthcare providers to
report medical errors to a centralized database. By April 2006, "new healthcare information
security provisions designed to protect data transmitted and stored electronically will go into
effect under the Health Insurance Portability and Accountability Act (HIPAA) medical privacy
law"(Swartz, 2004, p.26). The U.S. national healthcare plan is to facilitate EHR to most
Americans within the next 10 years. Consequently the objective of EHR implementation is to
achieve expected qualitative benefits, such as easy storage and access to medical information,
prompt response in medical services, elimination of errors and duplicative testing due to lost
laboratory reports, patient safety, and reduction in time and cost of the healthcare services.
Statement of the Problem
The problem in the U.S. healthcare industry, while emphasizing HIT documentation is a
lack of an EHR-centric, cost effective HIS model with uniform healthcare information standards
and pre-defined healthcare quality measures. Though several promising efforts and many
innovative measures are in progress for broader adoption of EHR across the entire U.S.
healthcare system, there are some barriers in attaining desired efficiency of services of the
healthcare systems while implementing EHR. Kibbe (2004, para. 5) evaluated key barriers to the
deployment of EHR at the national level such as "high prices, risk of implementation failure,
lack of connectivity and interoperability, confusion about the product and company reliability for
EHR, and variation in HIS and healthcare business practices." According to Maffei (1997),
though nature of the healthcare industry is basically customer service oriented, for the past
decade, focus of the U.S healthcare services is not only caring for the sick and injured, but also
preventing illness and injury, and reducing clinical errors in the healthcare practices Thus,
nationwide emphasis on HIT documentation and implementation of EHR has established a need
for an IT based model to help document, categorize, control, and transfer knowledge while
attaining the healthcare quality.
Purpose of the Study

The purpose of this study was to construct and evaluate a conceptual HIS model for EHR
implementation and suggest outcome measures to monitor the healthcare quality. The underlying
key to gaining the healthcare quality improvement is identifying critical success factors for
strategic HIS management during EHR implementation (Baker & Pink, 1997; Zani, 1970). With
a focus on predefined healthcare quality goals, the model is built on strategic contingency theory
of organizational management and economic value added concepts of IS planning.
Rationale
One of the advantages of good information systems (IS) is that these systems facilitate
healthcare providers in creating a budget and accurately calculating the costs to treat a group of
patients (Montague, 1994). EHR is one of the useful repository sources for documentation of a
patients medical information and healthcare outcomes that can capture required data and display
it to make timely decisions on healthcare. Brailer and Von Horn (1993) suggested investment in
employee education because more and more employees are getting involved in the control of
healthcare delivery that implicitly involves providing consequential information and relevant
data. Porter and Teisberg (2004) recommended a collection and wide distribution of standardized
healthcare information about individual diseases and treatments that would facilitate patients to
make informed choices about their care. According to Porter & Teisberg (2004), setting up a
transparent billing and pricing mechanisms by payers, providers, and health plans would reduce
cost, confusion in data handling, pricing inequality, and other possible inefficiencies in the
system. Thus, effective development methodology and business processes with HIS architectural
vision could be the key factors to implement and evaluate EHR in view of the associated costs,
benefits, risks, and predefined values.
Research Questions
While the U.S. healthcare costs are constantly escalating, there is also an increase in the
healthcare budget at the national level to expedite development and adoption of EHRs and
supporting technologies. As per the press release on October 13, 2004, The U.S. Department of
Health and Human Services announced $139 million in grants and contracts to promote a use of
health information technology (HIT)" (Anderson, 2004, p. 3). Consequently, as pointed by AlFaris (1995, p. 24), "the fundamental challenge to IS decision makers is how to sustain quality of
patient care delivery while earning profit." The implicit questions examined in the study are:
1. How can cost effective and value added healthcare quality be achieved through
strategic healthcare information management (HIM) while implementing EHR?
2. What are the critical success factors for achieving the healthcare quality while
implementing EHR?
Significance of the Study
Although the healthcare literature indicates varied strategies about classification of
medical errors, including types of healthcare services provided, severity of the resulting injury,
legal definition, type of setting, and type of the individual involved, to the best knowledge of this
author, those strategies lack a common framework. According to Borel and Rascati (1995),
researchers, healthcare providers, various healthcare agencies, and related businesses have tried
to develop their own solutions to decrease clinical errors. Kettelhut (1992, p. 18) suggested,
"Hospitals and clinics must upgrade feedback and control systems in order to track costs,
regulate inputs, and monitor quality." As per Pierson, and Williams (1994, p. 29), healthcare
organizations are "increasingly under pressure to juggle care, quality and cost effectiveness in
the wake of reform and competition." Hence, this study focused on EHR implementation not
only through a cost-centric approach, but also with healthcare quality views. Cerne (2003)
emphasized prior development of HIS for successful EHR implementation.
The healthcare literature indicates that, to realize positive outcomes of the healthcare
quality improvement, it is necessary to define and operationalize the healthcare qualitative
measures (Cerne, 2003). Significance of this study is due to its intent to provide a new
understanding of health information management, with an integrated and interoperable HIS
model for successful EHR implementation to achieve healthcare quality goals. The approach is
based on the strategic contingency theory, and EHR-centric building blocks of integrated
healthcare systems as critical success factors adapted from Goldsteins (1995) generic model of
healthcare systems. At present, the healthcare literature provides little evidence about EHR
systems' effects in the U.S. healthcare industry. This study hypothesized about both mechanisms
and magnitudes of the effects of EHR and attempts to identify the critical success factors of
successful EHR implementation with a predefined set of healthcare quality goals.
Definition of Terms
Healthcare. Healthcare is defined as "the prevention, treatment, and management of
illness and the preservation of mental and physical well-being through the services offered by the
medical and allied health professions" (WordNet, n.d.).
Healthcare system. A healthcare system is the organization that provides the healthcare
(WordNet, n.d.).
Acute care hospital. As per the description in Dorenfest database, it is a healthcare

facility that "services individuals with less than chronic diseases on an inpatient basis."
Sub-acute care hospital. According to the description in Dorenfest database, a healthcare
facility that "services individuals with chronic diseases: long-term, skilled nursing, behavioral
health, psychiatric facilities, inpatient hospice."
Ambulatory care hospital. According to the description in Dorenfest database, it is a
healthcare organization that "offers preventive, diagnostic, therapeutic, and rehabilitative
services to individuals not classified as inpatients or residents. This category also includes
physician offices."
Information systems. Hirschheim, Klein, and Lyytinen (1995) described information
systems (IS) as "a technologically implemented medium for recording, storing, and
disseminating linguistic expressions, as well as for drawing conclusions from such expressions."
Information systems application. Ferrand and Lay (1994) described an IS application as
an integrated group of computer programs and associated data that support end-users in carrying
out one or more of their business functions.
Healthcare information systems. The National Library of Medicine (Medicare Payment
Advisory Committee, 2001) defined healthcare information systems (HIS) as integrated
computer-assisted systems to store, manipulate, and retrieve healthcare administrative and
clinical data.
Data and information. Though the term data and information are often used
interchangeably, as per Tan (1995), data are primary building blocks of HIS while information is
meaningful derived output of processed data that is useful to clinicians and healthcare managers
(Austin & Boxerman, 1997; Bisbee, 1983).
Health information technology. HIS functions implicitly involve health information
technology, which is an application of information technology (IT) to the healthcare industry.
Here, IT encompasses hardware, software, telecommunications, database management, and other
information processing tools and technologies for the healthcare providers that include hospitals,
physicians, clinicians, and healthcare users (patients). These technologies support organizational
tasks and help the organization to achieve its key goals (Anderson & Dawes, 1991; Kramer,
Danziger, Dunkle & King, 1993; O'Brien, 1993).
Quality of healthcare. One of the goals of the healthcare information system is to
improve quality of services. The National Quality Measures Clearinghouse (NQMC), sponsored
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Medicare HMO. This is "the HMO that has contracted with the federal government under
the Medicare Advantage program to provide health benefits to persons eligible for Medicare who
choose to enroll in the HMO, instead of receiving benefits and care through the traditional feefor-service Medicare program" (Medicare HMO, n.d.).
HIPAA. HIPAA is the acronym for the Health Insurance Portability and Accountability
Act of 1996. The Center for Medicare & Medicaid Services (CMS) is responsible for
implementing various unrelated provisions of HIPAA. The administrative simplification
provisions of the HIPAA of 1996 (HIPAA, n.d.) require the Department of Health and Human
Services to establish the national standards for electronic healthcare transactions and national
identifiers for providers, health plans, and employers. HIPAA also addresses patients' safety and
security and privacy of health data (CMS, 2005).
Nature of the Study
This study is based on quantitative research methodology. Robson (2002, p. 6) mentions
"there are some circumstances where quantitative designs are preferred, and others where
flexible qualitative ones are more appropriate." This research has included a set of explanatory
variables based on HIS, operational characteristics, and internal and external factors of the
healthcare organization, and the healthcare quality as a dependent variable. The data variables
are operationalized with quantitative measures. Based on the proposed conceptual research
model, the study used descriptive and inferential multivariate statistical analysis and statistical
tests of hypotheses to observe the casual relationship between dependent variable and
explanatory independent variables. Hence, with such analytic methodology, quantitative analysis
with fixed research design is a suitable research methodology (Robson, 2002).
12
In this study, a non-experimental longitudinal design with multivariate data was

examined over an extended time series. As longitudinal data on some of the variables was not
available, cross sectional multivariate data was used in those situations. The individual
community hospital was considered a unit of analysis. Annual data containing information about
the hospital characteristics, predefined quality measures, and the healthcare information systems
and technology programs were collected from authentic secondary data sources. According to
Robson (2002), advantages associated with secondary data are as follows. It is possible to tap
into extensive data sets, often drawn from large representative samples well beyond the resources
of an individual researcher. It is an unobtrusive measure in a sense that any individual researcher
who is using it does not affect such data collection. Miles and Huberman (1994) mentioned that
pragmatic operationalization of research requires economy, convenience, and interpretability of
results. As discussed by Robson (2002), the secondary data records are in a permanent form,
which facilitates reanalysis, reliability checks, and replication studies, and provides a low cost
form of longitudinal multivariate statistical data analysis. In view of these advantages of
secondary data, longitudinal quantitative secondary data from 1999 through the most recent
available time period was collected from the American Hospital Association (AHA) annual
survey of hospitals and The Dorenfest Integrated Healthcare Delivery System Database (IHDS).
Assumptions and Limitations
HIS is not the entire solution to tackling quality related issues of the healthcare industry.
This study concentrates on a limited focus of the healthcare quality through HIS to better
understand how EHR implementation with HIS can be one of the effective controlling and
driving factors to improve the healthcare quality. As per Stetson and Andrew (1996), focus of
13
EHR is to improve the healthcare quality in terms of reducing the clinical processing time and
avoiding repetition of certain routine tasks, such as filling in the billing forms, writing
prescriptions, and requesting diagnostic studies. The healthcare literature indicates there are
several assumptions and characteristics of EHR, such as flexibility in information display format;
accessibility of information to the healthcare providers, administrators, and researchers; data
security; and authenticity in data access. Thus, this study has several assumptions including but
not limited to:
HIS-based healthcare quality evaluation is a comprehensive approach that includes not
only utilization of IS resources, financial indicators, and healthcare quality in terms of reduced
errors, increased safety measures, and cost reduction; but also should include patient satisfaction
of the services (Shortell, 2001). At present, EHR implementation is still in its developing stage at
macro level of the U.S. healthcare systems, and data to track EHR-related satisfaction of patients
and healthcare providers is not available to this writer. With widespread adoption of EHR
systems and robust HIS, her-related satisfaction of patients and healthcare providers should be
evaluated in future studies. Although this study used authentic data resources, such as AHA and
Dorenfest survey data, these data sets represent broad canvassing of only acute care hospitals,
chronic care facilities, and ambulatory practices on their adoption of and plans to adopt various
HIT components. The study did not include long-term care that should be considered for more
detailed analysis and conclusions in the future. Longitudinal data was not available for some of
the data variables described in this study. In those cases, the data analysis was based on cross
sectional data sets.
14
Although a conceptual model in the methodology section of this study has provided a
comprehensive healthcare quality model through critical success factors of EHR implementation;
data on few of the proposed critical success factors: (a) IS management of patients records, (b)
patients' awareness of EHR functionality, (c) remote patients' data access and management, (d)
prevention of clinical negligence and adverse events through HIS were not available at the time
of the study. Also, data on some predefined quality goals, namely- reduction in clinical data
errors, patient waiting time for the healthcare/clinical services and patient satisfaction of the
healthcare services, were not available to this writer at present.
Thus, data analysis has focused on the predictive influence of several critical success
factors as challenges impacting on the design and management of HIS with two proposed
measures of quality goals: cost effectiveness and HIPAA compliance. The research framework
acknowledges the existence of other challenges in view of the quality goals of an increase in
patient satisfaction and reduction in a patient waiting time for the healthcare and clinical
services. These challenges are beyond the scope of data analysis of this study; however, they are
reflected in the proposed conceptual model for completeness.
Overall, the estimators from the conceptual model did not provide predictions of what
will happen, but of what could happen by capturing dominant strategic IS management themes,
critical success factors of environmental determinants, organizational determinants, and
innovational determinants of the healthcare quality while implementing EHR.
Organization of the Remainder of the Study
The research problem, background, purpose, and rationale of the study, the research
questions, significance and nature of the study, relevant definitions of key terms and concepts,
15
and assumptions and limitations of the study are presented in Chapter 1. Chapter 2 presents the
literature review on HIS, EHR, and healthcare quality. Chapter 3 provides the research
methodology and develops the conceptual framework for modeling and evaluating HIS in view
of EHR implementation for healthcare quality. The research methodology contains quantitative
techniques for the conceptual research design, data sources, data variables and their measurement
criteria, and multivariate statistical techniques to examine and evaluate the relationships between
data variables involved in EHR implementation for improving the healthcare quality. Chapter 4
presents data collection tools and techniques and statistical data analysis. Chapter 5 provides the
evaluations of the research findings based on the statistical output of the tests of hypotheses.
Finally, implications, limitations and directions for future study are presented.
16
CHAPTER 2. LITERATURE REVIEW

This chapter presents the literature review relevant to the U.S. healthcare system
background, the U.S. healthcare information systems (HIS), and implementation of EHR through
HIS for managed healthcare delivery and quality. Also reviewed are general theoretical
development and IS models in view of HIS integrity and quality and HIS modeling for the
healthcare quality while implementing EHR. Finally, conclusions of the literature review are
summarized. The discussion is built on several concepts presented in this author's unpublished
paper work at Capella University (Kulkarni, 2005a, 2005b, 2005c, 2005d) and on review of
published scholarly literature on HIS and the U.S. healthcare quality.
The U.S. Healthcare Systems Background
Before World War II, U.S. healthcare and health insurance was available through some
community institutions (Beach, 2005). During World War II, the main goal of the healthcare
plan was "to attract skilled workers that resulted in increased productivity and lots of corporate
loyalty"(Brailer & Von Horn, 1993, p. 126). The literature review indicates that since the 1970s,
instead of providing an attractive employee benefit, healthcare cost is continuously rising.
During the early 1980s, growing private industrialization and governmental concerns over rising
healthcare costs resulted in managed healthcare systems. A managed healthcare system is
defined as "Any system that manages healthcare delivery with the aim of controlling costs; these
systems typically rely on a primary care physician who acts as a gatekeeper through whom the
patient has to go to obtain other health services, such as specialty medical care, surgery, or
17
physical therapy" (MedicineNet.com, n.d.). Since 1990, focus of managed healthcare is more on
operating procedures. The current healthcare infrastructure of the U.S. has significantly changed
to publicly provided healthcare coverage, largely through Medicaid and Medicare, which may
have implications on total cost of the healthcare, and on the communication system between the
healthcare providers (doctors, nurses, healthcare administrators, and hospitals), and patients who
are in need of the healthcare.
Review of the U.S. Healthcare Information Systems (HIS)
Information technology (IT) has played a major role in the healthcare delivery. Use of
computers in the healthcare arena is dated back to the 1960s (Shortliffe, 2005). During the early
60s, leading IT companies such as International Business Machine Corporation (IBM), National
Cash Register Company (NCR), and Honeywell started offering healthcare application devices to
U.S. hospitals with a goal of improving healthcare and hospital productivity in terms of cost
effectiveness (Bekey & Schwartz, 1972). During the early 1970s, there was a small group of
hospitals that started adopting HIS (Hodge, Gostin & Jacobson, 1999). However, in the past, HIS
initiative was basically for automation of the business office and for the healthcare tools and
techniques related to diagnostic, therapeutic and surgical applications. During the 80s, with
innovations in database designs, HIS applications made some developments in planning and
administration of the healthcare data. During the same period, HIS also introduced low cost
financial systems for hospitals under 200 beds in size (Sneider, 1987). One of the goals of HIS
was to facilitate "the administration, processing of the centralized and distributed healthcare data,
and the development of effective system networking" (Mantas, 1992, p. 570). Over time, HIS
expanded to cover departments, clinics, and hospitals (Berger & Ciotti, 1993).
18
As healthcare organizations grew in size and complexity of operational procedures,

"corporate philosophy focused more on core businesses and outsourced other activities"
(Sandrick, 1994, p. 60). As new trends emerged in the healthcare industry, it became more
challenging to incorporate innovation and competition into the risk-adverse healthcare industry
(Teisberg et al., 1994). These researchers suggested four categories of measures of the medical
outcomes that are adopted by the healthcare industry, as follows. These four measures of the
medical outcomes can provide a guideline to the healthcare providers for assuring quality of the
healthcare services.
1.
Clinical health is described as traditional biomedical and physiological health

status.
2.
Functional health is described as quality of life and general well-being is

considered in view of the subjective evaluation by the patient of himself.
3.
Healthcare satisfaction is described as consumers' attitude and responses to the

experience of seeking and receiving care.
4.
Healthcare cost is related to acquiring the desired level of health outcome.
Davenport (1994, p. 120) presented parallel views in his "human centered IT approach,"
pointing to the fact that the focus of corporations shifted from hardware and software to how
"people in an organization acquire, share, and make use of the information." As per Davenport
(1994), the objective of human centered IT is to employ adequate methodologies to enhance
usage of the information. These arguments are quite applicable to adoption of HIS to support
collection, processing, and dissemination of the healthcare data. Boynton (1993) also suggested
strategic management of the information while building long-term process capabilities.
19
According to the literature review, since the mid 1980s, different hospitals used varied
systems from different vendors in their departments. However, in spite of increase in the HIS
costs, there was inadequate HIS interface and communication, and overall, HIS integration
became a major issue in the process of improving healthcare services (Sneider, 1987). Since
then, HIS has played an important role in the structure of the healthcare systems.
Several researchers have proposed frameworks with various perspectives to examine HIS
integrity. Based on the sample survey analysis of hospitals, Longo, Bohr, Miller, and Miller
(1990) concluded there was an increased need for the healthcare information data. Griffith,
Smith, and Wheeler (1994) demonstrated the evolution of strategic governance of IS in the
hospitals. MacLeod (1995) emphasized strategic management of the healthcare information
systems. As pointed by Kongstvedt and Plocher (1995), the transition from fee-for-service to the
managed healthcare systems with a goal of cost minimization and quality improvement further
led to developments of an integrated HIS. Merlo and Freundl (1999) analyzed the factors
responsible for inefficient HIS in the healthcare organizations. These researchers concluded that
a lack of data integration is a barrier to the effective data analysis. Norrie and Blackwell (2000)
conducted a case-based study and concluded that a computerized patient data management
system can save administrative time and cost and can increase performance of the healthcare
organization. Ma (2003) analyzed the cross sectional sample survey data and reviewed HIS
applications on two dimensions, namely, basic functionality of HIS in administration and patient
care, and the global nature of the HIS application across and beyond the healthcare organization.
Based on his study, Ma (2003) concluded that HIS integrity is one of the driving factors of the
healthcare organization's performance.
20
Several IT developments evolved in the U.S. healthcare system through government,

professional, and research environments (Shortliffe, 2005). At present, the National Library of
Medicine (NLM), the National Center for Research Resources (NCRR), the Agency for
Healthcare Research and Quality (AHRQ), the American Medical Informatics Association
(AMIA), and the Healthcare Information and Management Systems Society (HIMSS), are some
leading agencies that are conducting research programs and making recommendations for
development of IT projects in the healthcare industry. Additionally, federal advisory groups such
as the National Committee on Vital and Health Statistics (NCVHS), National Research Council
(NRC), and the Institute of Medicine (IOM) are "educating the public, the health professions,
and policymakers regarding health IT topics" (Shortliffe, 2005, p. 27). He pointed out that
culture, the business case, and structural realities such as poor appreciation of IT as a strategic
asset; lack of structured knowledge and criteria in determining IS capabilities and
implementation processes; poor coordination; and a lack of generally accepted standards in
decision making regarding IT investment are the major barriers in successful implementation of
integrated HIS within the U.S. healthcare system (Shortliffe, 2005).
The literature review indicates an exponential increase in the use of the Internet during
the last decade, which made it possible to have easily accessible information on health
promotion, disease prevention, and disease management. Clinicians, politicians, and researchers
all have an increased recognizition of the inevitable role of IT in healthcare delivery. However,
as per Fadlalla and Wickramasinghe (2004, p. 65), along with cost reduction and quality
improvement, the U.S. healthcare industry is facing a challenge to meet a "stringent timeline to
become compliant with the health insurance portability and accountability act (HIPAA)
21
regulatory requirements." These researchers emphasized a need for robust HIS so that the
"information that is captured, generated and disseminated by HIS can be of the highest possible
integrity and quality, as well as compliant with regulatory requirements" (p. 65). Medicare's
recent pay-for-performance initiative encourages improved quality of care through approaches
requiring forms of monitoring and data management. However, these approaches are difficult to
implement due to the current lack of robust health information systems (CMS, 2005).
Electronic Health Record through Healthcare Information Systems for
Managed Healthcare Delivery and Quality
The literature review indicates a need for effective IS implementation, not only with a
cost-centric approach, but also with a healthcare quality focus. Although HIS is not the only
avenue to addressing all the quality issues of the healthcare industry, it can be one of the
controlling and driving factors to improve healthcare delivery. Austin (1989) commented that
quality information is the result of quality information systems. Many researchers emphasized a
need for strategic HIS developments and evaluations prior to the selection of an operation model
and linking HIS to improvement in the organization's performance (Cerne, 1993; Halverson,
1996; Martin, 1996; Teisberg et al., 1994; Ummel, 1997). Austin and Boxerman (1997)
demonstrated some qualitative benefits of HIS in clinical and administrative applications. Prince
and Sullivan (2000) presented the conceptual framework for HIS integration and suggested
implementation of EHR at various medical services to enhance HIM capabilities. The U.S.
Department of Health and Human Services estimated about $140 billion annual savingabout
10% of total U.S. health spending through implementation of EHR-centric nationwide health
information network, resulting in improved healthcare and reduction in duplication of medical
22
tests (Brailer, 2004). Thus, as pointed by the Institute of Medicine (2001), EHR could be one of
the potential key elements to improving healthcare quality through integrated and interoperable
healthcare information systems.
At present, when several healthcare practitioners treat a patient, they often do not have
complete information about their patient's illnesses or the medicines previously prescribed to the
patients. The IOM (2001) report mentioned that a majority of the clinical errors are not due to
carelessness of an individual, but due to errors in organization and management of the healthcare
systems. Independent studies have cited many situations of medical practices that do not meet
the required norms and result in healthcare errors that take several lives every year (Peirce,
2004). The research literature indicates that the healthcare and the non-health care organizations
are not different in maturity of quality management. As per Hartman, Fok, Fok, and Li (2002),
an increasing maturity in quality management appears to be related to at least some of the
changes in the information systems. HIS implicitly involves technology implications in the
organizational system. Technology has a potential to improve quality of the healthcare, safety,
effectiveness, patient-centered care, timeliness, and efficiency (Kohn, Corrigan, & Donaldson,
2000; Sokol & Molzen, 2002). Several healthcare studies indicated that archaic information
systems of the U.S. hospitals and clinics could have a negative effect on quality of patient care
(Swartz, 2004). Some of the reported causes of medical errors include "multiple physicians
treating the same patients without all having access to all the patients' medical records and with
each storing different, incomplete medical records in different places" (Swartz, 2004, p. 20).
Researchers have suggested integrated HIS for quality improvement in the healthcare
delivery. According to Swartz (2004), there is consensus among the healthcare industry experts
23
that EHR based HIS would provide more coordination and higher quality of healthcare and
would reduce errors due to hand written prescriptions. Werder and Deng (1999) pointed that, in
the past, HIS were mostly proprietary solutions, acquired in separate modules and tightly
coupled through ad hoc means. Such HIS resulted into the stovepipe systems: each collected
patient-care data differently and many had duplicated large amounts of data and noninteroperable functions. Today's HIS have to link together hospitals, clinics, physician offices,
and other business units that are mutually dependent, yet located at different places, each with
distinct business functions (Werder & Deng, 1999).
Today's HIS are quite complex and critical enterprise systems. As per the opinion of
Werder and Deng (1999), a transition from the earlier stovepipe systems to the next generation of
open HIS with interoperability and maintenance is a real challenge to healthcare information
management. Based on their case study, these researchers concluded that adoption of standard
architecture and infrastructure is the best approach to achieve interoperable, extensible, and
cohesive HIS. While suggesting HIS reforms, Porter and Teisberg (2004) recommended the
collection and wide distribution of standardized healthcare information about individual diseases
and treatments that would facilitate patients to make informed choices about their care.
According to Porter and Teisberg (2004), setting up transparent billing and pricing mechanisms
by payers, providers, and health plans would reduce cost, confusion in data handling, inequality
in pricing, and other inefficiencies in the system.
Thus, the literature review indicates that effective IS development methodology and
supporting business processes with HIS architectural vision could be some of the key factors
while implementing EHR. Also, the literature suggests to evaluation of IT project in terms of
24
associated costs, benefits, risks, and values. Researchers have described various approaches to
evaluate HIS and have constructed healthcare models based on different evaluation criteria of
decision making, durable products, financial benefits, and integration for optimal application of
IT in the healthcare industry, as well as using cost benefit analysis as evaluation tool (Maffei,
1997). The following section explores relevant theoretical background and conceptual models in
IT literature applicable to EHR implementation for healthcare quality improvement.
Theoretical Development and Information Systems Models for
Healthcare Information Systems Integrity and Quality
The information systems literature in general, and HIS literature in particular, contain
various organizational theories of performing HIS management and provide guidelines to
improve performance of the organization. The classical approach of the universalistic theories
focused on IS management and how it could be improved. However, as per Galliers and Leidner
(2003), the classical approach is narrow because it assumes that organizations have the same
structure, and the approach does not provide integrative perspectives of IS management.
According to the contingency theory, "organization design decisions are contingent (depend) on
environmental conditions" (Scott, 2003, p. 97). The contingency theory suggests the possibility
of alternative ways to organize and variation in the effectiveness of such alternative strategies;
and thus the theory provides an integrative strategic perspective of IS management (Galbraith,
1973).
Some researchers opposed the conventional contingency approach that considers
organizational environment as the determinant of its structure. Many researchers proposed a
strategic contingency theory that assumes several internal and external factors, such as
25
organizational size, resources, managerial perspectives, technological developments and

adaptiveness, market and regulatory constraints during organizational decision-making, IS
planning, and its strategic management, to achieve goals of the organization (Miller, 1992; Scott,
2003;Van de Ven, 1986). Several IS researchers (Chan, Barclay & Copeland, 1997; Sabherwal &
Kirs, 1994; Sambamurthy & Zmud, 1992) supported such a strategic contingency theory
approach. These researchers empirically demonstrated that there is improvement in the
organizational performance through greater alignment and coordination between IS and business
units.
Young, Parker, and Charns (2001) examined the value of the contingency theory for
guiding empirical studies on healthcare provider integration. In the opinion of these researchers,
healthcare organizations should match their information processing capabilities with information
processing requirements in order to achieve optimal performance. Young et al. (2001, p. 77)
argued that the value of the "contingency theory depends on its ability to withstand rigorous
empirical testing." Young et al. (2001) pointed to the challenge to assess whether healthcare
providers have achieved optimal fit "between their organization's operating environment and
organization's internal design" (p.79). Thus, the Young et al. (2001) conclusions imply that,
unlike a manufacturing industry that generally has only one-dimensional performance indicators,
such as return-on-investment or profit margin, the current healthcare environment has multiple
performance measures of interest, including profit margin, operating costs, and various
healthcare quality criteria such as patient satisfaction and reduction in documented errors.
Many researchers emphasized the importance of information systems for healthcare
quality improvement (Griffith, 1994; Ummel, 1997). Through their survey based study, Bajwa,
26
Rai, and Ramaprasad (1998) evaluated the associated structural factors of organizations and
concluded that executives in larger hospitals implemented HIS more than those in smaller
hospitals. Krohn and Broffman (1998) suggested integrated HIS for reliable financial and clinical
data. Killian (1999) demonstrated that healthcare organizations that have some system affiliation
often incline to adopt HIS. Ferrant, Lederer, Hall, and Krella (1998) conducted a survey based
study of HIS in seven community hospitals that shared patient healthcare information through a
common network. Through a questionnaire-based survey, these researchers collected and
analyzed data on perceived benefits of HIS in the views of physicians, medical record personnel,
and IS personnel. Ferrant et al. (1998) concluded that physicians' use of IS was quite low due to
less user friendly systems and due to doctors having inadequate time for handling such electronic
data. Also, conclusions of Ferrant et al. (1998) indicate that both physicians and IS personnel
considered use of electronic data as an essential technological requirement of the healthcare
services.
Lin and Wan (1999) conducted quantitative, cross sectional, secondary data analysis of
the structural design and performance of the top 100 integrated healthcare network services
(IHNS). The study concluded that IS integration indicates structural integration of the healthcare
organizations. Wan and Wang (2003) also examined the effects of integration on performance
ratings of the top 100 IHNS in the United States. The results of their cross-sectional data analysis
indicated high performance rated IHNS is related to more sophisticated HIS with managerial and
executive decision support systems. However, these researchers mentioned that clinical
integration is not yet well developed and needs to prove its efficiency. Wan and Wang (2003, p.
123) recommended use of "longitudinal data on the quality of healthcare network services and
27
time varying data to serve as predictors of network performance" for further study. Later, Begun,
Kaissi, and Sweetland (2005) conducted an exploratory study through interviews of leaders in 20
healthcare organizations in the metropolitan areas of Minneapolis/St. Paul, MN, and San
Antonio, TX. These researchers showed that strategic planning is a common and valued function
in the healthcare organizations.
Young et al. (2001) pointed that most of the empirical studies of the contingency theory
performed cross-sectional data analysis and measured environmental uncertainty of the
organization. However, as per the opinion of Young et al. (2001), these empirical studies of the
contingency theory lack rigorous testing and they do not include a variable for measuring
information processing capabilities. Hence it is "important for the contingency theory to be
tested further and for the healthcare managers to participate in these research efforts" (p. 79).
Some researchers have conducted studies on the status of electronic health information
systems and their usage by healthcare providers. Kralewski, Hammons, and Dowd (2005)
conducted a sample survey analysis of medical group practices to assess their current use of
information technology and concluded there is inadequate use of IT in the healthcare systems.
Gans et al. (2005) concluded that at present, EHR adoption is significantly slow. These
researchers highlighted complexity and variation in the process of choosing and implementing
EHR and also pointed to a need for greater technological support to smaller healthcare practices.
Through an interview based survey, Weber (2005) conducted an exploratory study to present the
current state of electronic health information systems among perceptions of the U.S. physicians
in the 2005. Webers (2005) results indicate that less than 40 % of respondents mentioned usage
of EHR and identified cost as the major obstruction for EHR implementation. According to
28
Weber (2005) results, the physicians believe that return on investment (ROI) through EHR is a
progressive benefit, which involves HIS project management with effective investment and
learning technology focus.
Miller and Sim (2004), in their exploratory study on physician's use of EHR technology,
commented that EHR has a potential to generate quality improvements in physician practices.
Kilo (2005), in his case based research study, explored aspects of the transformative changes
under way in an ambulatory care from the information technology perspective. The study
concluded that EHR as a knowledge-management tool is still in its development stage, which is
justifiable because the healthcare marketplace is not yet ready for such advanced products. Kilo
(2005, p. 1301) pointed that "funding sources--namely venture capitalists--are generally skeptical
of healthcare IT because of their adverse experiences in this sector in recent years". As per Kilo
(2005), while implementing EHR, it is essential to use the right technology in the right way so as
to improve healthcare quality. In his opinion, healthcare performance improvement efforts
require HIS intelligent system design through integration, connectivity, and the incorporation of
IT into the system.
Thus, while there is consensus amongst the researchers on IT as an enabling technology
for physician practices to pursue healthcare quality improvement, the research literature review
does not provide a specific solution to accelerate EHR adoption to advance healthcare quality.
However, in order to integrate and evaluate IS applications, researchers have proposed several
models based on the strategic contingency theory, as discussed in the following section.
29
Healthcare Information Systems and Electronic Health Record Modeling

With management perspectives for EHR implementation, healthcare information system
evaluation needs to establish the quantitative and qualitative benefits of IS to the healthcare
organization. According to Galliers & Leidner (2003), such HIS evaluation involves notions of
costs, benefits, risks, and values, and it involves organizational processes to assess these factors.
Information economics models can provide one of the approaches to evaluate both quantitative
and qualitative benefits of EHR implementation to the healthcare industry, as discussed below.
Information Economics Model
Parker, Benson, and Trainor (1988) proposed a broader concept of the effect of IT
investment on business performance of the organization. The model considers traditional cost
benefit analysis through four lenses of ROI. This approach could be applicable to assess the ROI
of EHR by considering the traditional cost-benefit analysis, along with a certain set of predefined
qualitative measures of EHR, such as patient data linking, reduction in patient's data processing
time, and documented errors .The approach is useful to assess how equipped the healthcare
industry organization is to implement EHR in view of new technological challenges and required
skills. The model seems quite adaptable to an organization's HIS framework and circumstances
and can enhance cost-benefit analysis through business and technology domain assessments
(Galliers & Leidner, 2003). The model can be evaluated through established goals of connecting
EHR directly to the patient care provision, such as providing, consuming, managing, reviewing,
and reimbursing for patient care services. Such assessment of business value of IS processes in
the Parker et al. (1988) information economics model involves top level management. However,
the model does not focus much on users of IS at lower levels during assessment of the process
30
(Galliers & Leidner, 2003). Goldsteins (1995) generic integrated model provides comparatively
more comprehensive ROI perspectives. Goldsteins (1995) model identifies causes of lower
quality performance and accordingly conducts effective quality improvement interventions to
eliminate those shortcomings.
Generic Integrated Model
Goldstein (1995) suggested three main targets of intervention: "The health professional,
the patient, and the health service delivery system and further suggested even the combinations
of these targets" (p. 55). The generic integration model has the widest perspective of modeling,
i.e., clinical practices, value evaluations and organizational studies. As per Goldstein (1995), the
focus of the generic integration model is to develop evolutionary structures and processes. This
approach allows "physicians and managers to learn to share information and clinical
perspectives, and to set financially directed performance criteria" (p. 56). Goldstein (1995)
formulated an 11 block and 4 level model based on his theory of high quality of healthcare
administered by an error free healthcare delivery system, as described in the Figure 1.
As described by Goldstein (1995), level one (L1) contains the fundamental blocks of any
healthcare system. In this model, a physician's decisions account for almost 80% of healthcare
costs. Primary care networks are primary care providers. The IS management is responsible for
collecting dispersed clinical data. Reengineering and continuous quality improvement (CQI) of
care are enablers of an efficient and comparatively less costly delivery system. Also, according
to the model, continuum of care requires effective coordination within the system modules.
Level two (L2) identifies blocks that improve access and quality of the delivered care. Level
three (L3) blocks support the patient and the provider, while level four (L4) is "the empowering
31
of the people responsible for restructuring the healthcare system" (p. 62). Thus Goldstein (1995)
model encompasses structural, technical and managerial issues of the healthcare organization
that can be used as a framework for useful collaborative systems while implementing EHR. The
model emphasizes leadership of healthcare managers and providers for transformation of the
healthcare delivery to function in a proactive manner and involvement of users at various levels,
while controlling cost and improving healthcare quality. As pointed by Maffei (1997), the
generic integrated model suggests major enhancement and collaboration of existing healthcare
information systems and healthcare information management.
Linking the HIS Integrity Model with Consolidated BSC & CSF Analysis
While the information economics model goes beyond costbenefit to value, Goldsteins
(1995) generic integrated model provides a wider perspective by linking HIS evaluation across
various stages of the healthcare delivery system in view of internal and external components of
the organization. As per the opinion of Ward and Peppard (2002), for a successful IT project in
general and EHR implementation in particular, it is essential to understand the current HIS
processes that are in place. Maffei (1997) argued that these HIS processes include several
interlinked activities that involve patients, as well as the roles of those who deliver healthcare,
such as doctors, nurses, pharmacy, laboratory, and healthcare administrators. According to
Maffei (1997), evaluation of an integrated HIS model requires fact-finding, analysis, and
interpretations. According to a GAO Report (2004), with an expected increase in the U.S.
healthcare spending in the subsequent decade, and with important stakes such as encouraging
high-quality clinical services while implementing EHR, the healthcare organizations need to
improve accountability. In this sense, unless healthcare delivery system performance indicators
32
are linked to the drivers of EHR effectiveness in a meaningful way, desired improvements in
healthcare quality are unlikely to occur.
Thus, as described by Ward and Peppard (2002), the real challenge for the healthcare
organizations while implementing EHR is to create meaningful systems for strategic
organizational assessment and then use that information in internal policy and strategic decisionmaking. The challenge can be achieved by the critical success factors analysis that has its roots
nearly 40 years back. The critical success factors analysis is a cumulative research approach
about decision-making, IS planning, and identifying the organization's important performance
objectives (Cleland & King, 1968; Zani, 1970). In their study, Baker and Pink (1997),
Castaneda-Mendez, Mangan, and Lavery (1998) pointed the relevance of the balanced score card
(BSC) and critical success factors (CSF) analysis to the healthcare organizations. These
researchers suggested BSC and CSF analysis to link healthcare practices with outcome, value,
and cost of the healthcare services and related projects. Thus, while Goldsteins (1995) model is
a collaborative framework of structural, technical, and managerial issues of the healthcare
organization systems, consolidated balanced scorecard and identification and analysis of the
critical success factors of the generic integrated healthcare system could provide a
comprehensive integrated view of EHR project in view of healthcare quality performance as
discussed below.
Consolidated Balanced Scorecard and Critical Success Factors Analysis
Kaplan and Norton (1992) introduced the balanced scorecard (BSC) as a set of measures
used to facilitate a holistic, integrated view of the business performance. Initially, Kaplan &
Norton (1996, p. 75) created the scorecard to supplement "the traditional financial measures with
33
the criteria that measured performance from additional perspectives such as those of customers,
internal business processes, and learning and growth. Later, organizations developed BSC as a
strategic management system linking organizational long-term strategy to its short-term goals. In
view of the limitation of financial measures to display only past decisions, BSC emphasizes
identification of a certain balanced set of objectives and measures for managing the performance
of an organization or the industry. As per Ward and Peppard (2002, p. 208), the BSC approach
can provide a structured methodology for "monitoring current performance of the healthcare
industry/organization with four perspectives of finance, patient satisfaction and quality issues,
internal business, and innovative and learning perspectives." This approach suggests identifying
objectives for each of these perspectives and assigning relevant measures to these objectives as
"key performance indicators"(p. 208). Thus, the BSC approach can provide information needed
to measure the performance of healthcare business process results, as well as to improve the
processes and to motivate and educate the healthcare employees.
According to Ward and Peppard (2002), CSF analysis is helpful in identifying critical
factors in achieving the objectives set by BSC. The technique involves identifying structural,
managerial needs and performing strengths, weaknesses, opportunities and threats (SWOT)
analysis of existing systems against CSF in view of each objective. The consolidated BSC and
CSF technique supports the economic value model and provides a rigorous assessment of
"prioritized" IS opportunities, given the "current business strategy" (Ward & Peppard, 2002, p.
213).
Thus, Goldsteins (1995) HIS integrity model supplemented with consolidated BSC and
CSF analysis can provide a conceptual framework for EHR implementation. The approach can
34
provide a comprehensive understanding of current performance of the organization (Ward &

Peppard, 2002). The technique can be applied to examine the healthcare organizations in the U.S.
healthcare industry (p. 213). The approach can assist in prioritizing healthcare activities, HIS
requirements, and evaluation of predefined variables of healthcare quality, such as reduction in
medical and medication errors, time and cost factors, meeting the regulations' requirement, and
improvement in patient safety. Therefore, using the balanced scorecard, healthcare organization
can construct a scorecard of objectives and associated measures for the previously described four
perspectives of finance, patient satisfaction and quality issues, internal business, and innovative
and learning perspectives of the organization. The literature review indicates use of such a BSC
approach to evaluate hospital performance.
During the 1998 system-wide report on Ontario, Canada, hospitals, researchers adapted
the BSC approach and provided information on the performance of Ontario's acute care hospitals
(Pink et al., 2001). Later, during 1999, the same team of researchers utilized BSC to extend the
information on the performance of Ontario's acute care hospitals at two levels, namely at
aggregate and subgroups of small, community, and teaching hospitals (Pink et al., 2001). These
researchers developed indicators of Canadian hospitals' healthcare performance in four areas:
system integration and change, financial conditions, patients' satisfaction, and clinical
deployment and outcomes. Such a BSC and CSF approach can be extended and adopted to
evaluate the U.S. hospitals' healthcare performance by analyzing the relationships among EHR
related HIS integration, as well as healthcare quality in terms of financial indicators, clinical
outcomes, and patient security and privacy issues. As pointed by Zelman, Pink, and Matthias
(2003), the consolidated BSC and CSF approach in healthcare is in its growth stage. Hence it is
35
essential to have appropriate modifications in the approach to reflect the U.S. healthcare
organization's perspectives that include healthcare quality goals with some predefined measures
of healthcare quality.
Summary of the Literature Review
The literature review explored historical developments of healthcare information systems
and identified several methodological problems and approaches in current HIS management. At
present, hospitals are motivated by a need to increase healthcare quality through reduction in
medical and medication errors and cost, improvement in patient safety, and creation of effective
IS processes. Healthcare organizations are looking at and drawing from quality management
processes used by manufacturers and other industries, such as the International Organization for
Standardization (ISO) 9000 series quality management systems standards, six sigma rigorous
data driven processes, and failure mode effect analysis: a systematic way to identify and prevent
product and process problems before they occur (Rossow & Grimes, 2003; Swan & Boruch,
2004).
While there exist several IT/IS press articles on EHR implementation and healthcare
quality through HIS that are accessible through the Internet, at present, academic research in this
area seems quite limited. For example, for 1995-2005, Google search engine returned 4,710,000
hits for information systems and healthcare quality, of which 920 hits for information systems,
healthcare quality, and EHR. However, for 1995-2005, the academic search through Business
Source Premier search engine returned only 84 research articles on information systems and
healthcare quality; of these hits, 21 are academic. There were 644 hits on EHR, of which 87are
academic papers and fewer than 15 are academic articles on EHR that focus on healthcare
36
quality. Thus, in the opinion of this writer, a very limited number of empirical studies on HIS
and EHR implementation for healthcare quality have been conducted. Some of the academic
studies were exploratory and descriptive in nature and were case based studies or adopted crosssectional data analysis. These studies lack comparability and generalizability of the results and
derived conclusions.
So far, most academic literature for EHR implementation and healthcare quality in the
HIS literature seems discrete in nature, and hence, difficult to quantify and research. With regard
to the strategic contingency theory approach, a healthcare organization needs to bring strategy,
structure, and context into natural alignment while building unique solutions to the problems
(Miller, 1987; Mintzberg, 1991). This requires building a comprehensive conceptual framework
and evaluating HIS projects of EHR implementation in view of the predefined healthcare quality
goals. The generic integrated model with a foundation of the strategic contingency theory and
evaluation tool of consolidated BSC and CSF analysis for quality performance of healthcare
industry was the basis of construction of EHR-centric conceptual model in this study. Emphasis
of the conceptual model was on the integrative analysis for predefined set of healthcare quality
goals by looking at critical success factors as drivers of successful EHR implementation at both
methodology and process level, which involved healthcare providers, HIS integrity, and
associated internal and external factors of the healthcare organization.
37
CHAPTER 3. METHODOLOGY
The two research questions described in Chapter 1 are:
1. How can cost effective and value added healthcare quality be achieved through
strategic healthcare information management (HIM) while implementing EHR?
2. What are the critical success factors for healthcare quality while implementing EHR?
To address these two research questions, a conceptual model is presented in this study. The
model is based on the strategic contingency theory, Goldsteins (1995) integrated healthcare
systems model, and the consolidated balanced scorecard and critical success factors analysis
approaches. Quantitative methods are suggested to examine the critical success factors in terms
of HIS integrity, environmental factors, basic functionalities, operational characteristics, and
innovation and learning perspectives of the healthcare organization for healthcare quality
improvement during EHR implementation. The proposed model, data sources, measurement of
data variables, and statistical methods to test the hypotheses are presented.
In view of to the two research questions described above, the research objectives of this
study were to: (a) Perform an exploratory research into a series of proposed relationships
between organizational internal and external factors considering the two important systems for
successful EHR implementation and enhancing healthcare organizations; namely, healthcare
information systems (HIS) and healthcare quality. (b) Identify the critical success factors (CSF)
and quantify the perceived importance of each CSF during EHR implementation for the
healthcare quality goals. (c) Construct a regression analysis based predictive model using the
38
proposed critical success factors for healthcare quality improvement during EHR
implementation, and compare and contrast the results of (a), (b) and (c) for small, medium, and
large size healthcare organizations to better understand how critical success factors and EHR
implementation decisions vary with size of the healthcare organization.
Research Design with the Conceptual Model
With a foundation of the strategic contingency theory, the generic integrated model
(Goldstein, 1995), and an evaluation tool of consolidated BSC and CSF analysis, the EHR
centric conceptual model is developed in this study to achieve healthcare quality goals. The
approach attempted to make a theoretical case to extend CSF to facilitate HIS planning in view
of the relationships between organization's internal and external attributes and goals. The model
considered healthcare organizations' context, structure and quality variable. Goldstein (2001)
explained the four fundamental blocks of the healthcare system as follows. Physicians decisions
account for almost 80% of healthcare costs. Primary healthcare providers constitute the primary
care network in the healthcare system. IS management is responsible for collecting dispersed
clinical data. Finally, reengineering and CQI of care is essential for a cost effective, efficient
healthcare delivery system. Adapting and restructuring these fundamental blocks of the
healthcare system of the Goldstein (1995) model, an EHR centric conceptual model for
healthcare quality is derived as follows.
In view of the level one building blocks of the healthcare systems in the Goldstein (1995)
model, in the conceptual model, physician's responses to HIS systems and technology represent
the physician's decisions block of the Goldstein (1995) model. Such approach during EHR
implementation would facilitate timely information and retrieval of specific information,
39
particularly daily operational information for monitoring the organizational performance

(Galliers & Leidner, 2003; Huber & MacDaniel, 1986).
To represent the level one primary care network block of the Goldstein (1995) model, the
conceptual model used the healthcare organization's environmental factors and basic
functionality such as hospital bed size, healthcare facilities' affiliation status, managed healthcare
status, and HIS structural functionality. This approach supports Scotts (2003) suggestions to
consider the contingent control variables that relate to an organization's environment, mission,
technology, firm, and industry variables.
In view of the EHR mission of management of patients' record, the conceptual model
used EHR related structural functionality and connectivity of HIS with effective database
management of patients electronic records to represent the level one IS management block of
Goldstein (1995) model. According to Galliers and Leidner (2003), HIS management around the
healthcare business processes allows greater focus on the goals of the healthcare organization,
rather than just operationalizing organization's objectives around existing activities. Also,
researchers (Wickramasinghe, 2000; Wickramasinghe & Mills, 2001), suggested that HIS
management around the healthcare business processes can effectively link the key players within
the basic EHR system to facilitate patient information data management properly, with a cost
effective value added outcomes. To represent the building block of reengineering and CQI of
care of Goldsteins (1995) model, the conceptual model used strategic application of HIS with
learning perspectives, responses to new IT tools, and the executive decision support
functionality. Such approach considered process reengineering strategies, change, and quality
management, which is essential to build flexible systems and continuous improvement of
40
management processes while adapting dynamic software technology and medicine. The
approach supports Lams (1995) views that "process reengineering requires characteristics of a
learning organization that has continuous capacity to adapt and change" (Kulkarni, 2005a, p. 30).
Also, the Continuum of care Network is the level-one building block of the Goldstein (1995)
model, which requires effective coordination within system modules. Hence, the conceptual
model represented this building block in terms of HIS connectivity aspect of facilitation of
communication and coordination.
Level two building blocks of healthcare systems in the Goldstein (1995) model are to
improve access and quality of the delivered care. Fadlalla and Wickramasinghe (2004) suggest
that new technologies and techniques in the healthcare organization could be driving forces of
cost effective healthcare quality. Hence, the conceptual model represented this building block in
terms of supplementary technology applications and EHR supporting systems, applications of
patient safety and data security tools, and remote patient data access and management.
Level three building blocks of healthcare systems in the Goldstein (1995) model support
patients and healthcare providers. As per IOM (2001), high quality healthcare initiative involves
patient centered healthcare services that are responsive to patient preferences, needs and safety.
Hence, the conceptual model considered the level three building blocks of Goldsteins (1995)
model in terms of patients' awareness to EHR functionality and applications to reduce clinical
negligence and adverse events. Finally, the level four building block of healthcare systems in the
Goldstein (1995) model considers "the empowering of the people responsible for restructuring
the healthcare system" (p. 62), which is implicitly assumed in the conceptual model without
41
deriving a separate building block. Nevertheless, the model assumed involvement and
collaboration between all the stakeholders and the end users' awareness.
People
L4
C12 : Healthcare providers, policy makers and end users

L3
Empowered consumers
Preventions
C10 : Patient awareness and

knowledge about
EHR adoption.
L2
Teleservices
C7 : EHR supporting
systems
L1
Information Systems
C4 : IS management of
patient Records
L0
C11 : EHR applications to

prevent clinical negligence
and adverse events.
Outcome management
C8 : Patient safety, electronic data
security tools,
Regional alliances
C9 : Remote access of patient
records by physician in other
locations
Re-engineering & CQI

C5 : Strategic usage of HIS
with learning perspectives,
Executive decision support
functionality to encompass
reengineering strategies and
quality management.
Continuum of Care Network

C6 : HIS connectivity for
facilitation of
communication and
coordination in
clinical data
and healthcare services
EHR Implementation Relevant

Physician's Leadership
C1 : Physicians', healthcare providers
responses to HIS systems and
technology
Primary Care Network

C2 : Healthcare organization's internal, external
environmental factors - hospital bed size,
affiliation status, managed healthcare,
C3 : Basic functionality- HIS structural

Figure 1. EHR-centric building blocks of
healthcare integration
functionality
Figure 1. Electronic Health Record-centric building blocks of healthcare integration
Note. Adapted & revised from Goldstein (1995) Generic Healthcare Systems Integration Model
42
Thus, as described in Figure 1, the restructured fundamental blocks of the healthcare

system from Goldstein (1995) model proposed the EHR-centric critical success factors of
healthcare quality. Using these critical success factors of healthcare quality, the conceptual
model constructed a scorecard of objectives and associated healthcare quality measures in view
of the previously described perspectives of finance/healthcare cost effective quality issues,
patients, internal business, and innovative and learning aspects, while implementing EHR. As per
Kaplan and Norton (1996, p. viii), such analysis through a balanced scorecard can reflect "the
balance between short- and long-term objectives, between financial and non-financial measures,
between lagging and leading indicators, and between external and internal performance
perspectives" of healthcare organization while implementing EHR. Ittner and Larcker (1998, pp.
223-224) argued, "The use and performance consequences of BSC measures appear to be
affected by organizational strategies and the structural and environmental factors confronting the
organization."
According to Galliers and Leidners (2003) suggestions, the first step in identifying
critical success factors during HIS plans of EHR implementation is to remove the currently
encountered barriers to the healthcare quality goals that are set forth by the Committee on the
Quality of Healthcare in the United States. As explained in an IOM (2001) report, most of the
poor quality connected with healthcare is related to a highly fragmented delivery system, which
lacks even basic clinical information capabilities and results in inadequate information flows and
poorly designed care processes characterized by unnecessary duplication of services, long
waiting times, and numerous medical errors in healthcare and clinical data systems (Chandra,
Knickrehm, & Miller, 1995; Merlo & Freundl, 1999; Mandke, Bariff, & Nayar, 2002).
43
Thus, it is critical to design and manage strategically robust, updated, reengineered HIS,
with cost effective healthcare treatments, and support the statutes such as HIPAA and its
operational information requirements. This requires an organization's environmental factors and
basic functionalities to support managerial and healthcare provider communication, coordination,
and continuum of care; educate the healthcare providers and users of healthcare quality issues;
and continuously develop new information quality skills (Bajwa et al., 1998; Huang, Lee, &
Wang, 1999). Researchers have suggested that healthcare organization size; affiliation status;
relevant structural components; and HIS functionality could affect healthcare system services
and quality (Bajwa et al., 1998; Morrisey, et al., 1999; Scott, 2003). Also, with the transition of
healthcare industry from fee-for-services to managed healthcare, and with increased pressure for
reducing healthcare costs while improving quality, comprehensive EHR systems through HIS
integrity of structural functionality, connectivity, and executive decision support functionality
could deploy clinical resources effectively while improving cost effective healthcare quality
(Hebert, 1998; Ma, 2003; Prince & Sullivan, 2000). Thus, Table 1 presents the proposed critical
success factors of healthcare quality in the consolidated BSC and CSF analysis through four
perspectives of healthcare quality- financial, patients, innovations and learning, and EHR centric
building blocks of integrated healthcare systems.
44
Table 1.
Consolidated Balanced Scorecard and Critical Success Factors Analysis
Perspective
Objectives
Quality Measures
Financial
HIS cost reduction
Q1 : Reduction in HIS
annual operating cost
per bed
Patient
Increased
responsiveness
Improved access to
healthcare
Expediting orders for
medical tests
Q2 : Reduction in
patient wait time for
services
Q3 : Increase in patient
satisfaction with
healthcare services
Internal
Improvement in
Clinical data services
Treatments protocols
Patient safety
Security of
healthcare data
Q4 : Reduction in
clinical data errors
and adverse events
Q5 : Compliance with
HIPPA for safety,
security and privacy
of healthcare data
Innovation,
Learning
Adoption of new
technology
EHR tools and
techniques
Q5 : Meeting HIPPA
standards for EHR
45
Actions
EHR-centric building blocks as
critical success factors
C4 : IS management of patient
records with cost effective
viable electronic repositories
C5 : Reengineering, CQI of care
with executive decision
support functionality
C5 : Continuum of care through
strategic plan of HIS use
C6 : HIS connectivity for
facilitation of communication
and coordination
C9 : Remote patient data access
and management
C10 : Patient/end user awareness
of EHR utility
C11 : EHR functionality to
prevent clinical negligence
and adverse events
Identification of relevant
environmental factors
C2 : Managed care, hospital bed
size, affiliation status
C3 : HIS structural functionality
C5 : HIS strategic use
C6 : HIS connectivity
C8 : Patient safety, data security
tools
C1 : Physician HIS responses
C5 : HIS learning perspectives to
educate users
C7 : Application of HIS support
tools
This study proposed the above described critical success factors as potential drivers of
widespread adoption of EHR systems. The Committee on the Quality of Healthcare in America
(IOM, 2001) recommended the following key aims of healthcare quality:
1.
2.
3.
4.
5.
6.
Healthcare safety: avoiding injuries to patients from the care that is intended to
help them.
Effective: providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those who will not benefit (i.e.
avoiding under use and overuse);
Patient-centered: providing care that is respectful of and responsive to individual
patient preferences, needs, and values and ensuring that patient values guide all
clinical decisions;
Timely: reducing waiting and sometimes harmful delays for both those receiving
care and those who give care.
Efficient: avoiding waste.
Equitable: providing care that does not vary in quality based on personal
characteristics.
These key aims of healthcare quality support the EHR centric five quality goals described
in Table 1.Also, these key aims are in accordance with the U.S. HIPAA focus of security,
privacy and standards for electronic submissions, and exchange of healthcare information,
(HIPAA, n.d.; Moore & Wesson, 2002). At present, most of the EHRs are still in their infancy,
and do not consider workflow at various levels of the healthcare systems (Fleming, 2005). The
conceptual model has filled this void by hypothesizing about both mechanisms and magnitudes
of effects of EHR through its critical success factors. Also, the conceptual model has attempted
to develop interoperability and robust information exchange networks, which is essential to
achieve healthcare goals in the opinion of Hillestad, Bigelow, Bower, and Girosi (2005). The
strategic contingency theory based conceptual model exploited HIS and implicit internal and
external features of healthcare organizations and their abilities as critical success factors of EHR
systems. According to Hillestad et al. (2005, p. 1110), "communication, coordination,
46
measurement, and decision support are potentially high-leverage areas for improving
healthcare."
The study used the CSF approach with in-depth analysis of various factors derived from
the building blocks of integrated healthcare systems as described in Figure 1, to assess business
processes of healthcare organizations while implementing EHR. This has provided an insight for
developing HIS framework, and identifying opportunities to improve HIS performance in terms
of healthcare quality. The fundamental assumption was, EHR would offer the possibility of cost
effective healthcare quality improvement through HIS integrity, as put forth by Mantas (1992).
Thus, EHR implementation is not just an installation of electronic tools and use of technology,
but also an opportunity to transform the healthcare organization and improve healthcare quality.
IOM (2003a), recommended information and data storage, order entry and management,
decision support, electronic communication connectivity, patient support, administrative
processing, and reporting as the key functions of EHR. The conceptual model built on the above
premises is a linkage between key functions and drivers of EHR implementation (Figure 1) with
predefined healthcare quality goals (Table 1). The model encompasses HIS integrity and
contingency factors of healthcare organization such as organizational size, resources, managerial
perspectives, HIS planning, development, and strategic management, healthcare providers'
adaptiveness, market, and regulatory constraints during EHR implementation decision-making.
Thus, referring to the strategic contingency theory and EHR-centric building blocks of an
integrated healthcare system, the conceptual model in this study proposed critical success factors
to capture environmental determinants, organizational determinants, and innovational
determinants as described in Figure 2.
47
C1 : Physicians' and healthcare

providers' responses to HIS
systems and technology.
C2 : Healthcare
organization
internal, external
environmental factors
C2 a: Bed
size
C4 : IS management of
patient records with
electronic repositories of
viable information
C5 : Strategic HIS usage
(operational characteristics,
learning perspectives, executive
decision support functionality
process reengineering, quality
management)
C2 b :
Affiliation
status
EHR
implementation
for healthcare
quality
C2 c: Managed
healthcare
programs
C6 : HIS
connectivity
(facilitation of
communication
and coordination)
C8 : Patient/end user
awareness of
EHR functionality
and utility
C7 : EHR compatible
supplementary technology
C7 a: Other
technology
applications
supporting
EHR
systems
C3 : Healthcare
organization
basic functionality (HIS
structural functionality)
C7 b : Patient safety
software applications
C7c: Electronic
data security
tools
Healthcare
quality
perspectives,
measures/goals
C9 : EHR
functionality to
prevent clinical
negligence and
adverse events
C 7d : Remote patient data

access and management
Financial
perspective
Q1 : HIS_Cost effectiveness
Q2 : Reduction in patient
waiting time for clinical or
healthcare services
Patient
perspective
Internal
perspective
Q4 : Reduction in
clinical data errors
Q3 : Increase in patient
satisfaction with
healthcare services
Innovation and
learning perspective
Q5 : HIPAA compliance
(meeting EHR national
standards, patient safety,
security and
privacy of health data )
Figure 2. The conceptual model of Electronic Health Record centric healthcare quality
48
Thus, the conceptual model presented in Figure 2 has proposed a guideline for measuring
performance of the healthcare systems in a complex and changing environment by incorporating,
along with financial indicators, the quality clinical outcomes, patient safety, and security through
EHR systems with HIS integrity. Such approach involved simultaneous consideration of multiple
factors at multiple levels for cost effective healthcare quality perspectives by influencing HIS in
general, and EHR implementation in particular. Based on the conceptual model and log
transformed linear and logistic regression technique for data analysis, this study illuminated
cause-and-effect relationships of the key processes as critical success factors of EHR derived
from the building blocks of integrated healthcare systems for healthcare quality. The conceptual
model can be useful to healthcare managers to quantify a link between tactical measures and
EHR goals of healthcare quality. Data availability, operationalization of dependent and
independent variables for data measurement, and proposed techniques of data analysis based on
the conceptual model are discussed in the following sections.
Measurement of Variables
In view of the conceptual model depicted in Figure 2, this study addressed the analytical
quantitative research methodology with descriptive and inferential statistical analysis of the
healthcare industry data. An individual community hospital was considered as a unit of analysis.
The research work involved a longitudinal design with a majority of the multivariate data sets
examined over an extended time series (Robson, 2002).
The population data consisted of all registered hospitals in the U.S. as healthcare
providers. According to AHA (2005, para. 4), "registered hospitals are those hospitals that meet
AHA's criteria for registration as a hospital facility and this includes AHA member and
49
non-member hospitals." The sampling plan for this study involved valid secondary survey data
on the U.S. healthcare providers with multivariate data variables. As per Miles and Huberman
(1994), pragmatic operationalization of research requires economy, convenience, and
interpretability of results. The sample data sets in this study consisted of The American Hospital
Association (AHA) Annual Survey of Hospitals, and Dorenfest integrated Healthcare Delivery
Systems Database from 1999 through the most recent comparable yearly databases that were
available at the time of this study. AHA datasets were used to identify hospital trends in
utilization, personnel, and finance. The Dorenfest IHDS database was used to perform
descriptive and inferential statistical analysis. These data sets are updated annually and provide
detailed information about the hospital characteristics and the healthcare information technology
programs of approximately 30,000 healthcare facilities associated with almost 1,500 integrated
healthcare delivery systems (IHDS) and provide a source of rich references of IT efforts of
healthcare providers and organizational characteristics.
The AHA data collection procedure involves data validation at several levels and
consistency and internal edit checks to assure the integrity of the submitted data. The participants
in the Dorenfest data collection instrument includes chief information officers and directors of
the information systems, planning, and marketing at the integrated health care delivery systems,
as well as representatives from the vendors of automation products and services. The Dorenfest
database presents profiles of each healthcare organization as accurately as possible by
conducting independent and in-depth research, consulting healthcare industry experts, and
collecting experiences by interviewing the top planning, marketing, and information systems
officers of the integrated health care delivery systems. As a result, these databases are recognized
50
as authentic source of healthcare information systems by many academicians, as well as by

leading HIT companies, market leaders, and hardware and software vendors (HIMSS, n.d.b).
In view of the conceptual model presented in Figure 2, at the time of study, no data was
available to this writer for measuring some healthcare quality indicators: patient waiting time for
healthcare or clinical services (Q2 ), patient's satisfaction of healthcare services (Q 3 ), reduction in
clinical data errors (Q 4 ), and some critical success factors such as Management of patient records
through IS (C4 ), remote patient data access and management (C 7d), patient awareness of EHR
functionality (C8 ), and data on prevention of clinical negligence and adverse events through HIS
(C 9 ). Hence, the data analysis in this study focused on the remaining CSFs described in Figure 2,
namely-C1 , C2 , C3 , C4 , C6 , C7a C7b, and C7c as explanatory variables, and the three quality goals:
reduction in HIS cost (Q 1 ), and HIPAA compliance (Q 5 ) as dependent variables. Also, at the time
of this study, for some data variables described in the conceptual modelnamely HIPAA
compliance (Q5 )--and for some critical success factorsnamely physician usage of HIS (C1 ),
strategic usage of IT with learning perspectives (C 5 ), technology applications (C7a), utilization of
patient's safety applications (C 7b), and electronic data security issues (C 7c)only two years of
data during 2002 and 2003 was available. Hence, for these variables and for the regression
analysis based predictive model, this study used the two years data sets. For descriptive statistics
on all other data variables, the study used the most recent longitudinal five years available data
during the year 1999 to 2003 from the Dorenfest database and the AHA survey.
A unit of analysis in this study was a community hospital that is defined as "all
nonfederal, short-term general, and other special hospitals that include obstetrics and
gynecology; eye, ear, nose, and throat; rehabilitation; orthopedic; and other individually
51
described specialty services; and nonfederal short-term academic medical centers or other
teaching hospitals. However, definition excludes those hospitals that are not accessible by the
general public, such as prison hospitals or college infirmaries"(AHA, 2005, para 5).
In view of the strategic contingency theory as described in Chapter 2, with a focus on
healthcare quality improvement through EHR implementation, this study considered the generic
integrated model based context, structure, and quality variables of the healthcare organization.
According to the IOM (2003a), key functions of EHR-centric healthcare systems are storage of
health information data, efficient administrative processing, decision support, electronic
communication, connectivity, and patient safety. The research literature indicates that a systems
approach to the strategic contingency theory incorporates multiple variables that affect an
organization's performance characteristics (Drazin & Van de Ven, 1985; Meyer, Tsui, &
Hinings, 1993). Burton and Obel (1998) pointed that multidimensional strategic contingency
approach considers not only the traditional contingency factors of environment, strategy,
technology, and size, but also management preferences in view of information processing
capacity of the organization. Therefore, in the opinion of this researcher, a multidimensional
strategic contingency approach was suitable to this study.
In response to the research questions described earlier, the study considered the two
variables. Healthcare quality was considered as a dependent variable. IS literature indicates that
IS has facilitated organizations across many industry segments in addressing various business
challenges and achieving a level of sustainable competitive advantage (Croasdell, 2001; Thorne
& Smith, 2000). HIS could provide financial and qualitative benefits to the healthcare industry
(Wickramasinghe, Fadlalla, Geisler, & Schaffer, 2003). Hence, strategic HIS management for
52
successful EHR implementation was considered an explanatory dependent variable that

implicitly involves HIS integrity; organizational internal and external environmental factors and
operational characteristics; and technological innovations. As described in Chapter 1, according
to Maffei (1997), the focus of HIS integrity is on structural functionality (system ability to
automate), connectivity (capability of IS systems for communication and coordination among
various elements of the organization) and executive decision support functionality (ability of IS
to retrieve and manipulate IS data for meaningful decision making through process
reengineering, quality management, and learning perspectives of HIS usage). Mantas (1992)
emphasized HIS integrity to achieve healthcare quality results. The above descriptions of the
independent and dependent variables are qualitative in nature. As per the theory of statistics,
independent variables are those that are manipulated, and dependent variables are only measured
or registered. Quantitative measures for the above-described dependent and independent
variables are operationalized as follows.
Dependent Variables
Healthcare quality. As described previously, healthcare quality in this study is partially
measured only through two quality goals as a multivariate performance index of reduction in HIS
cost and HIPAA compliance in the organization. Thus, the variables for healthcare quality
operationalized in terms of reduction in HIS cost, reduction in clinical data errors of healthcare
services, and HIPAA compliance follow.
HIS cost factor (Q1). A traditional ROI analysis emphasizes the financial impact of
operating expenses with gains in revenue from the service delivery (Rosenstein, 1999). Thus, if
projected revenue gains exceed costs, the investment is justified, and if funds are available, then
53
capital is provided for the investment. However, in healthcare services, benefits are usually
found in cost reduction rather than revenue enhancement (Rosenstein, 1999; Scott, 2003; Wan,
2002). Therefore, in this study, HIS cost factor (IS-Cost) was measured as a ratio type variable in
terms of IS system annual operating cost per hospital bed size. Such a variable of ratio type
measurement is quantitative in nature, which allows meaningful mathematical computations on it
(Larson & Farber, 2003). It is expected that EHR implementation with HIS integrity would
reduce costs associated with patient record keeping, due to elimination of transcription,
prevention of test duplication, and automated sharing of patient information.
HIPAA compliance (Q5 ). HIPAA suggests administrative simplification rules that may
encourage HIS to support coordination and communication within and across the healthcare
systems (Burton, Anderson, & Kues, 2004). Hence, healthcare organization's HIPAA
Compliance (Hipaa_C) is described as a nominal variable with values defined as: Two for 100%
compliant, zero for 0% compliant or no response to HIPAA compliance, and one for some
progress and efforts in becoming HIPAA compliant. It is a variable of nominal type
measurement, which allows qualitative classification and is categorized using names, labels, or
indicator numbers (Larson & Farber, 2003). In this study, HIPAA compliance involved the
guideline of meeting national standards for EHR, patient safety, and security and privacy of
health data (CMS, 2005).
Explanatory Variables as Critical Success Factors
Physicians' usage of HIS (C 1 ). According to Larkin (2005), as physicians dictate about
80% of healthcare spending, EHR systems should be user friendly and usable to physicians and
other healthcare providers during the decision making process. With these perspectives, this
54
study described a variable for physician usage of HIS (Physicians_Usage) as a nominal variable,
in view of healthcare providers' various usage of IT in healthcare decision making. The variable
was categorized by assigning values zero through eight. Value one was assigned when software
use is not mandatory for physicians. Value two was assigned when IT support is not available to
physicians, value three was assigned when all or almost all physicians use IT systems, value four
was assigned when too little IT training is provided to physicians, value five was assigned when
IT usage is easier in the opinion of physicians and administrative staff members, value six was
assigned to physician response that IT usage/learning takes too much time, value seven was
assigned to physicians' reluctance to change and adapt to IT usage, and value eight was assigned
to physicians' other responses that include HIS systems are not user-friendly, and not beneficial.
Value zero was assigned to all other situations of no response to the survey on healthcare
providers' various usage of IT in healthcare decision making.
Healthcare organization's size (C 2a ). Scott (2003, p. 263) mentions that an organization's
size is a "variable at the interface of organization and environment. As per Scott (2003), size of
an organization is its "internal feature shaped by external conditions and market requirements
and determines the organization's other structural variables" (p. 263). The number of beds in a
hospital reflects the physical capability of the healthcare organization to perform the tasks.
According to the World Health Organization (WHO, 2000a), a regularly maintained and staffed
bed provides full-time care of a succession of inpatients within various medical care units of the
hospital, which reflects structural characteristics and indicates the hospital's physical and
functional capacity. Hence, this study used the number of staffed beds in the healthcare facility
(BedSizeStaffed) as a measure of discretionary resources available to the healthcare
55
organization. For data analysis, staffed bed size was classified into three categories: Small,
Medium, and Large, as described in the Appendix A.
Affiliation status (C 2b ). As per the strategic contingency theory, market forces may
interact with the traditional organizational structure, and the form of an organization would
reflect the dominant imperative (Miller, 1992). Hence, considering organizational internal
characteristics, structural components, and environmental fit, a healthcare organization facilities'
this study described the affiliation status (Affiliation_status) as a nominal variable with five
categories: Owned, Leased, Managed, Affiliated and Other, which included Contracted, Joint,
Joint Venture, and Sponsored.
Managed healthcare (C 2c). Managed healthcare is one of the environmental factors
associated with broader structure of the healthcare organization (Wholey, Feldman, Christianson
& Engberg, 1996; Lin & Wan, 1999). According to the literature review, the focus of managed
healthcare is on cost reduction and quality improvement of the healthcare. Growth in managed
healthcare programs is affecting healthcare organizations operations and performance (Wang,
Wan, Burke, Bazzoli & Lin, 2005). Hence, based on Dorenfest IHDS data sets, a quantitative
ratio type variable for managed healthcare (Mng_Hcare) was described as the aggregate
percentage of revenue from managed care organizations, Medicare, and Medicaid that the
healthcare delivery system owns.
Structural functionality (C 3 ). As per Barnett (1987), the primary aim of HIS is to
automate business functions of the healthcare organization through the organization's structural
composition. Hence, the study defined a quantitative variable for HIS structural functionality
(Struct) as available total number of facilities, which includes number of computers (PCs), IS
56
servers, and IS staff including managers, programmers, helpdesk personnel, IS system operators,
and others.
Strategic HIS usage (C 5 ). A common theme in the strategic contingency theory in the
organization management literature is that organizations must adapt to their environments if they
are to maintain or increase their effectiveness. Scott (2003) described adaptation as incremental
change in a given organizational system. Such an approach, according to Robbins (2003), often
assumes conscious rational choice and learning from self or other's experiences. Robbins (2003,
p. 562) proposed the five strategies, namely "education, communication, participation,
facilitation and support." to counteract resistance to change. Many researchers have
recommended integrating HIS by optimizing its functions through financial, clinical,
administrative, managerial and informatics integration (Lin &Wan, 1999; Lin& Wan, 2001; Wan
& Wang, 2003). In the opinion of Segars and Grover (1999), in order to be effective, HIS
planning must be strategic as well as highly participative. Also, such HIS planning should
involve executive decision support systems that facilitate managerial decision-making and IS
effectiveness by combining data and user-friendly software (Galliers & Leidner, 2003; Huber &
McDaniel, 1996). While learning organization and knowledge management promotes
mechanisms to encourage collection and dissemination of knowledge, change management
through behavioral strategy, structural strategy, and technical strategy supports the goal of
improved quality and performance of the organization (Quinn, Mills, & Friesen, 1992).
With the above perspectives on strategic HIS implementations, the study considered
healthcare organization's operational characteristic in terms of strategic usage of HIS
(Strat_Usage) as one of the critical success factors while implementing EHR for healthcare
57
quality. This variable was described as a nominal variable with categorical values ranging from
one to four. Value one was assigned to no strategy; value two was assigned to communication,
education, and training strategy; value three was assigned to improve accessibility and usability
strategy; value four was assigned to planning strategy to replace, upgrade, or purchase new IS
and software; value five was assigned to not an issue: 100% of physicians and administrative
staff use IT, and value six was assigned to no response. Thus, the variable Strat_Usage used in
this study encompasses process reengineering strategies during executive decision-making, HIS
perceived importance, learning perspectives, and technological and cultural implications in the
healthcare organization.
Connectivity (C 6 ). Wan (2002) suggested the HIS connectivity aspect of facilitation of
communication and coordination. Also, as per Galliers and Leidner (2003), the focus of HIS
connectivity should be on adequate coordination among functional departments with supporting
networks and client server architecture that would provide the benefits of synergy and
effectiveness to the users. Hence, this study described a variable for HIS connectivity (Conct) as
IHDS networking and integration status. It was a dichotomous nominal variable with value one
for in use status of IHDS networking and integration and value zero for not in use status of IHDS
networking and integration.
Technology applications (C 7a ). According to Scott (2003), complexity, uncertainty, and
interdependence are the most important dimensions in view of the technological and structural
complexity of the organization. "The strategic contingency theorists emphasize flexibility of
connectionsloose couplingbetween technology and structure" (Scott, 2003, p. 245). As
discussed by Fadlalla, and Wickramasinghe (2004, p. 67), "adopting and adapting of
58
technologies and new techniques throughout the healthcare industry appears to be the way not
only to stem the escalating costs currently facing this industry but also to provide a means to
address other challenges such as poor quality and HIPAA compliance." Hence, for achieving
healthcare quality through EHR support systems, the study considered the status of the other
clinical data management application systems (Tech_Appl) as a critical success factor. It was
described as an explanatory nominal variable that has three possible categories of status:
automated and self managed, automated and contracted, and not automated. Technology affects
the characteristics of organizational structure, the division and routinization of work associated
(Scott, 2003). Thus, the study considered the variable Tech_Appl as one of the critical success
factors that may affect organization's structure and healthcare quality while implementing EHR.
Patient's safety (C 7b ). In view of the IOM (2001) recommendations of Healthcare Safety,
the study described a variable P_Safety in terms of avoiding injuries and utilization of patient
safety software applications in the healthcare organization. It was an explanatory dichotomous
variable with value one for in use and value zero for not in use. It was a variable of nominal type
measurement, which can be categorized using names, labels, or indicator numbers to allow
qualitative classification of data (Larson & Farber, 2003).
EHR relevant data security (C 7c). As per IOM (2003a), electronic healthcare data security
is one of the key functions of EHR-centric healthcare systems. Therefore, this study described
the status of EHR related Clinical Data Security issues (D_Safety) in the healthcare organization
as an explanatory dichotomous nominal type measurement variable with value one for
nonexistence of data security issues or problems, value two for no response, and value zero for
59
existence of data security issues or problems in the healthcare organization. The Appendix A
presents definitions and descriptions of these data variables.
Validity of the Secondary Survey Data Instrument
Cooper and Schindler (2003) described three measurement criteria for evaluating a
measurement tool for data analysis: validity, reliability and practicality. According to Cooper and
Schindler (2003), validity refers to the degree to which the research instrument measures what it
is supposed to measure, reliability refers to the degree of accuracy or precision in measurements
that the instrument provides, and practicality is concerned with convenience, economy, and
interpretability of the research instrument. This study addressed the construct validity by
ensuring that the definition of each data variable and the applicability of the log transformed
linear and logistic regression model of statistical estimation has a strong theoretical basis. The
study addressed the content validity by ensuring representativeness or sampling adequacy of the
data. Cooper and Schindler (2003) mentioned that the sample instrument must contain enough
items or questions to represent the variable being measured as comprehensively as possible. The
internal validity is concerned with reducing or eliminating measurement errors in the instruments
used to collect data on variables. As per Cooper and Schindler (2003), researching secondary
sources is complex and challenging and it requires evaluation of the quality of the information.
With these perspectives, this study collected quite detailed secondary source data from the
authentic resources.
Data collection procedure in this study involved data validation at several levels and
internal edit checks to assure data integrity. Also, while applying the regression model to the data
set, the analysis followed the appropriate guidelines of statistical techniques for missing data
60
cases in the study. AHA data sets and Dorenfest IHDS database used in the study are updated
annually. These data sets provide detailed information about characteristics and healthcare
information technology programs of the healthcare organizations in the U.S. healthcare industry.
Thus, a use of an authentic secondary sample survey instrument with relevant data
variables justified internal validity. The external validity refers to a degree to which, the results
of the research study are generalizable to a larger population. The study ensured the external
validity using a sufficiently large size authentic longitudinal time series data. Thus the
conceptual model was built on a valid theoretical base of the strategic contingency theory of the
organizational management literature. Also, an appropriate secondary survey instrument
provided a low cost form of longitudinal multivariate statistical data analysis with reliability,
generalizability, and replicability of the survey instrument.
Hypothesis Testing
The quantitative analytic methodology first validated the assumption that different sizes
of healthcare organizations have significantly different critical success factors and organizational
characteristics while considering EHR adoption for healthcare quality. The relevant tests of
hypotheses referring to the conceptual model in Figure 2, and data variables in the Appendix A,
are described as follows:
The organization literature quite often indicates that larger organizations have more
resources and opportunities to innovate, experiment, and successfully implement new technology
and projects (Banaszak-Holl, Zinn, & Mor, 1996; March, 1991). Mandate and size of the
organization influence the hospital structure, strategies, and IT diffusions (Chau & Tam, 2000;
61
Pink, et al., 2001; Shortell & Zajac, 1990). Therefore, considering the influence of hospital size
during EHR implementation strategies, this study postulated the following two hypotheses.
H1 : There is a difference in the healthcare quality profiles across small, medium, and
large size healthcare organizations in the U.S. healthcare industry.
H2 : There is a difference in the critical success factors across small, medium, and large
size healthcare organizations in the U.S. healthcare industry.
The study used the techniques of descriptive statistics, analysis of variance, and
discriminant score analysis (Lattin, Carroll, & Green, 2003), to evaluate significant differences in
the healthcare organizations' quality profiles and critical success factors for various sizes of the
organizations. Consequently, assuming the validity of the conceptual model, referring BSC and
CSF analysis from Table 1, the conceptual model from Figure 2, and descriptions of the data
variables from the Appendix A, this study postulated the following tests of hypotheses for
various sizes of the healthcare organizations in the U.S. healthcare industry. The following
statistical tests of hypotheses were constructed to verify the relevance of critical success factors
of EHR centric healthcare quality according to the healthcare quality goals: HIS cost
effectiveness and HIPAA compliance. The other quality goals namely, reduction in patient
waiting time for clinical services, and reduction in the clinical data errors though described in the
conceptual model were not included in the tests of hypotheses due to a lack of measurable data
on these variables at the time of this study.
H3 : Physicians' usage of HIS is likely to affect the healthcare quality in terms of HIS cost
effectiveness, and HIPAA compliance.
62
H4 : Healthcare organization's affiliation status is likely to affect the healthcare service

quality in terms of HIS cost effectiveness and HIPAA compliance.
H5 : HIS integrity component structural functionality of the healthcare organization is
likely to affect the healthcare quality in terms of HIS cost effectiveness and HIPAA compliance.
H6 : A higher percent of revenue from the managed care programs that the healthcare
delivery system owns is likely to improve the healthcare quality in terms of HIS cost
effectiveness and HIPAA compliance.
H7 : Strategic HIS usage with learning perspectives of the organization is likely to
improve the healthcare quality in terms of HIS cost effectiveness and HIPAA compliance.
H8 : HIS integrity component connectivity of the healthcare organization is likely to
improve the healthcare quality in terms of HIS cost effectiveness and HIPAA compliance.
H9 : Technology status of the clinical data management application systems to support
EHR is likely to affect the healthcare service quality in terms HIS cost effectiveness, and HIPAA
compliance.
H10 : Utilization of patient safety software applications in the healthcare organization is
likely to affect the healthcare service quality in terms of HIS cost effectiveness HIPAA
compliance.
H11 : Status of the clinical data security issues/problems relevant to EHR is likely to affect
the healthcare service quality in terms of HIS cost effectiveness and HIPAA compliance.
For ratio or interval type data variables, descriptive statistical analysis was performed,
which involved summarization and display of the data (Larsen & Farber, 2003). Descriptive
statistics included use of the measures of central tendency, variation, and skewness to summarize
63
the healthcare data on organizational characteristics and to understand their statistical data
distributions. For nominal/categorical data variables, percentage frequency distributions were
constructed. Also the study performed Analysis of Variance (ANOVA) and discriminant
analysis, in addition to the descriptive statistics, to test the hypotheses H1 and H2, which allowed
comparison of differences between organizational characteristics, quality profiles, and critical
success factors for different sizes of the healthcare organizations (Lattin, Carroll, & Green,
2003). The ANOVA is useful to compare and determine whether the means of two or more
groups are not significantly different. Thus, the study used ANOVA for scale type dependent
variables on bed size as factor, and used discriminant analysis for nominal type dependent data
variables on bed size as factor. An important first step in the ANOVA of variance is establishing
the validity of assumptions. One assumption of ANOVA is that the variances of the groups are
equivalent, which can be verified using Levene statistic, while in general, F statistic establish
that there is or is not a difference between group means (Cooper & Schinder, 2002; Larson &
Farber, 2003; Lattin, Carroll, & Green, 2003). The discriminant analysis test does not make any
assumptions about independent or paired observations in a data. However, this study verified the
validity of the Chi square test in discriminant analysis, noting that it should have at least 20
cases, and not more than 20% of data cells should have expected values less than 5 (Cooper &
Schinder, 2002). Next, based on EHR centric critical success factors for the healthcare quality,
predictive regression equations were constructed. Also, inferential statistical techniques with the
log transformed linear and logistic regression analysis used to test the remaining hypotheses as
discussed below.
64
Log Transformed Linear and Logistic Regression Model

Inferential statistical analysis involves sample survey based analysis to draw conclusions
about the original population data (Larsen & Farber, 2003). This study conducted an inferential
statistical analysis for testing the hypotheses that are described before. Based on the perceived
critical success factors of healthcare quality, this study proposed a predictive log transformed
linear and logistic regression model of healthcare quality. The results of the analysis have
provided a predictive value of the healthcare quality as a composite performance index of
HIPAA compliance, and cost effectiveness of HIS. Each of these quality measures were
separately evaluated for different bed sizes considering each perceived critical success factor.
The dependent variable- HIPAA compliance as described in the Appendix A is a multinomial
variable with values: 100 percent compliant as two, zero percent compliant as zero, and
Administrative or IT efforts in progress for becoming HIPAA compliant as value one. The
dependent variable (IS_cost) is an annual HIS cost per hospital bed size.
The proposed explanatory independent variables described in the Appendix A were
derived from the critical success factors in terms of HIS integrity, and the organization's internal
and external environmental factors and operational characteristics, which may not necessarily be
normally distributed. This is because this study described HIS structural functionality as a
discrete quantitative variable, HIS connectivity as a dichotomous variable with values zero and
one, the variable-physician's HIS usage defined as a nominal variable for healthcare providers'
usage of IT, taking values one to 10 as defined earlier, and the HIS strategy of IT usage with
learning perspective of the organization described as a nominal variable, taking values one to six,
as defined earlier. Also, the study described explanatory variable technology applicability, which
65
refers to a status of other clinical data management application systems supporting EHR, as
categorical variable, utilization of patient safety software applications in the healthcare
organization and status of the clinical data security issues or problems as dichotomous nominal
variables. The variable managed healthcare was described as a quantitative ratio variable, which
was an aggregate percent of revenue for the various managed care programs that the healthcare
delivery system owns. The explanatory variable healthcare facilities' Affiliation_status was
defined as a categorical variable as given in the Appendix A.
Thus, explanatory/ independent variables in this study were a mix of nominal,
categorical, and ratio type data variables. Rather than using a traditional normal distribution
based ordinary least square (OLS) regression model, the study proposed a log transformed linear
and logistic regression model to establish a predictive relationship between the dependent and
the independent or the explanatory variables. Log transformed linear regression is useful to
model the value of a dependent scale variable-HIS annual operating cost per bed size, based on
its linear relationship to one or more explanatory /independent variables. The linear regression
model assumes that there is a linear, or "straight line," relationship between the dependent
variable and each explanatory independent variable/predictor. This relationship is described in
the following formula:
Y= a + b1X1 + b2X2 +.....+bnXn + e. In this equation, Y is a dependent scale variable,
which is a healthcare quality indicator in the conceptual model. X1, X2,, Xn are the
explanatory independent variables, which are the critical success factors described in the
conceptual model. The values of, b1, b2,., bn are the regression coefficients determined by the
linear regression equation, and e is the error term in the estimation. For the purpose of testing
66
hypotheses about the values of model parameters, as per Lattin et al.(2003), the linear regression
model also assumes the following: The error term has a normal distribution with a mean of zero,
the variance of the error term is constant across cases and independent of the variables in the
model, and the value of the error term is independent of the values of the variables in the model.
In view of these facts, this study verified the applicability of the regression technique, prior to the
data analysis of dependent scale variables. In case of lack of some of these assumptions, Logtransformed values of the dependent scale variable are useful for linear regression analysis. As
per Lattin et al. (2003), such log transformed linear regression model works better with normal
variables. For more precise regression estimates, a collinearity diagnostics was performed.
Logistic regression is most useful to model the event probability for a categorical
response variable such as HIPAA compliance in the conceptual model. Garson (n.d., para. 4)
described, "Logistic regression has many analogies to OLS regression and can be used as a
predictive model." However, as per Garson (n.d.), the advantage of logistic regression is that,
unlike OLS regression, logistic regression does not assume linearity of relationship between the
dependent and independent variables; it does not require normally distributed variables; and
variables in the logistic regression may be discrete, continuous, dichotomous, categorical, or a
mix of any of these. Also, as per Garson (n.d.), logistic regression does not assume
homoscedasticity; in other words, it does not assume equality of variance within each group of
independent variables.
Thus, logistic regression has less stringent requirements of data distributions. However,
as pointed by Garson (n.d.), logistic distribution requires that observations are independent and
that the logit (means natural logarithmic value) of the independent variables is linearly related to
67
the dependent variables. In view of these facts, the applicability of the logistic regression
technique was verified prior to the data analysis. Regarding adequacy of size of the sample data
used in logistic regression analysis, for multivariate regression model, Peduzzi et al. (1996)
recommends a minimum of 10 observations per parameter in the model. For the assumed 10
critical success factors of healthcare quality as the explanatory independent variables, and the
two healthcare quality indicators as the dependent variables as described in Appendix A, there
were 10 regression coefficients and one constant term in the regression model. Thus there were
11 parameters for estimation, which required 110 minimum data cases as per Peduzzi et al.
(1996). Also, Garson (n.d.) suggested no more than one independent per 10 cases in a data. So
for 10 independent variables, as per Garson (n.d.), approximately at least 100 observations
required to perform confirmatory analysis and investigate using the more predictive capability of
the multivariate logistic regression model. As the two years data sets used in the regression
analysis study contained over 2000 cases, the sample size was quite adequate for the data
analysis. Also, the analysis classified the data into small, medium, and large bed size category
healthcare organizations with a sample size over 200 in each category. As the logistic regression
model is not tolerant of missing data (Garson, n.d.), incomplete responses from the secondary
survey data sets were be discarded.
In the logistic regression model, what is predicted from a knowledge of relevant
independent variables is not a precise numerical value of a dependent variable, but it is a
probability value (p) that dependent variable takes particular value (Garson, n.d.). Here, p cannot
be mathematically expressed as a linear function of independent variables, because such linear
combination may result in an unrealistic probability value more than 1, which is never true. This
68
problem is overcome by making a logistic transformation of p, also called taking the logit of p.
Logit (p) is the logarithm to the base e of the odds or likelihood ratio that the dependent variable
takes a particular value. In symbols, this is defined as: logit (p) = log (p/ (1-p)). Here, p being a
probability can only range from values of zero to one (Larson & Farber, 2003). However, the
transformation logit (p) ranges from negative infinity to positive infinity values (Garson, n.d.).
Such logistic regression technique involves fitting to the data an equation of the form:
Y= logit (p) = a + b1X1 + b2X2 +.....+bnXn. In this equation, Y is a dependent variable,
which is the healthcare quality indicator in the conceptual model. X1, X2,, Xn are the
explanatory independent variables, which are the critical success factors described in the
conceptual model. The values of, b1, b2,., bn are the regression coefficients determined by the
logistic regression equation.
Also, according to Cooper and Schindler (2002), statistical goodness-of-fit tests, such as
model chi-square, were used as indicators of model appropriateness. All null hypotheses were
tested at the value of alpha = 0.05 level of significance, which assured 95 percent confidence
about the statistical inferences drawn from the results of the tests of hypotheses (Larson &
Farber, 2003). The statistical data analysis was performed using the software Statistical Package
for Social Sciences-Graduate Pack Version 13.0 (SPSS-Grad Pack 13.0).
Possible Research Study Implications and Recommendations
The research objectives were to identify the critical success factors and quantify the
importance of each factor to achieve cost effective and value added healthcare quality while
implementing EHR. The findings were based on comparing and contrasting the quantified results
through descriptive and inferential statistical techniques, a regression predictive model, and the
69
tests of hypotheses based on EHR-centric critical success factors of healthcare quality for
different sizes of healthcare organizations. It has provided an understanding of how EHR
implementation decisions would vary with the healthcare organization size and various
predefined variables and organizational characteristics, while achieving cost effective value
added quality goals of the healthcare clinical services. The findings have provided a planning
structure to healthcare providers and EHR vendors to work together for betterment of healthcare
information systems (HIS) in view of the predefined healthcare quality. The particular
implications of the critical success factors of healthcare quality through health information
management (HIM) in this study have provided guidelines for HIS planning strategies. Also, it
provided a knowledge about how to deal with the organization's structural, technological,
cultural, and decision-making factors, if any may be impeding the healthcare quality goals. By
learning about the critical success factors, healthcare professionals, administrators, and decision
makers could increase their knowledge base and incorporate HIM strategies to promote the
attainment of healthcare quality goals through EHR implementations. The validated regression
model of this study could be used to specify the causal relationships between healthcare quality,
HIS integrity, and associated contextual factors of healthcare organizations while adopting EHR.
The practical implication of EHR implementation could be germane to the strategies and
performance of the healthcare organization and the healthcare industry
The conceptual model in this study with BSC and CSF analysis contained measures on
quantitative and qualitative data variables. In the future, healthcare management should extend
the model to construct a comprehensive view of operational results of the EHR project by
creating a composite performance index of healthcare quality and weighting of quantitative and
70
qualitative indicator variables of each quality measure. Such weighting criteria may depend on
planned strategies and goals of the healthcare industry. As EHR implementation and HIS
systems would become more mature with the initiatives of the U.S. government for progress
toward standardized health information infrastructure, this study could be replicated in the future
with inclusion of longitudinal data for all the critical success factors that are proposed in the
conceptual model. Thus, in future, data analysis could be extended to include the remaining critical
success factors proposed in the conceptual model, namely Reduction in clinical data errors;
electronic repositories with viable information; patient awareness of EHR functionality; remote
patient data access; and prevention of clinical negligence and adverse events. Such
comprehensive data analysis could quantify the healthcare quality measures, such as reduction in
a patient's waiting time for healthcare services and increase in a patient's satisfaction associated
with widespread adoption and IS management of EHR.
71
CHAPTER 4. DATA COLLECTION AND ANALYSIS

In view of the conceptual model described in Chapter 3, this study addressed the
analytical quantitative research methodology with descriptive and inferential statistical analysis
of healthcare industry data. An individual community hospital was considered as a unit of
analysis. The population data on healthcare providers consisted of all registered hospitals in the
United States (U.S.). The sample data sets used in this study consist of the American Hospital
Association (AHA) annual survey of hospitals, and the Dorenfest Integrated Healthcare Delivery
Systems (IHDS) databases. The AHA datasets from 1999 to 2004 were used to identify hospital
trends in utilization, personnel, and finance and the Dorenfest IHDS database during 1999 to
2003 was used for descriptive statistical analysis. These were the most recent comparable yearly
databases available at the time of this study. While most of the descriptive data analysis
considered five years data, for some data variables, data from only 2002 and 2003 was available,
which was used for inferential statistical analysis and regression models. The output summary of
the data analysis, generated using the Statistical Package for Social Sciences (SPSS) version
13.0, has been presented in this chapter, while the detailed output has been presented in
Appendix B. The following section presents an overview of the trends in utilization, personnel,
and finances from 1999 to 2004 for AHA registered hospitals, and the descriptive statistics on
the dependent and independent variables as per the conceptual model of this study.
72
Data Descriptives
The Total Hospitals During 1999-2004 in the U.S.

5,900
Hospitals
5,850
5,800
5,750
5,700
5,650
1999
2000
2001
2002
2003
2004
Year
The Beds (in Thousands) During 1999-2004 in the U.S

Hospitals.
1000
990
Beds
980
970
960
950
940
930
1999
2000
2001
2002
2003
2004
Year
Figure 3. The number of beds and hospitals for American Hospital Association-registered
hospitals.
Note. Numerical Data Source AHA (2006)
73
The Bed Size Category During 2000-2004

in the U.S. Hospitals
3,000
Bed Size
2,500
2,000
< 100 = Small

100-500 = Medium
500 & Above = Large
1,500
1,000
500
0
2000
2001
2002
2003
2004
Year
The Admissions (in Thousands) During 1999-2004

Admissions
38,000
37,000
36,000
35,000
34,000
33,000
32,000
1999
2000
2001
2002
2003
2004
Year
Figure 4. The bed size category and patients' admissions for American Hospital
74
The Out Patients' Visits (in Thousands) During 1994-2004

680,000
Out Patients' Visits
660,000
640,000
620,000
600,000
580,000
560,000
540,000
520,000
1999
2000
2001
2002
2003
2004
Year
Full Time Equivalent Personnel ( FTE ) in Thousands
During 1999-2004 in the U.S. Hospitals.
4,800
4,700
FTE
4,600
4,500
4,400
4,300
4,200
1999
2000
2001
2002
2003
2004
Year
Figure 5. The Out patients' visits & full time equivalent personnel for American Hospital
75
The Total Expenses (in Millions of Dollars) During

1999-2004 in the U.S. Hospitals
Expenses
$600,000
$500,000
$400,000
$300,000
$200,000
$100,000
$0
1999
2000
2001
2002
2003
2004
Year
Net Revenue & Expenses
Net Revenue & Expenses-Totals in Millions of Dollars

(Includes Inpatient and Outpatient) During 2000-2004
in the U.S.Hospitals
$600,000
$500,000
$400,000
Revenue
Expenses
$300,000
$200,000
$100,000
$0
2000
2001
2002
2003
2004
Year
Figure 6. Total expenses and revenue for American Hospital Association- registered
hospitals.
Thus, data trends displayed in Figure 3, Figure 4, Figure 5 and Figure 6 indicated that
during 1999-2004, there was a slight decline in the number of beds. However, except for the
small bed size category, the data trends indicated a continuous increase in the patients'
76
admissions, out patients' visits, full time equivalent staff, net revenue, and total expenses for the
AHA registered U.S.hospitals. Using the Dorenfest IHDS database, descriptive and inferential
statistical analysis was performed on the dependent and independent variables, described in the
conceptual model, as follows. Using the SPSS missing data handling procedure, incomplete or
missing responses observed in the database were eliminated during the analysis.
Table 2.
Secondary Survey Responses by Bed Size
Classified by Number of Staffed Beds During 1999-2003
Bed Size
Descriptive Category
Code
Number of IHDS
Less than 100
Small
395
Between 100-500
Medium
4388
500 & Above
Large
1860
Total Available
Missing Data
6643
0
484
Thus using the Dorenfest database, the bed size based classifications indicated a majority
of the IHDS hospitals lie in the medium size category (coded as value two).
For the dependent variables that correspond to the healthcare quality indicators in the
conceptual model, the means and standard deviations (SD) in the small, medium, and large
category of bed size were calculated as follows.
77
Table 3.
Healthcare Quality Descriptives for Small, Medium and Large Integrated Healthcare
Delivery Systems
# Dependent Variables
Small
Medium
Large
as Quality Indicators
Q1
HIS Annual
Mean 672227.36
Operating Cost
SD 2371596.87
in Dollars per Bed
Missing data code = 99
(Five years data for 1999-2003)
Q5 HIPAA Compliance Mean
0.77
for Safety, Security SD
0.42
and Privacy of
healthcare data
100% Compliant = 2,
0 % Compliant = 0,
Administrative/ IT efforts
in progress for becoming
HIPAA Compliant = 1
Missing data code = 99
(Two years data for 2002-2003)
Mean 687430.25 Mean 719899.47

SD 15610984.61 SD 9862195.90
Mean
SD
0.92
0.27
Mean
SD
0.94
0.23
Thus, Table 3 indicates a difference between mean and standard deviation values of the
healthcare quality indicators for small, medium, and large size healthcare organizations. The
results of data analysis indicated average HIS annual operating cost per bed, and HIPAA
compliance in the IHDS increased from small to medium to large category, while standard
deviation in these values increased from small to medium and then decreased from medium to
large category. A possible explanation is that higher bed size implied an increase in HIS Annual
operating cost per bed, but the variation in HIS annual cost decreased as the bed size increased
because HIS annual operating costs seemed to stabilize. Also, higher bed size, implied an
78
increase in HIPAA compliance, which suggests, while these quality indicators vary by hospital
size, as size increased, hospitals might have more stringent HIPAA compliance procedures. For
the independent/explanatory variables, the means and standard deviations (SD) in the small,
medium and large category of healthcare organizations observed as follows.
Table 4.
Descriptives of Electronic Health Record Centric Critical Success Factors of Healthcare
Quality
#
C1
Explanatory Variables
as EHR centric CSF
Physicians
Usage of HIS
Small
Mean
SD
3.41
2.01
Medium
Mean 3.80
SD 2.09
Large
Mean
SD
3.95
2.12
Code: Software-use is not mandatory = 1; IT support is not available = 2;

All/almost all use IT systems = 3 ; Too little IT training provided = 4; IT usage is
easier in the opinions of physicians and administrative staff = 5; The physician's
response that IT usage/learning takes too much time = 6; Physicians' reluctance to
change and adapt to IT usage = 7; Other responses-HIS are not user-friendly,
Unrecognized benefits of software = 8; Missing data code = 0. (Two years data
during 2002-2003)
C2b
Affiliation_
Status
Mean
SD
1.38
1.11
Mean 1.90
SD
1.64
Mean
SD
2.34
1.85
Code: Affiliation Status of Facility: Owned = 1; Leased = 2; Managed = 3;

Affiliated = 4; Other (Joint or Joint Ventured or Sponsored or contracted) = 5;
Missing data code = 0.(Five years data during 1999-2003)
79
C2c
Managed
Healthcare
Mean
SD
0.71
0.13
Mean 0.75
SD
0.14
Mean
SD
0.75
0.15
Aggregate percent of patient revenue referring Payor-MngCare-Total (Managed

care organizations), Payor-Medicare, Payor-Medicaid (public insurance).
Missing data code = 0. (Five years data during 1999-2003)
C3
HIS Structural Functionality: Available Number of:
Computers
Mean 224.00
SD 745.00
Mean 950.00
SD 1905.00
Mean 5551.00
SD 11402.00
IS Servers
Mean 66.00
SD 119.00
Mean 75.00
SD 146.00
Mean
SD
86.00
120.00
Mean
SD
104.00
318.00
IS Staff
Mean 24.00
Mean 43.00
SD
75.00
SD 107.00
Missing data code = 0 (Five years data during 1999-2003)
C5 Strategic
Usage of
HIS
Mean 2.08
SD 1.33
Mean 2.41
SD
1.28
Mean
SD
2.63
1.25
Code: No strategy =1; Communication, education and training strategy = 2;Improve

Accessibility and/or usability strategy = 3; Planning strategy to replace, upgrade,
purchase new IS systems/software = 4; Not an issue - 100% physician and
administrative usage of IT = 5; Missing data code = 6. (Two years data
during 2002-2003)
C6
HIS
Connectivity
Mean 0.88
SD 0.33
Mean 0.94
SD
0.25
Mean
SD
0.97
0.17
Code: Status of IHDS networking and integration In Use = 1; Not in Use = 0;

Missing data code = 99. (Two years data during 2002-2003)
80
Table 4.
Descriptives of Electronic Health Record Centric Critical Success Factors of Healthcare
Quality (Continued)
# Explanatory Variables
Small
Medium
Large
as EHR centric CSF
C7a EHR Supporting
Technology
Mean 0.14
SD 0.34
Mean 0.08
SD
0.29
Mean
SD
0.21
0.47
Code: Not Automated = 0 ; Automated and Self Managed = 1;Automated and

Contracted = 2 ; Missing data code = 99. (Two years data during 2002-2003)
C7b Utilization of
Mean 0.53
Mean 0.62
Mean
0.69
Patients Safety
SD 0.50
SD 0.49
SD
0.46
Software Applications
Code: In use = 1; Not in use = 0 ; Missing data code = 99. ( Two years data
during 2002-2003)
C7c Status of Clinical
Data Security
Issues
Mean 0.57
SD 0.50
Mean 0.54
SD 0.50
Mean
SD
0.68
0.47
Code: Non existence of data security issues/problems =1; Existence of data security
issues/problems = 0; Missing data code = 2. (Two years data during 2002-2003)
Thus, Table 4 indicates a difference between mean and standard deviation values of the
explanatory /independent variables for small, medium, and large category of the healthcare
organizations. The results indicated an increase in both average and standard deviation values for
these independent variables in the IHDS from small to medium to large category, while standard
deviation in these values decreased from small to medium to large category for these
independent/explanatory variables that correspond to the EHR-centric critical success factors
(CSF) of the healthcare quality. As discussed in Chapter 3, to further verify the significant
81
differences in the healthcare organizations' quality profiles and critical success factors across the
various sizes of the healthcare organizations, the study conducted an analysis of variance and
discriminant score analysis as per Lattin, Carroll, and Green (2003). Validity of the Chi square
test in discriminant analysis was verified, noting that it had at least 20 cases, and no more than 20
percent of data cells had expected values less than five (Cooper & Schinder, 2002). The analysis
included far more than 20 cases for each category of the organization. There were respectively
209, 1819, and 829 cases for small, medium, and large size categories of the healthcare
organizations in the regression models.
Hypothesis Testing of Healthcare Quality Profiles
In order to test the significant differences in the healthcare quality profiles of small,
medium and large healthcare organizations categorized on bed size, the analysis of variance
(ANOVA) techniques was used for the dependent scale-type data variable: HIS Annual operating
cost per bed. As the histogram of the annual operating cost per bed indicated a non-normality
curve, the variable HIS annual operating cost per bed was first transformed with logarithms to
the base 10 to smooth out non- normality of the original variable. This log transformation
resulted in normal approximation for the variable as suggested by Lattin et al. (2003). As
discussed in Chapter 3, discriminant analysis was used for the dependent variable- HIPAA
compliance, which was a nominal type data variable in this study. Thus, considering the
influence of hospital size on the healthcare quality profiles during EHR implementation
strategies, the following hypothesis was tested.
H1 : There is a difference in the healthcare quality profiles across small, medium, and
large size healthcare organizations in the U.S. healthcare industry.
82
Based on the ANOVA techniques for HIS Annual Operating Cost per Bed and
discriminant analysis for HIPAA compliance, with 0.95 confidence level of the test, and 0.05
level of significance, the null hypotheses H1 (1) a and H1(2)a were rejected. Therefore, the derived
test hypotheses H1(1) and H1(2) were accepted, which implied acceptance of H1. Thus, a
significant difference was observed in the healthcare quality profiles across small, medium, and
large size healthcare organizations in the U.S. The analysis is summarized in Table 5 and Table 6
as follows.
Table 5.
Analysis of Variance for Quality Profile -Healthcare Information Systems Annual
Operating Cost per Bed
# Dependent Variables
Analysis of Variance (ANOVA) Factor:
Staffed Bed Size (C2a)
Test of Homogeneity of Variances
Q1 HIS Annual
Levene Statistic
df1
df2
Significance
Operating Costs
in Dollars per Bed
Zscore: Log10(IS Cost) 9.261
2
2214
0.000
Between Groups
Within Groups
Total
Sum of Squares d.f.

33.042
2
2182.958 2214
2216.000 2216
Mean Square
16.521
0.986
F
16.756
Significance
0.000
Derived Hypotheses from H1:

H1(1): There is a difference in the healthcare quality profile in terms of IS cost per
bed across small, medium and large size healthcare organizations in the U.S. healthcare
industry.
H1(1) a : There is no difference in the healthcare quality profiles in terms of IS cost per
bed across small, medium, and large size healthcare organizations in the U.S. healthcare
industry.
Both, the Levene Statistic and F test Statistic have significant value 0.000 which is
less than 0.05, hence the null hypothesis H1 (1) a rejected. Therefore, H1 (1) accepted.
83
Table 6.
Discriminant Analysis for Quality Profile - Health Insurance Portability and
# Dependent Variables Discriminant Analysis Factor: Staffed Bed Size (C2a )
Tests of Equality of Group Means
Wilk's Lambda F
df1
df2
Significance
Q5 HIPAA Compliance 0.986
40.509
1
2853
0.000
for Safety, Security
and Privacy of
healthcare data
Box's Test of Equality of Covariance Matrices
Canonical Correlation Box's M
F
df1
df2
Significance
0.188
8.601
8.589 1
1556656 0.003
Derived Hypotheses from H1:
H1 (2): There is a difference in the healthcare quality profile in terms of HIPAA
compliance across small, medium and large size healthcare organizations in the U.S.
healthcare industry.
H1(2)a : There is no difference in the healthcare quality profiles in terms of HIPAA
Compliance across small, medium, and large size healthcare organizations in the U.S.
healthcare industry.
Both, the Wilks Lambda and Boxs M Statistic have significant values 0.000 and 0.003
respectively, which are less than 0.05, hence the null hypothesis H1(2)a is rejected, thus
H1(2) is accepted .
Hypothesis Testing of Critical Success Factors' Profiles

In order to test the differences in the critical success factors of the healthcare quality for
small, medium, and large size healthcare organizations categorized on bed size, as explained in
Chapter 3, the study used ANOVA techniques for the scale type independent data variables
namely, managed healthcare and HIS structural functionality. Also, the study conducted, the
discriminant analysis for the nominal data type independent variables in the conceptual model
84
namely, healthcare organization facilities' affiliation status, strategic HIS usage, HIS
connectivity, EHR supporting technology applications, utilization of patient safety software
applications, and status of EHR related clinical data security issues in the healthcare
organization. As per the conceptual model, the independent variables in ANOVA technique and
discriminant score analysis, represented the critical success factors of healthcare quality. Thus,
considering the influence of hospital size on the profiles of the critical success factors of
healthcare quality during EHR implementation strategies, the following hypothesis was tested.
H2 : There is a difference between the critical success factors of small, medium, and large
size healthcare organizations in the U.S. healthcare industry.
For various critical success factors, corresponding hypotheses are derived from H2 and
tested as follows. For the critical success factors, which are scale type and nominal/categorical
type variables respectively, the hypotheses derived from H2 are as follows.
H2(1): There is a difference in the critical success factors, namely managed healthcare and
HIS structural functionality, across small, medium, and large size healthcare organizations in the
U.S.
H2(2): There is a difference in the critical success factors of physician's usage of HIS,
affiliation status of IHDS facility, strategic usage of HIS, HIS connectivity, status of other
clinical data management application systems to support EHR; utilization of patient safety
software applications, and the status of clinical data security issues across small, medium, and
large size healthcare organization in the U.S.
For the above null hypotheses, the tests were conducted with 0.95 confidence level of the
test and 0.05 level of significance, and the results observed are as follows.
85
Table 7.
Analysis of Variance for Electronic Health Record Centric Critical Success Factors of
Healthcare Quality.
# Explanatory Variables Analysis of Variance (ANOVA) Factor: Staffed Bed Size (C2a)
as EHR-centric CSF
C2c Managed Healthcare

Levene Statistic
df1
df2
Significance
5.026
2
4226
0.007
C3 HIS structural functionality: Available number of:

PC
1016.493
2
Servers
416.414
2
IS Staff
657.581
2
Sum of Squares
C2c Managed Healthcare
Between Groups
20.693
Within Groups 16565.974
Total
16586.667
d.f.
19018
21908
22007
0.000
0.000
0.000
Mean Square F
2
0.341
4996 3.323
4998
3.124
Significance
0.044
C3 HIS structural functionality: Available number of:

PC
Between Groups 7344963560.652

2 3672481780.322 823.772 0.000
Within Groups 84784367182.984 1918
4458111.643
Total
92129330743.631 1920
Servers Between Groups
12300572.232
2
6150286.114 304.714 0.000
Within Groups
442195612.064 21908 454496184.294
Total
454496184.292 21910
IS Staff Between Groups 151437519.952
2
75718759.973 471.791 0.000
Within Groups 3531928894.924 22007
160491.161
Total
3683366414.876 22009
H2(1) a : There is no difference in the critical success factors-Managed healthcare and
HIS structural functionality across small, medium, and large size healthcare organizations
in the U.S.
Both, the Levene Statistic and F Statistic show significant values, which are less than
0.05, hence the null hypothesis H2(1) a is rejected. Thus, the test hypothesis H2(1) is
accepted.
86
Table 8.
Discriminant Analysis for Electronic Health Record Centric Critical Success Factors of
Healthcare Quality.
# Explanatory Variables- Discriminant Analysis Factor: Staffed Bed Size (C2a)
as EHR-centric CSF
Wilk's Lambda F
C1
Physicians
Usage of HIS
C2b Affiliation_
Status
0.992
0.987
df1
2.351
431.230
df2
Significance
2095
0.022
131305
0.000
C5
Strategic
Usage of
HIS
0.975
14.633
2305
0.000
C6
HIS
Connectivity
0.983
1234.745
71240
0.000
C7a EHR Supporting

Technology
0.983
24.245
2852
0.000
C7b Utilization of
0.996
Patients Safety
12.941
2919
0.000
C7c Status of Clinical 0.993

Data Security Issues
11.006
1641
0.001
H2(2)a : There is no significant difference in the critical success factors namely,

physician's usage of HIS; affiliation status of IHDS facility; strategic usage of HIS; HIS
connectivity, status of other clinical data management application systems to support
EHR; utilization of patient safety software applications; and status of clinical data
security issues across small, medium, and large size healthcare organizations in the U.S.
Wilks Lambda shows significant values, which are less than 0.05. Hence the null
hypothesis H2(2)a is rejected. Box's M statistic and canonical correlation as showed below
further supports this result.
87
Table 9.
Canonical Discriminant Functions for Electronic Health Record Centric Critical Success
Factors of Healthcare Quality
Small, Medium, and Large Integrated Healthcare Delivery Systems Organizations.
# Explanatory Variables Discriminant Analysis Factor: Staffed Bed Size( C2a )
as EHR-centric CSF
Canonical
Boxs M
F
d.f1
df2
Significance
Correlation
C1 Physicians
0.088
15.788
2.246 7
543334
0.028
Usage of HIS
C2b Affiliation_
Status
0.114
1332.745
C5
Strategic
Usage of HIS
0.157
6.599
C6
HIS
Connectivity
0.131
4119.433
C7a EHR Supporting 0.129

Technology
C7b Utilization of
Patients Safety
Software
Applications
333.042
1.647
25519417
1606939
0.000
0.159
4119.373 1 13484809018
0.000
22.603
11.240
124604
0.000
0.066
2.318
2.317
12451317
0.128
C7c Status of Clinical 0.082

7.798
7.793
7681178
0.005
H2(2)a: There is no significant difference in the critical success factors of physician's

usage of HIS, affiliation status of IHDS facility, strategic usage of HIS, HIS connectivity,
status of other clinical data management application systems to support EHR, utilization
of patient safety software applications, and status of clinical data security issues across
small, medium, and large size healthcare organizations in the U.S.
Both, the Wilks Lambda and Boxs M Statistic show significant values, which are less
than 0.05 for most of the critical success factors. Though Box M statistic for C5, and C7b
showed non significant values which are greater than 0.05, those variables show
significant Wilk's Lambda and positive canonical correlation assessing the relationship
between the variables. Therefore, the null hypothesis H2(2)a is rejected, and H2(2) is
accepted.
88
Thus, the results shown in Tables 7, Table 8, and Table 9 implied an acceptance of the
test hypothesis H2 , indicating a significant difference in the profiles of critical success factors of
healthcare quality amongst small, medium, and large IHDS organizations in the U.S. Overall, the
data analysis in Table 5 through Table 9 showed significant differences between the profiles of
healthcare quality namely, HIS annual operating cost per bed and HIPAA compliance, and also
significant differences in the profiles of critical success factors of healthcare quality such as
managed healthcare, HIS structural functionality, physician's usage of HIS, affiliation status of
IHDS facility, strategic usage of HIS, HIS connectivity, status of other clinical data management
technology application systems to support EHR, utilization of patient safety software
applications in the healthcare organization, and status of clinical data security issues for small,
medium, and large size healthcare organizations in the U.S. healthcare industry. Based on the
perceived critical success factors of healthcare quality discussed in the conceptual model in
Chapter 3, the study tested the log transformed linear and logistic regression models of
healthcare quality, separately for small, medium, and large size IHDS as follows.
Log Transformed Linear and Logistic Regression Models
Having shown the perceived differences between the profiles of the healthcare quality
indicators, and differences in the EHR-centric critical success factors of the healthcare quality for
small, medium, and large size IHDS category, the log transformed linear regression procedure
for scale data type dependent variable, and logistic regression procedure for nominal data type
dependent variable were applied for the three categories of IHDS bed size. The respective
regression equations were constructed for HIS annual operating cost per bed and HIPAA
compliance, based on the dependent variables, which were the proposed critical success factors
89
of the healthcare quality in the conceptual model. As described in Chapter 3, these regression
equations were used to test the following hypotheses separately for small, medium, and large size
IHDS.
H3 : Physicians' usage of HIS is likely to affect the healthcare quality in terms of HIS
annual operating cost per bed, and HIPAA compliance.
H4 : Healthcare organization's affiliation status is likely to affect the healthcare service
quality in terms of HIS annual operating cost per bed, and HIPAA compliance.
H5 : HIS integrity component structural functionality of the healthcare organization is
likely to affect the healthcare quality in terms of HIS annual operating cost per bed,and HIPAA
compliance.
H6 : A higher percent of revenue from the managed care programs that the healthcare
delivery system owns is likely to improve the healthcare quality in terms of HIS annual operating
cost per bed, and HIPAA compliance.
H7 : Strategic HIS usage with learning perspectives of the organization is likely to
improve the healthcare quality in terms of HIS annual operating cost per bed, and HIPAA
compliance.
H8 : HIS integrity component connectivity of the healthcare organization is likely to
improve the healthcare quality in terms of HIS annual operating cost per bed, and HIPAA
compliance.
H9 : Technology status of the clinical data management application systems to support
EHR is likely to affect the healthcare service quality in terms HIS annual operating cost per bed,
and HIPAA compliance.
90
H10 : Utilization of patient safety software applications in the healthcare organization is

likely to affect the healthcare service quality in terms of HIPAA compliance.
H11 : Status of the clinical data security issues/problems relevant to EHR is likely to affect
the healthcare service quality in terms of HIPAA compliance.
Thus, log transformed regression procedure used to build the predictive equations for each of the
following cases.
1. Regression equation for HIS annual operating cost per bed size for the healthcare
organizations with small bed size category was built on the EHR-centric critical success factors
as the dependent variables.
organizations with medium bed size category was built on the EHR-critical success factors as the
dependent variables.
organizations with a large bed size category was built on the EHR-centric critical success factors
as the dependent variables.
Also, as discussed in Chapter 4, logistic regression procedure was applied to build predictive
equations for each of the following cases.
4. For HIPAA compliance of the healthcare organizations with a small bed size category,
based on the EHR-centric critical success factors, regression equation was built.
5. For HIPAA compliance of the healthcare organizations with a medium bed size
category, based on the EHR-centric critical success factors, regression equation was built..
91
6. For HIPAA compliance of the healthcare organizations with a large bed size category,
based on the EHR-centric critical success factors, regression equation was built Regression.
As discussed in Chapter 3, the most recent available two years data for 2002-2003 from
the Dorenfest database was used in the regression analysis. The log transformed linear regression
and logistic regression models were built following the procedure in SPSS 13.0 as described
below. To construct a log transformed linear regression of HIS annual operating cost per bed
size for the healthcare organizations, the corresponding database was selected for the small,
medium, and large size category of the healthcare organizations. The dependent variable was
selected as the log transformed HIS annual operating cost per bed size. The distribution of log
transformed HIS annual operating cost per bed size was observed to be closer to normal than the
distribution of annual operating cost per bed size, indicating that the log transformed linear
regression model worked better with the statistical normal distribution variables. The critical
success factors namely, managed healthcare, HIS structural functionality, physician's usage of
HIS, affiliation status of IHDS facility, strategic usage of HIS, HIS connectivity, status of other
clinical data management technology application systems to support EHR, and utilization of
patient safety software applications in the healthcare organizations were selected as the
independent variables. Along with the regression coefficients, and collinearity diagnostics, for a
non-significant F value in the ANOVA, as per Lattin et al (2003), a stepwise regression was
performed to verify seriousness of the problem of collinearity, and validity of the log
transformed regression model. The SPSS generated the following summary output.
92
70
60
Frequency
50
40
30
20
10
0
0.00
1000000.00
2000000.00
3000000.00
4000000.00
IS Cost- Annual opearting cost per staffed bed
__
50
Frequency
40
30
20
10
0
4.00
5.00
6.00
7.00
Log10(IS Cost)
__
Figure 7. Normal approximation of log transformed healthcare information systems

annual operating cost per bed for small bed size healthcare organizations.
93
Table 10.
Log Transformed Linear Regression Model Summary
The Conceptual Model based HIS Annual Operating Cost per bed as a Dependent
Variable; and the EHR Centric Critical Success Factors of Healthcare Quality as
Independent Variables for Small, Medium and Large IHDS Organizations.
(Dorenfest Data During 2002- 2003)
Organization Data Size R
R Square
F Statistic
Significance
Category as per
for ANOVA
Bed Size ( C2a )
Small
207
0.602
0.362
0.878
0.577
Medium
1819
0.522
0.273
9.685
0.000
Large
829
0.269
0.072
0.782
0.658
Model summary for small size category after removing the significant collinear factors
namely, structural functionality factorsavailable IS servers, available IS staff from the
predictive model:
Small
207
0.601
0.361
2.133
0.050
Model summary for large Size category after removing the significant collinear factors
namely, structural functionality factorsavailable IS servers, available IS staff from the
predictive model
Large
829
0.245
0.060
0.978
0.457
Model summary for large Size category, by step wise regression/backward regression
after removing the significant collinear factors namely, structural functionality factorsavailable IS servers, available IS staff also resulted in a non-significant predictive mode
with the following results.
Large
829
0.177
0.031
3.861
0.052
R Squared value indicates percent variation in HIS annual operating cost per bed
explained by the model.
94
Table 11.
Log Transformed Linear Regression Model for Small Size Integrated Healthcare
Delivery Systems Organizations
Coefficients and Collinearity Statistic Summary:
HIS Annual Operating Cost per bed: Dependent variable, EHR centric Critical Success
Factors (C.S.F.) of Healthcare Quality: Independent variables.
(Staffed Bed Size (C 2a) - Category Small)
C.S.F.
Unstructured Coefficients and Collinearlity Statistics
B
Tolerance V.I.F
B
Tolerance V.I.F
(Constant)
5.835
5.856
Managed Healthcare
-.447
.654
1.529
-.186
.895
1.117
HIS Connectivity
-.148
.470
2.126
-.329
.902
1.109
EHR Supporting
Technology
-.149
.767
1.303
-.139
.795
1.258
Application Status
Strategic usage of IS
-.048
.416
2.403
-.035
.609
1.641
Physician's Usage of
.013
.673
1.487
-.008
.699
1.431
HIS
Affiliation Status of
.029
.503
1.989
.016
.841
1.188
Facility
Utilization of Patient
.227
.530
1.888
.199
.551
1.814
Safety Software
Applications
Status of clinical
-.007
.607
1.648
.091
.823
1.215
Available number of
.000
.457
2.189
.000
.665
1.504
pc
Available number of
-.001
.104
9.574
servers
Available number of
.001
.100 10.043
IS staff
B denotes regression coefficients in the model. Tolerance is the percentage of the
variance in a given predictor that cannot be explained by the other predictors. The small
tolerances close to 0 considered causing high multicollinearity. Variance inflation factor
(V.I.F) greater than 2 is usually considered problematic. Only for 2 variables- Available
number of servers, and Available number of IS staff, Tolerance values are 0.104, and
0.100; and V.I.F. are greater than 2, violating multi collinearity. Removing these 2
factors from the model results in model fit with all V.I.F less than 2 and the test
significance value is 0.05 as per Table 10. Hence, the stepwise log transformed predictive
model accepted for the variable HIS annual operating cost per size organizations.
95
Table 12.
Log Transformed Linear Regression Model for Medium Size Integrated Healthcare
HIS Annual Operating Cost per bed: Dependent variable
EHR centric Critical Success Factors (C.S.F.) of Healthcare Quality: Independent
variables.
(Staffed Bed Size (C 2a ) - Category Medium)
C.S.F.
Unstructured
Collinearity Statistics
Coefficients
B
Tolerance V.I.F
(Constant)
Managed Healthcare
HIS Connectivity
EHR Supporting
Technology
Application Status
Strategic Usage of IS
HIS
Facility
Safety Software
Applications
Status of clinical Data
Security Issues
Available number of
pc
Available number of
servers
Available number of
IS staff
5.374
.027
-.017
.963
.941
1.038
1.063
-.009
.974
1.026
.010
.949
1.054
.005
.927
1.078
.000
.936
1.068
.041
.905
1.105
.044
.872
1.147
.000
.892
1.122
.000
.777
1.287
.000
.781
1.281
For all the factors, Tolerance >0, and Variance inflation factor (V.I.F) <2.Thus,
multicollinearity assumption was valid. Also test significance value was 0.000 as per
Table 10, thus the step wise log transformed predictive model accepted for the variable
HIS annual operating cost per bed size for medium size organizations.
96
Table 13.
Log Transformed Linear Regression Model for Large Size Integrated Healthcare
HIS Annual Operating Cost per bed: Dependent variable
EHR centric Critical Success Factors (C.S.F.) of Healthcare Quality: Independent
variables
C.S.F.
(Constant)
Managed Healthcare
EHR Supporting
Technology
Application Status
HIS
Facility
Safety Software
Applications
Security Issues
Available number of
pc
(Staffed Bed Size (C 2a ) - Category Large)

Unstructured Collinearity Statistics
Coefficients
B
Tolerance
V.I.F
5.292
.246
.952
1.051
-.059
.797
1.254
.029
.922
1.084
-.007
.914
1.094
.010
.868
1.152
.062
.907
1.103
-.045
.891
1.123
1.15E-005
.872
1.147
For all the factors, Tolerance >0, and Variance inflation factor (V.I.F) <2; thus
multicollinearity assumption was valid. However, as shown in Table 10,the test
significance value was >0.05. Hence, the log transformed predictive model rejected for
the variable HIS annual operating cost per bed size for large size organizations.
Thus, for the medium size organizations, the regression analysis indicated an evidence to
accept the predictive log transformed regression model, indicating a relationship between the
97
HIS annual operating cost per bed size and the proposed critical success factors of the healthcare
quality in the model. For small and large size organizations, the significance value of F statistics
was found to be more than the level of significance 0.05. However, using stepwise regression for
small size organizations, after removing the two factors namely, the available number of IS
severs, and IS staff, the log transformed regression model resulted in the F statistic significance
value 0.05, which was the same as the level of significance. Hence by removing those two
factors namely, the number of IS severs and IS staff from the predictive model, the regression
model was accepted for the small size organizations. For large size organizations, neither the step
wise nor the forward regression method provided a model fit, because in all those cases, the
significance value of F statistic was more than 0.05, which was the level of significance for the
test. Also, for large size organizations, the R squared value was 0.06, which showed very low
percent variation in HIS annual operating cost per bed explained by those critical success factors
of the healthcare quality for large size organizations. However, as per SPSS guideline and Lattin
et al.(2003), the ANOVA test statistic is not enough criteria of the linear regression model.
There were several significant coefficients such as, all V.I.F less than two and tolerance values
not close to zero, indicating that these variables also contribute to the model for large size
organizations.
Thus, while the results did not imply acceptance of log transformed predictive model for
large-sized healthcare organizations, the results did not indicate that the critical success factors
are invalid. So, for large-sized healthcare organizations, an additional research and more data
sets are required for log-transformed model of HIS annual operating cost per bed.
98
As discussed in Chapter 3, using SPSS 13.0, a logistic regression model was built for
HIPAA compliance based on the pre-defined critical success factors of the healthcare quality for
small, medium, and large healthcare organizations as described below.
For the small, medium, and large size category, the corresponding organizations' database
was selected. Binary logistic regression method was then selected, because data on the
categorical variable HIPAA compliance had two values. A value of zero means a zero percent
compliance, and value of one indicates administrative/ IT efforts in progress for becoming
HIPAA compliant. During the SPSS analysis, HIPAA compliance was selected as the dependent
variable. The proposed critical success factors namely, managed healthcare, HIS structural
functionality, physician's usage of HIS, affiliation status of IHDS facility, strategic usage of HIS,
HIS connectivity, status of clinical data management technology application systems to support
EHR, and utilization of patient safety software applications in the healthcare were selected as the
independent variables. The SPSS model option, Hosmer-Lemeshow goodness-of-fit, was then
selected to run the logistic regression procedure. According to Lattin et al. (2003) and the SPSS
guideline, the Hosmer-Lemeshow statistic indicates a poor fit, if the significance value is less
than 0.05. Also, as per SPSS guideline, the pseudo r-squared value measures the variability in the
dependent variable that is explained by the regression model, based on comparing the likelihood
of the current model to the "null" model (one without any predictors). Larger pseudo r-squared
value indicates that the model explains more of the variation, from a minimum of zero to a
maximum of one. The maximum value of the Cox and Snell r-squared statistic is actually
somewhat less than one; the Nagelkerke r-squared statistic is a "correction" of the Cox and Snell
99
statistic so that its maximum value is one. The summary of the SPSS generated output for the
binary logistic regression models was presented as follows.
Table 14.
Logistic Regression Model Summary for Small Size Integrated Healthcare Delivery
HIPAA Compliance: Dependent variable
EHR centric Critical Success Factors (C.S.F.) of Healthcare Quality: Independent variables.
Total Number of Cases 207
HIPAA Compliance: 0% Compliant = 0; Administrative IT Efforts in Progress = 1
Step 0 Constant B
1.910
Variables not
in equation
mng_hcare
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
S.E.
Wald Statistic d.f. Significance Exp(B)
0.536
Score
.721
.317
.492
1.525
.213
.317
.043
2.526
.319
.043
.452
12.703
0.000
6.750
d.f. Significance Standardized Canonical

Discriminant Function
Coefficients (STCDF)
1
1
1
1
1
1
1
1
1
1
1
.396
.574
.483
.217
.645
.574
.835
.112
.572
.836
.501
-.201
-.095
.392
1.068
.406
.156
-.505
.955
-.041
-.898
1.240
Step 1:
Model Summary: 2 Log likelihood
Cox & Snell R square Nagelkerke R Square
0.000
0.537
1.000
Estimation terminated at iteration number 23 because a perfect fit is detected.
Hosmer and Lemeshow Test
Chi-Square d.f. Sig.
Step 1
0.000
4 1.000
100
Table 15
Logistic Regression Model Summary for Medium Size Integrated Healthcare Delivery
HIPAA Compliance: Dependent variable, EHR centric Critical Success Factors (C.S.F.)
of Healthcare Quality: Independent variables, Number of Cases: 1819
HIPAA Compliance: 0% Compliant = 0 ; Administrative IT Efforts in Progress = 1
Step 0 Constant B
S.E.
3.055
0.273
124.754
1
0.000
21.214
Backward Regression: Hosmer and Lemeshow Test (Estimation terminated at seventh
iteration because parameters estimate changed by less than 0.001)
Chi-2 Log
Cox & Snell
Nagelkerke
Step square
d.f.
Sig.
likelihood
R Square
R Square
1
6.964
8
.541
94.050(a) .063
.204
2
2.944
8
.938
94.253(a) .062
.202
3
10.318
8
.243
94.870(a) .060
.196
4
14.472
8
.070
95.450(a) .058
.190
5
3.748
8
.879
96.248(a) .056
.182
6
9.365
7
.227
97.766(a) .051
.167
7
5.836
7
.559
99.150(a) .047
.154
Variables in the Equation
B
S.E Wald Statistic d.f. Sig. Exp(B) STCDF
Step 1
Step 7
mng_hcare
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Constant
connct
tech_appl
p_safety
d_security
struct_pc
Constant
1.008
1.923
-1.323
-.313
-.150
-.222
-1.564
2.326
.001
-.003
.003
2.819
1.830
-1.233
-1.636
2.334
.001
1.979
2.226
1.302
.645
.272
.141
.154
1.074
1.138
.001
.002
.005
2.589
.205
2.180
4.200
1.325
1.128
2.070
2.120
4.181
2.962
1.297
.527
1.185
1
1
1
1
1
1
1
1
1
1
1
1
.651
.140
.040
.250
.288
.150
.145
.041
.085
.255
.468
.276
2.739
6.841
.266
.731
.861
.801
.209
10.241
1.001
.997
1.003
16.763
1.220
.618
1.064
1.132
.000
1.600
2.251
3.975
2.365
4.248
1.684
1.529
1
1
1
1
1
1
.134
.046
.124
.039
.194
.216
6.236
.292
.195
10.315
1.001
7.237
101
-.144
-.329
.443
.239
.137
.308
.379
-.585
-.305
.290
-.209
Table 16
Logistic Regression Coefficients Summary for Large Size Integrated Healthcare Delivery
Systems Organizations with Backward Regression
Number of Cases: 829
Variable(s) entered on step 1: mng_hcare, connct, tech_appl, strat_usage, p_his_usage,
affil_status, p_safety, d_security, struct_pc, struct_server, struct_staff.
Step 9 Variables
mng_hcare
tech_appl
tech_appl(1)
tech_appl(2)
p_his_usage
p_his_usage(1)
p_his_usage(2)
p_his_usage(3)
p_his_usage(4)
p_his_usage(5)
p_his_usage(6)
p_his_usage(7)
Constant
S.E.
-197.177 15392.309
4.143 15321.573
-56.974 15484.896
20.446
56.246
4.970
52.500
60.462
-6.350
-1.388
198.728
24946.515
4499.841
3314.400
12328.630
5847.292
27295.926
8920.531
20652.883
102
Wald
d.f. Sig.
Statistic
.000
1 .990
.000
2 1.000
.000
1 1.000
.000
1 .997
.000
7 1.000
.000
1 .999
.000
1 .990
.000
1 .999
.000
1 .997
.000
1 .992
.000
1 1.000
.000
1 1.000
.000
1 .992
Table 16 a.
Logistic Regression Model Summary for Large Size Integrated Healthcare Delivery Systems
Organizations
Number of Cases: 829
Step 0 Constant B
S.E.
4.227
0.712
35.218
1
0.000
68.500
Backward Regression Hosmer and Lemeshow Test (Estimation terminated at ninth iteration
because parameters' estimate did not change by removing the non significant variables from the
model in subsequent steps).
Cox &
Chi-2 Log
Snell R
Nagelkerke
square
d.f.
likelihood
Square
R Square
Step
Sig.
1
.000
3
1.000
.000
.140
1.000
2
.000
3
1.000
.000
.140
1.000
3
.000
2
1.000
.000
.140
1.000
4
.000
2
1.000
.000
.140
1.000
5
.000
1
1.000
.000
.140
1.000
6
.000
2
1.000
.000
.140
1.000
7
.000
2
1.000
.000
.140
1.000
8
.000
2
1.000
.000
.140
1.000
9
.000
2
1.000
.000
.140
1.000
Variables not in the Equation
HIS Connectivity
EHR Supporting Technology Application Status
STCDF
.026
.706
Physician's Usage of HIS
Affiliation Status of Facility
Utilization of Patient Safety Software
Applications
.315
.438
-.260
Status of clinical Data Security Issues
.142
Available number of pc
Available number of servers
Available number of IS staff
-.407
-.140
.042
.315
103
Summary of the Predictive and Significant Variables

From the results presented in Table 10 through Table 16a), a summary of the predictive
and significant variables is provided in Table 17 and Table 18. These tables display the
predictive and significant factors of the healthcare quality in terms of HIS annual operating cost
per bed and HIPAA compliance, respectively, across the size classifications of the healthcare
organizations. In Table 17 and Table 18, * denotes the critical success factor as a possible
predictor variable in the log transformed regression equation for HIS annual operating cost per
bed, and the logistic regression equation for HIPAA compliance respectively (at the significance
level 0.05 for the test statistic). In Table 17, + indicates the variable as a possible significant
factor of the healthcare quality in terms of HIS annual operating cost per bed, based on the
criteria of collinearity statistics. In Table 18, + indicates the variable as a possible significant
factor of the healthcare quality in terms of HIPAA compliance, based on the criteria of
standardized canonical discriminant function coefficients. Collinearity statistics based on
Tolerance and Variance Inflation Factor (V.I.F.) was used in the log transformed predictive
regression method as per SPSS guideline. The tolerance is the percentage of the variance in a
given predictor that cannot be explained by the other predictors. When the tolerances are close to
zero, there is high multicollinearity and the standard error of the regression coefficients will be
inflated. V.I.F greater than two is usually considered problematic, violating the assumptions of
the model. For the factors that were not determined by the logistic regression model, as per
Lattin et al. (2003), standardized canonical discriminant function (STDCF) coefficient criteria
was used. In Table 18, STDCF with large absolute values correspond to the variables as critical
success factors, which have greater discriminating ability of the healthcare quality.
104
Table 17.
Summary of Predictive and Significant Factors of Healthcare Information Systems (HIS)
Annual Operating Cost per Bed
Critical Success Factors (C.S.F.) in the Predictive Models, and the Variables Significant but not
in the Predictive Equations for HIS Annual Operating Cost per Bed (Q 1):
C2a Staffed Bed Size
Small
Medium
Large
Number of Cases (N)
207
1819
829
HIS Annual Operating Cost Q1
Q1
Q1
Per Bed
Significant Predictive Significant Predictive Significant Predictive
Factors Factors
Factors Factors
Factors Factors
C1: Physician's Usage
of HIS
C2b: Affiliation Status of

Facility
C2c: Managed Healthcare
C3 : Structural Functionality
Available # of PC:
+
Available # of Servers Available # of IS Staff -
*
-
+
+
+
*
*
*
+
-
C5 : Strategic Usage of IS
C6 : HIS Connectivity
C7a : EHR Supporting

Technology
Application Status
C7b : Utilization of Patient +

Safety Software Applications
C7c: Status of clinical Data

Security Issues
Note. + denotes Significant, * denotes Predictive, and - denotes Undetermined Factors.
105
Table 18.
Summary of Predictive and Significant Factors of Health Insurance Portability and
The Critical Success Factors (C.S.F.) in the Predictive Models, and theVariables Significant but
not in the Predictive Equations for HIPAA Compliance (Q 5 ):
C2a Staffed Bed Size
Small
Medium
Large
Number of Cases (N)
207
1819
829
HIPAA Compliance
Q5
Q5
Q5
Significant Predictive Significant Predictive Significant Predictive
Factors
Factors Factors
Factors Factors
Factors
C1: Physician's Usage
of HIS
C2b: Affiliation Status of

Facility
C2c: Managed Healthcare
C3 : Structural Functionality
Available # of PC:
+
Available # of Servers +
Available # of IS Staff +
+
+
+
+
+
+
C5 : Strategic Usage of IS
C6 : HIS Connectivity
C7a : EHR Supporting

Technology
Application Status
C7b : Utilization of Patient +

Safety Software Applications
C7c: Status of clinical Data +

+
*
+
Security Issues
Note. + denotes significant, * denotes predictive, and - denotes undetermined factors.
106
As can be noted from Table 17, the critical success factors namely, managed healthcare;
HIS structural functionality in terms of available number of PC, physician's usage of HIS,
affiliation status of IHDS facility, strategic usage of HIS, HIS connectivity, status of other
patient safety software applications in the healthcare were significant factors affecting HIS
annual operating cost per bed, in small, medium, and large sized healthcare organizations. Also,
HIS structural functionality in terms of available number of IS servers and IS Staff were
significant factors affecting HIS annual operating cost per bed in the case of medium sized
healthcare organizations. However, for small and large size organizations, log transformed
models could not determine the effect of HIS structural functionality in terms of available
number of IS servers and IS Staff on HIS annual operating cost per bed. Also, the results
described in Table 10 and Table 11, and summary in Table 17 implied acceptance of the log
transformed predictive model, after removing the non-significant factors namely, available
number of IS Staff and IS servers, for small size organization. The model is given by:
Log (is_cost) = a +b1 (mng_hcare) +b2 (connct)+ b3 (tech_appl)+ b4 (Strat_usage)+
b5 (p_his_usage)+ b6 (affil_status) +b7 (p_safety)+b8 (d_security)+ b9 (struct).
In the above equation, Log (is_cost) is the natural logarithm of HIS annual operating cost per bed
size for the healthcare organizations;
a is a constant for the regression model,
b1 through b9 are the regression coefficients' values in the model indicating change in a
dependent variable per unit change in the corresponding independent variable.
107
As described in Appendix A, for HIS annual operating cost per bed in the above model, the
EHR-centric critical success factors are described as follows:
mng_hcare is the managed healthcare ,
connct is the HIS connectivity,
tech_appl is the status of other clinical data management application systems to support
EHR,
Strat_usage is the HIS strategy of IT usage, process reengineering, quality management,
executive decision support functionality and learning perspectives,
p_his_usage is the Physician usage of HIS,
affil_status is the status of the healthcare organization facilities' affiliation,
p_safety is the utilization of patient safety software applications in the healthcare
organization,
d_security is the status of clinical data security issues in the healthcare organization, and
struct is the HIS structural functionality in terms of available total number of facilities
that include number of computers, IS servers, and IS staff. Thus, from Table 11,
Log (is_cost) Small bed size = 5.856 0.186(mng_hcare)-0.329(connct) 0.139(tech_appl)0.035(Strat_usage)-0.008(p_his_usage)+ 0.016(affil_status) +0.199(p_safety)+0.91(d_security)+
0(struct), where,
Log (is_cost) Small bed size is the natural logarithm of HIS annual operating cost per bed size
for the healthcare organizations with number of staffed beds less than 100.
In view of a negative value of the regression coefficients in the above equation, an
increase in managed care, HIS connectivity, status of other clinical data management application
108
systems to support EHR, implementation of HIS strategy of IT usage, process reengineering,

quality management, executive decision support functionality and learning perspectives, and
physician usage of HIS might have caused a decrease in HIS annual operating cost per patient.
The positive value of the regression coefficients in the above equation implied that, increase in
the corresponding value of independent variable has caused an increase in the value of the
dependent variable in the equation.Therefore, in view of the description of data variables as
given in Appendix A, the healthcare organization facilities' affiliation status, which includes
Contracted, Joint, Joint Venture, and Sponsored utilization of patient safety, and clinical data
security software applications in the healthcare organization, might have increased HIS annual
operating cost per patient for small size healthcare organizations.
The results described in Table 10 and Table 12, implied acceptance of the log
transformed predictive model including all the proposed critical success factors was accepted for
medium size healthcare organizations. The model is given by:
Log (is_cost) Medium bed size = 5.374+0.27(mng_hcare)-0.017(connct)
0.009(tech_appl)+0.10(Strat_usage)+0.005(p_his_usage)+ 0.000(affil_status)
+0.041(p_safety)+0.44(d_security)+ 0(struct), where,
Log (is_cost) Medium bed size is the natural logarithm of HIS annual operating cost per bed
size for the healthcare organizations with number of staffed beds 100 to less than 500.
The positive value of the regression coefficients indicated increase in managed care,
implementation of HIS strategy of IT usage, process reengineering, quality management,
executive decision support functionality and learning perspectives, Physician usage of HIS,
utilization of patient safety and clinical data security software applications in the healthcare
109
organization, might have increased HIS annual operating cost per patient for the medium size
organizations. Also, the negative value of the regression coefficients in the above equation
indicated increase in HIS connectivity and higher status of other clinical data management
application systems to support EHR might have decreased the HIS annual operating cost per
patient for medium size healthcare organizations.
For large healthcare organizations, as per the results described in Table 10 and Table 13,
though the dependent variables were significant, log transformed predictive model could not be
established for HIS annual operating cost per bed size.
The logistic predictive model described for HIPAA compliance is given by:
Logit (p) HIPAA Compliance = a' +b1'(mng_hcare) +b2'(connct)+ b3'(tech_appl)+
b4'(Strat_usage)+ b5'(p_his_usage)+ b6'(affil_status) +b7'(p_safety)+b8'(d_security)+ b9'(struct).
In the above equation, Logit (p) HIPAA Compliance is the logarithm to the base e of the odds or
likelihood ratio that the dependent variable HIPAA compliance takes a particular value. In
symbols, this is defined as: logit (p) = log (p/(1-p)). Here, p being a probability can only range
from values of zero to one (Larson & Farber, 2003).
a' is a constant term for the logistic regression equation in the model,
b1' through b9' are the regression coefficients' values in the model indicating change in a
dependent variable per unit change in the corresponding independent variable.
As per the results described in Table 14 through 16a, and indicated in Table 18, for small,
medium, and large size healthcare organizations, the critical success factors namely, managed
healthcare, HIS structural functionality in terms of available number of PC, physician's usage of
HIS, affiliation status of IHDS facility, strategic usage of HIS, HIS connectivity, status of other
110
patient safety software applications in the healthcare were significant factors for HIPAA
compliance. However, based on the analysis of the available two years data, except for the two
predictive factors, namely, EHR supporting technology application status, and status of clinical
data security issues in the medium size healthcare organizations, logistic predictive model for
HIPAA compliance could not be established for any bed size categories of the healthcare
organizations. Thus as per the results described in Table 15,
Logit (p) HIPAA Compliance for Medium Size = 1.979-1.233(tech_appl) +2.334(d_security),
Thus, the above equation indicates that the status of other clinical data management technology
application systems to support EHR and utilization of patient safety software applications in the
healthcare might have influenced HIPAA compliance. Thus, the data analysis leads to the
following conclusions about the test of hypotheses.
The hypothesis H1 was accepted, implying that there is a difference between the profiles
of healthcare quality namely, HIS annual operating cost per bed, and HIPAA compliance across
the small, medium, and large size healthcare organizations in the U.S. healthcare industry.
The hypothesis H2 was accepted, implying that there is a difference between the profiles
of EHR centric critical success factors of healthcare quality, namely HIS annual operating cost
per bed and HIPAA compliance across the small, medium, and large size healthcare
organizations in the U.S. healthcare industry.
For medium size healthcare organizations, the results of the log transformed regression of
HIS annual operating cost per bed, implied acceptance of hypotheses H3 through H11 . Thus,
physicians' usage of HIS, healthcare organization's affiliation status, HIS integrity component
111
structural functionality of the healthcare organization, a higher percent of revenue from the
managed care programs that the healthcare delivery system owns, strategic HIS usage with
learning perspectives of the organization, HIS integrity component connectivity of the healthcare
organization, technology status of the clinical data management application systems to support
EHR, utilization of patient safety software applications and the status of clinical data security
issues/problems relevant to EHR are predictive and significant success factors that are likely to
affect the healthcare service quality in terms effectiveness of HIS annual operating cost per bed
for medium size healthcare organizations.
For small size healthcare organizations, the results of step wise log transformed equation
of HIS annual operating cost per bed implied acceptance of hypotheses H1 through H11 excluding
hypothesis H5 . Thus, results indicated that physicians' usage of HIS, healthcare organization's
affiliation status, a higher percent of revenue from the managed care programs that the healthcare
delivery system owns, strategic HIS usage with learning perspectives of the organization, HIS
integrity component connectivity of the healthcare organization, technology status of the clinical
data management application systems to support EHR, utilization of patient safety software
applications, and status of the clinical data security issues/problems relevant to EHR are
significant and predictive factors that are likely to affect the HIS annual operating cost per bed
for small size healthcare organizations.
For large size healthcare organizations, based on the available data, the results of
stepwise log transformed equation of HIS annual operating cost per bed could not imply
acceptance of hypotheses H1 through H11 . However collinearity statistics indicate that physicians'
usage of HIS, healthcare organization's affiliation status, a higher percentage of revenue from the
112
managed care programs that the healthcare delivery system owns, strategic HIS usage with
learning perspectives of the organization, HIS integrity component connectivity of the healthcare
EHR, utilization of patient safety software applications, and status of the clinical data security
issues/problems relevant to EHR are significant, though not predictive factors, that may affect
the healthcare service quality in terms of effectiveness of HIS annual operating cost per bed for
large size healthcare organizations.
For small and large size healthcare organizations, the results based on the analysis of
available data for the logistic regression of HIPAA compliance could not imply acceptance of
any hypotheses H3 through H11 . For medium size healthcare organizations, the results implied
acceptance of the hypotheses H9 and H11, indicating that the technology status of the clinical data
management application systems to support EHR and status of the clinical data security
issues/problems relevant to EHR are predictive and significant success factors that are likely to
affect the healthcare service quality in terms of HIPAA compliance. In addition, considering the
standardized canonical discriminant function coefficients criteria as per the SPSS guideline, the
suggested EHR-centric critical success factors namely, physicians' usage of HIS, healthcare
organization's affiliation status, a higher percent of revenue from the managed care programs that
the healthcare delivery system owns, strategic HIS usage with learning perspectives of the
healthcare organization, HIS integrity component connectivity of the healthcare organization,
technology status of the clinical data management application systems to support EHR,
utilization of patient safety software applications, and status of the clinical data security
113
issues/problems relevant to EHR are significant, though not predictive factors, that are likely to
affect the healthcare quality in terms of HIPAA compliance.
One of the possible explanations of some factors observed to be significant but not
predictive of the healthcare quality is that EHR implementation is still in its developing stage,
and there may be a lack of sufficient data to compare and contrast the healthcare quality
measures described in the conceptual model. For these cases of significant but not predictive
factors of the healthcare quality, the results do not indicate that these measures are not valid, but
rather that additional research over time and inclusion of all the variables described in the
conceptual model presented in Chapter 3 is required for completeness of the model testing.
Based on the findings of the data analysis, the evaluations of this study and suggestions for
further research are provided in Chapter 5.
114
CHAPTER 5. RESULTS, RECOMMENDATIONS, AND CONCLUSIONS

In view of the conceptual model described in Chapter 3, this study addressed the
analytical quantitative research methodology. In order to test the regression model of healthcare
quality in terms of healthcare information systems (HIS) annual operating cost per bed, and
HIPAA compliance, descriptive and inferential statistical analysis of the healthcare industry data
was performed as discussed in Chapter 4. The explanatory variables in the model were the
electronic health record (EHR)-centric proposed critical success factors (CSF) of healthcare
quality. The critical success factors examined in the study were: Physicians' usage of HIS,
healthcare organization's affiliation status, HIS integrity component-structural functionality and
connectivity of the healthcare organization, revenue from the managed care programs that the
healthcare delivery system owns, strategic HIS usage with learning perspectives of the
EHR, utilization of patient safety software applications, and the status of the clinical data
security issues/problems relevant to EHR. Table 17 and Table 18 in Chapter 4 have provided an
overview of the significant and predictive critical success factors of HIS annual operating cost
per bed and HIPAA compliance for small, medium, and large size healthcare organizations. The
findings of this study, implications of the empirical results, and limitations of this study are
presented in the following sections. Finally, recommendations for the theoretical and methodical
designs of future study are made, and the conclusions are presented.
115
Results
The descriptive and inferential statistical data analysis performed in this study suggest
that there is a difference between the profiles of healthcare quality namely, HIS annual operating
cost per bed and HIPAA compliance, across the small, medium, and large size healthcare
organizations in the U.S. healthcare industry. The analysis also indicated a difference between
the profiles of EHR-centric critical success factors of healthcare quality.
For medium size healthcare organizations, the results of regression analysis indicated that
the proposed critical success factors are predictive and significant success factors that are likely
to affect the healthcare service quality in terms of effectiveness of HIS annual operating cost per
bed.
For small size healthcare organizations, the regression analysis indicated that except for
HIS integrity component structural functionality of the healthcare organization, all other
proposed critical success factors are predictive and significant success factors, which are likely to
affect the healthcare service quality in terms of effectiveness of HIS annual operating cost per
bed. The possible explanation of structural functionality found to be non-predictive and
insignificant success factor in terms of its effect on HIS annual operating cost per bed is that
small size healthcare organizations may have limited resources in terms of number of PC,
number of IS staff and number of IS servers that represent one of the components of structural
functionality in the conceptual model.
For large size healthcare organizations, the results of regression analysis and collinearity
statistics indicated that the proposed critical success factors, though not predictive, are significant
factors that may affect the healthcare service quality in terms of effectiveness of HIS annual
116
operating cost per bed. One possible reason for the proposed significant factors found to be
significant, but not predictive for effectiveness of HIS annual operating cost per bed, may be due
to existing constraints on HIS operating cost per bed in the large size healthcare organizations.
For small and large size healthcare organizations, the logistic regression analysis of
HIPAA compliance indicated that none of the proposed critical success factors are predictive,
while for medium size healthcare organizations, the results indicate that the technology status of
the clinical data management application systems to support EHR and status of the clinical data
security issues/problems relevant to EHR are predictive and significant success factors that are
likely to affect the healthcare service quality in terms of HIPAA compliance. Also, considering
the standardized canonical discriminant function coefficients criteria for each of the small,
medium, and large size healthcare organizations, the proposed EHR-centric critical success
factors namely, physicians' usage of HIS, healthcare organization's affiliation status, revenue
from the managed care programs that the healthcare delivery system owns, strategic HIS usage
with learning perspectives of the healthcare organization, connectivity of the healthcare
EHR, utilization of patient safety software applications, and the status of clinical data security
issues/problems relevant to EHR, were found significant (though not predictive), that are likely
to affect the healthcare quality in terms of HIPAA compliance.
A possible explanation for some of the proposed EHR-centric factors observed to be
significant but not predictive of HIPAA compliance is that EHR implementation is still in its
developing stage. Another possible explanation lies in that the regression analysis for HIPAA
compliance conducted on only two years available data, and thus, there may be a lack of
117
sufficient long-term data to compare and contrast the healthcare quality measures in terms of
HIPAA compliance described in the conceptual model.
Practical Implications
In order to be successful in the implementation of EHR, as confirmed by this study, the
healthcare practitioners should pay attention to the following key factors: Physicians' usage of
HIS, Affiliation status of healthcare facility, HIS integrity component- structural functionality
and connectivity of the healthcare organization, revenue from the managed care programs that
the healthcare delivery system owns, strategic HIS usage with learning perspectives of the
EHR, utilization of patient safety software applications, and the status of clinical data security
issues/problems relevant to EHR.
The healthcare practitioners should have different expectations as to how the proposed
critical success factors may contribute to the reduction in HIS annual operating cost per bed and
HIPAA compliance. For medium size healthcare organizations, practitioners can expect that the
proposed critical success factors to have more direct impact on the healthcare quality objectives.
For small and large size healthcare organizations, the impact may be significant but not direct.
This may occur due to a delayed effect or that there may exist critical factors that are not
included in the analysis of this study.
Thus, healthcare organizations seeking to promote the use of EHR with a goal of
improving healthcare quality can apply this research in various ways. The conceptual model can
provide useful information for EHR-centric strategic and business planning of the healthcare
organization while achieving healthcare quality goals. The model can be helpful to gain insights
118
into the efforts of an individual healthcare organization, or of a group of healthcare organizations

towards healthcare quality improvements. For the healthcare organizations, evaluation of
regression equations can provide insights into what relevant actions might be taken through the
EHR-centric proposed critical success factors to raise their healthcare quality profile.
Results based on the log transformed regression equations for small and medium size
healthcare organizations, and logistic regression model for medium size healthcare organizations,
indicated that the healthcare quality is influenced by sets of variables that may change for the
actual quality measure of the healthcare. In other words, amongst the proposed critical success
factors of healthcare quality, some may be more or less significant than the others, while
achieving healthcare quality. Therefore, the regression equations based on Log (is_cost), Logit
(p) could be used to evaluate the healthcare quality indicators and determine the probable effect
of specific actions related to the proposed critical success factors of the healthcare quality for a
particular healthcare organization or a group of healthcare organizations. Finally, regarding the
statistically insignificant log transformed regression model for large size healthcare
organizations, and the logistic regression model for small and larges size healthcare
organizations observed in data analysis of this study, no attempt can or should be made to derive
practical implications. For these cases of statistically insignificant regression models of
healthcare quality, the results do not indicate that the proposed critical success factors are
invalid, but rather that additional research over time and inclusion of all the variables described
in the conceptual model of Chapter 3 is required for completeness and testing of the model.
119
Limitations
This study encountered some problems and highlighted some areas of shortcomings in
the survey instrument, which may be useful for future study. Although data analysis in this study
is based on the authentic data resources namely, the American Hospitals Association (AHA) and
Dorenfest survey data, these data sets represent broad canvassing of only acute care hospitals,
chronic care facilities, and ambulatory practices on their adoption of and plans to adopt various
healthcare information technology components. The study did not include long-term healthcare
that should be considered for more detailed analysis and conclusions in the future. Longitudinal
data is not available for some of the data variables included in this study. In those cases, data
analysis was performed on cross sectional data sets, which may affect generalizability of the
results.
Although the conceptual model in the methodology section of this study has provided a
comprehensive healthcare quality model through EHR-centric proposed critical success factors,
data on a few of the proposed critical success factors, namely IS management of patients records,
patients' awareness of EHR functionality, remote patients' data access and management, and
prevention of clinical negligence and adverse events through HIS was not available at the time of
this study. Also, data on some predefined quality goals described in the conceptual model,
namely- reduction in clinical data errors, patient waiting time for the healthcare/clinical services
and patient satisfaction of the healthcare services was not available to this researcher at the time
of this study. Therefore, data analysis in this study focused on only two measures of quality
goals, namely HIS cost effectiveness and HIPAA compliance. Also, this study considered the
predictive influence of many, though not all, of the proposed critical success factors of healthcare
120
quality. This researcher is aware of the fact that HIS based healthcare quality evaluation is a
comprehensive approach that includes not only utilization of IS resources, financial indicators,
and healthcare quality in terms of reduced errors, increased safety measures, and cost reduction,
but also should include patient satisfaction of the services, and reduction in a patient waiting time
for the healthcare and clinical services.
Another limitation of this study is that while descriptive statistical analysis performed on
longitudinal five yearly multivariate data on the healthcare organizations, inferential statistical
analysis was based on only two years available data. Thus, in these cases, this study might have
lacked a sufficient long-term data to compare and contrast the healthcare quality measures.
Finally, some of the proposed EHR-centric factors observed significant but not predictive of
healthcare quality and need further research because EHR implementation is still in its
developing stage. Therefore, this researcher acknowledges the existence of the above-described
challenges present in this study, which are beyond the scope of the survey instrument and need
further research.
Recommendations for Further Study
It is recommended to replicate this study in the future using longitudinal data and
including all the proposed critical success factors and healthcare quality indicators for
completeness of the conceptual model described in Chapter 3. Thus, in the near future, data
analysis can be extended by including all the remaining critical success factors proposed in the
conceptual model, namely- electronic repositories with viable information, patient awareness of
EHR functionality, remote patient data access, and the prevention of clinical negligence and
adverse events. Also, its is recommended to quantify the various aspects of healthcare quality
121
measures including reduction in a patient's waiting time for healthcare services and increase in a
patient's satisfaction associated with widespread adoption and information systems management
of electronic health records.
It is recommended to construct a comprehensive view of operational results of the EHR
project by creating a composite performance index of healthcare quality with a unique measure.
Considering the consolidated balanced scorecard and critical success factors analysis of the
healthcare quality described in the conceptual model of this study, the measures of the healthcare
quality (Qi) could be viewed through the four perspectives, namely Financial, Patient, Internal,
and Innovation and Learning, where Q1 denotes reduction in HIS annual operating cost per bed,
Q2 denotes reduction in a patient wait time for healthcare services, Q3 denotes increase in a
patient satisfaction with healthcare services, Q4 denotes reduction in clinical data errors and
adverse events, and Q5 denotes HIPAA compliance for safety, security and privacy of healthcare
data, and meeting HIPAA standards for EHR. Thus, in view of the above-described four
perspectives and the corresponding measures of healthcare quality (Qi), it is recommended to
establish a predictive multivariate regression model, and derive a pooled measure of healthcare
quality as,
Q= a1 Q1 + a2 Q2 + a3 Q3 + a4 Q4 + a5 Q5 , where,
ai are the weights or relative importance of the expected Qi, and i = 1, 2, 3, 4, 5.
The weighting criteria for these healthcare quality measures may depend on planned strategies,
goals and relative importance of each goal for the healthcare organization, or in general, for the
healthcare industry. Finally, future studies could also focus on some of the following questions:
How do the EHR-centric critical success factors of healthcare quality change over time?
122
How do the results of the U.S based study of EHR-centric healthcare quality model and
healthcare quality evaluation compare to some other developed countries, for example, Canada
and the United Kingdom?
Conclusions
The estimators from the conceptual model did not provide predictions of what will
happen, but of what could happen, by capturing dominant strategic IS management themes,
EHR-centric critical success factors of environmental determinants, organizational determinants,
and innovational determinants of the healthcare quality. This study may be a first step of what
can be an ongoing process of longitudinal surveys across different sizes of healthcare
organizations. The findings of the study can be examined from various points of view as follows:
The observed variation in HIS annual operating cost per bed and HIPAA compliance
across the small, medium, and large size healthcare organizations in the U.S. healthcare industry
suggests distinct differences in the attitudes, efforts, and resources of small, medium, and large
size healthcare organizations towards healthcare quality. The differences in how small, medium,
and large size healthcare organizations evaluate and reach the healthcare quality is further
reflected by the observed variation in the proposed critical success factors of healthcare quality
across the different sizes of organizations in the U.S. healthcare industry. Thus, the proposed
critical success factors of healthcare quality may not be equally important across the small,
medium, and large size organizations in the U.S. healthcare industry.
The observed significance of the EHR-centric critical success factor of healthcare quality,
namely- physician's responses to HIS systems and technology suggests the importance of EHR
systems usable to physicians and other healthcare providers during the healthcare decision
123
making process. Also, the observed significance of healthcare organization facilities' affiliation
status, and managed healthcare suggests these factors contribute in the EHR centric operations
towards healthcare quality.
The observed significant factors, namely HIS structural functionality and HIS
connectivity could strengthen automation of business functions of the healthcare organization
and could contribute towards healthcare quality in terms of HIS annual operating cost per bed
and HIPAA compliance. Also, the observed EHR-centric critical success factor, namely strategic
usage of HIS (described in the conceptual model as a nominal variable with categories of
strategies namely, communication, education, and training, improving HIS accessibility,
usability, and upgrading the information systems) has significant implications on healthcare
quality improvements.
The observed significance of the technology applications factor in achieving the
healthcare quality suggests healthcare organizations ability to adopt and adapt EHR supporting
technologies and new techniques while focusing on reduction in annual operating cost per bed,
and HIPAA compliance. Also, the EHR-centric utilization of patient safety and data security
software applications in the healthcare organization, seem to contribute towards HIPAA
compliance. Thus, this study suggests that healthcare organization's EHR-centric environmental,
organizational, and innovational factors have an influence on the healthcare services' quality.
In the opinion of this researcher, there are two contributions of this study to the
healthcare services' research that are worthy of attention. First, from a theoretical point of view,
this study has developed a comprehensive framework of healthcare quality through the approach
of consolidated balanced scorecard and critical success factors analysis. Second, in the opinion
124
of this researcher, this study is the first one to develop and examine the healthcare quality model
through EHR-centric critical success factors of healthcare quality exploring information systems
integrity, and associated contextual factors of healthcare organizations. In this respect, this study
has made a unique contribution to the healthcare information systems literature. Future studies
should examine and evaluate the conceptual model using longitudinal multivariate data,
including all the proposed critical success factors and healthcare quality measures for
completeness of the proposed information systems model of healthcare quality.
125
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139
APPENDIX A. DEFINITION AND DESCRIPTION OF THE DATA VARIABLES
Dependent
Variables
Data Definition and Measurement Criteria
Data Source and

Description
Healthcare
Quality
HIS cost effectiveness, HIPAA compliance,

Reduction in clinical errors,
Reduction in patient waiting time,
Increase in patient satisfaction for
clinical/healthcare services.
Dorenfest and AHA

Database as described in
the following rows.
Q1 : IS_Cost
Cost effectiveness considered by HIS annual

operating cost per bed size of healthcare
organization.
Missing Reponses coded as 99.
Dorenfest Database,
HIS annual operating
cost and hospital bed
size
longitudinal numerical
data
Q5 : Hipaa_C
Healthcare organization's HIPAA compliance:

100% compliant = 2,
0% compliant = 0,
Administrative/ IT efforts in progress for
becoming HIPAA compliant = 1,
Missing Reponses = 0
Dorenfest Database
HIPAA strategy table,
Two years numerical
data.
140
Explanatory/
Independent
Variables
Data Source and

Description
Strategic
Management
of HIS
Physician usage of HIS,

Organization environmental factors,
Basic functionality,
Strategic HIS usage with learning perspectives
Process reengineering and quality management,
HIS connectivity and operational characteristics
Dorenfest Database
as described
below.
C1
Physicians
Usage of HIS
Physician usage of HIS is defined as a nominal

variable for healthcare providers' usage of IT.
Software-use is not mandatory for physicians = 1
IT support is not available to physicians = 2
All/almost all physicians use IT systems = 3
Too little IT training provided to physicians = 4,
IT usage is easier in the opinions of physicians and
administrative staff members = 5,
The physician's response that IT usage/learning takes
too much time = 6,
Physicians' reluctance to change and adapt to IT usage
= 7,
Physician's other responses-HIS are not user-friendly,
unrecognized benefits of software = 8.
Missing Responses = 0
Dorenfest Database
Physician's IT
nonuse table
Two years
descriptive data
C2a
BedSizeStaffed
(Internal Factor)
BedSizeStaffed: Less than 100 = Small,

100-500 = Medium,
500 and above = Large.
Coded from 1 through 3, Missing Response = 0
Dorenfest Database
IHDS main table
Longitudinal five
years numerical
data
C2b
Affiliation_status
(Organizational
characteristic)
Healthcare organization facilities' affiliation status is

described as a categorical variable with categories:
Owned, Leased, Managed, Affiliated, and Other,
which includes Contracted, Joint, Joint Venture,
and Sponsored) coded from 1 through 5. Missing
Responses coded as 0.
Dorenfest Database
IHDS facility look
up table
Longitudinal five
years descriptive
data
141
Explanatory/
Independent
Variables
Data Source and

Description
C2c
Mng_Hcare
(External factor)
Managed healthcare variable defined as various

managed care programs that the healthcare delivery
system owns along with their percentage of patient
revenue.
Here an aggregate percent of patient revenue is
considered referring Payor-MngCare-Total (Managed
care organizations) , Payor-Medicare, Payor-Medicaid
(public insurance) . Missing Responses code = 0
Dorenfest Database
IHDS Main table
Longitudinal five
years numerical
data
C3
Struct
HIS structural functionality defined as available total

number of hardware facilities that include number
of computers, IS servers, and IS staff that consists
of managers, programmers, helpdesk personnel, IS
system operators and others for healthcare
organization. (Missing Responses code = 0).
Dorenfest Database
IHDS server table,
IHDS PC table ,
IHDS IS table
Longitudinal five
years numerical
data
C5
Strat_Usage
(Internal Factor)
HIS strategy of IT usage, process reengineering,

quality management, executive decision support
functionality and learning perspectives.
No strategy=1,
Communication, education and training strategy =2,
Improve accessibility and/or usability strategy,
and /or require physician-usage =3,
Planning strategy to replace, upgrade, purchase new
IS and software =4,
Not an issue - 100% physician and administrative
usage of IT=5,
No Response =6.
Dorenfest Database
Strategy to increase
IT usage table
(2002)
Physician increase
usage of IT table
(2003)
Two years
descriptive data
C6
HIS connectivity is defined as dichotomous variable

for IHDS networking and integration status.
In use status for IHDS networking and integration = 1,
Not in use for IHDS networking and integration = 0,
No Response = 2.
Dorenfest Database
IHDS networking
and integration
table
Longitudinal five
years descriptive
data.
Connct
142
Explanatory/
Independent
Variables
Data Source and

Description
C7a
Tech_Appl
(Internal Factor)
Status of other clinical data management application

systems to support EHR:
Automated and self managed = 1,
Automated and contracted = 2,
Not automated = 0,
No Response = 99.
Dorenfest Database
IS applications
table,
Enterprise wide
automation data
table
Two years
descriptive data.
C7b
P_Safety
(Internal Factor)
Utilization of patient safety software applications in

healthcare organization.
In use = 1
Not in use = 0,
No Response = 99.
Dorenfest Database
Patient safety table
Two years
descriptive data.
C7c
D_Security
(Internal Factor)
Status of clinical data security issues in healthcare

organization.
Non existence of data security issues/problems =1,
Existence of data security issues/problems = 0,
No Response = 2.
Dorenfest Database
Security Issues
table (Existence of
data security
issues/problems
related to network
security, firewall,
patient's privacy
issues, data access,
data storage, data
encryption,
electronic virus and
disaster control.
Two years
descriptive data.
143
APPENDIX B. Output from Statistical Package for Social Sciences-Graduate Pack Version 13.0
Descriptive Statistics
Table B1.
Dependent Variable: Healthcare Information Systems (HIS) Annual Operating Cost per Staffed
Bed (1999-2003)
N
Small
Medium
Large
Total
Mean
Std. Deviation
672227.36
2371596.87049
48
687430.24
3757
15610984.60810
46
719899.46
1476
9862195.89261
65
695250.88
5537
13840781.24571
68
304
Table B2.
Dependent Variable: Health Insurance Portability and Accountability Act (HIPAA) Compliance
(2002-2003)
Small
Medium
Large
Mean
Std. Deviation
207
1819
829
.77
.92
.94
.423
.273
.234
144
Table B3.
Dependent/Explanatory Variables: Descriptive Statistics
Small Bed size
Managed Healthcare
HIS Connectivity
EHR Supporting Technology
Application Status
Utilization of Patient Safety
Security Issues
Medium Bed size
Managed Healthcare
HIS Connectivity
Application Status
Security Issues
Mean Statistic
.7104
.88
Std. Deviation
.13448
.327
.14
.343
2.08
3.41
1.38
1.327
2.007
1.115
.53
.501
.57
.498
224.44
745.150
66.23
118.877
24.23
75.058
Mean Statistic Std. Deviation

.7524
.13911
.94
.247
.08
.289
2.41
3.80
1.90
1.278
2.088
1.645
.62
.486
.54
.499
950.12
1904.726
74.61
145.663
42.64
106.791
Valid N (list wise)
145
Table B3.
Dependent/Explanatory Variables: Descriptive Statistics (Continued)
Large Bed Size

Managed Healthcare
HIS Connectivity
EHR Supporting
Technology
Application Status
HIS
Facility
Safety Software
Applications
Security Issues
Available number of
pc
Available number of
servers
Available number of
IS staff
Valid N (list wise)
Mean Statistic
.7484
.97
Std. Deviation
.14998
.168
.21
.470
2.63
1.252
3.95
2.123
2.34
1.848
.69
.462
.68
.466
5550.76
11401.933
85.99
120.462
103.66
318.179
146
Analysis of Variance (ANOVA)
Table B4.
Variable: Log 10 (IS cost), Factor: Bed size

Levene
Statistic
9.261
df1
df2
Sig.
2
2214
.000
Sum of
Mean
Squares
df
Square
Between
6.010
2
3.005
Groups
Within Groups
397.084
2214
.179
Total
403.094
2216
Variable: Managed Healthcare, Factor: Bed size
Levene
Statistic
df1
df2
Sig.
5.026
2
4996
.007
Sum of
Mean
Squares
df
Square
Between
20.691
2
10.345
Groups
Within Groups 16565.96
4996
3.316
7
Total
16586.65
4998
8
147
F
16.756
F
3.120
Sig.
.000
Sig.
.044
Table B4.
Test of Homogeneity of Variances (Continued.)
Variable: HIS structural functionality, Factor: Bed size
Levene
Statistic
HIS structural
functionality-number
of available pc
HIS structural
of available servers
HIS structural
of available IS staff
df1
df2
1016.493
19018
.000
416.414
21908
.000
657.581
22007
.000
Sum of Squares
Mean Square
HIS structural
functionalitynumber of
available pc
Between
Groups
Within
Groups
Total
HIS structural
available servers
Between
Groups
Within
Groups
Total
HIS structural
available IS staff
Sig.
Between
Groups
Within
Groups
Total
df
7344963560.6
49
84784367182.
981
92129330743.
630
1901
8
1902
0
12300572.229
442195612.05
7
454496184.28
6
2190
8
2191
0
151437519.94
8
75718759.974
3531928894.9
18
2200
7
160491.157
3683366414.8
66
2200
9
148
3672481780.3
25
Sig.
823.775
.000
304.708
.000
471.794
.000
4458111.641
6150286.114
20184.207
Discriminant Analysis
Table B5.
Discriminant Analysis: Health Insurance Portability and Accountability Act (HIPAA)
Compliance
Variable: HIPAA Compliance, Factor: Bed Size
Wilks' Lambda
Test of
Wilks'
Chidf
Sig.
Function(s)
Lambda
square
1
.986
40.217
1
.000
Box's M
8.601
F
Approx.
8.589
df1
1
df2
1556655
.552
Sig.
.003
Tests null hypothesis of equal population covariance matrices.
% of
Cumulative
Canonical
Function
Eigenvalue
Variance
%
Correlation
1
.014(a)
100.0
100.0
.118
a. First canonical discriminant functions were used in the analysis.
149
Table B6.
Discriminant Analysis: Physicians Usage of Healthcare Information Systems
Factor: Bed Size
Wilks'
F
df1
df2
Sig.
Lambda
Staffed Bed
.992
2.351
7
2095
.022
size
Box's M
15.788
F
Approx.
2.246
df1
7
df2
54333
3.658
Sig.
.028
% of
Cumulative
Canonical
Function
Eigenvalue
Variance
%
Correlation
1
.008(a)
100.0
100.0
.088
150
Table B7.
Discriminant Analysis: Affiliation Status
Factor: bed Size
Wilks'
F
df1
df2
Sig.
Lambda
Staffed Bed
.987 431.230
4
131305
.000
Size
Box's M
1332.745
F
Approx.
333.042
df1
4
df2
25519416.8
10
Sig.
.000
% of
Cumulative
Canonical
Function
Eigenvalue
Variance
%
Correlation
1
.013(a)
100.0
100.0
.114
151
Table B8.
Discriminant Analysis: Strategic Usage of Healthcare Information Systems
Factor: Bed Size
Wilks'
Lambda
Staffed
Bedsize
Box's M
F
Approx.
df1
df2
.975
F
14.633
df1
df2
4
2305
Sig.
.000
6.599
1.647
4
16069
39.432
Sig.
.159
% of
Cumulative
Canonical
Function
Eigen value
Variance
%
Correlation
1
.025(a)
100.0
100.0
.157
152
Table B9.
Discriminant Analysis: Healthcare Information Systems Connectivity
Factor: Bed Size
Wilks'
F
df1
df2
Sig.
Lambda
Staffed Bed
1234.74
.983
1
71240
.000
size
5
Box's M
4119.433
F
Approx.
4119.373
df1
1
df2
13484809017.
594
Sig.
.000
% of
Cumulative
Canonical
Function
Eigenvalue
Variance
%
Correlation
1
.017(a)
100.0
100.0
.131
153
Table B10.
Discriminant Analysis: Electronic Health Record Supporting Technology Application Status
Factor: Bed Size
Wilks'
Lambda
F
df1
df2
Sig.
Staffed
.983
24.245
2
2852
.000
Bedsize
Box's M
22.603
F
Approx.
11.240
df1
2
df2
12460
4.402
Sig.
.000
% of
Cumulative
Canonical
Function
Eigenvalue
Variance
%
Correlation
1
.017(a)
100.0
100.0
.129
154
Table B11.
Discriminant Analysis: Utilization of Patient Safety Software Applications
Factor: Bed Size
Wilks'
Lambda
F
df1
df2
Sig.
Staffed Bed
.996
12.941
1
2919
.000
size
Box's M
2.318
F
Approx.
2.317
df1
1
df2
12451
317.47
4
Sig.
.128
% of
Cumulative
Canonical
Function
Eigenvalue
Variance
%
Correlation
1
.004(a)
100.0
100.0
.066
155
Table B12.
Discriminant Analysis: Status of Clinical data security issues
Factor: Bed Size

Wilks'
Lambda
F
df1
df2
Sig.
Staffed Bed
.993
11.006
1
1641
.001
size
Box's M
7.798
F
Approx.
7.793
df1
1
df2
76811
77.997
Sig.
.005
% of
Cumulative
Canonical
Function
Eigenvalue
Variance
%
Correlation
1
.007(a)
100.0
100.0
.082
156
Log Transformed Linear Regression Model for Healthcare Information Systems Cost per Bed
Table B13
Small Bed Size Model Summary
Variable: Log Transformed Healthcare Information Systems (HIS) cost per bed
Model
1
2
3
4
5
6
7
8
9
10
11
.602(a)
.602(b)
.598(c)
.596(d)
.593(e)
.583(f)
.571(g)
.557(h)
.526(i)
.455(j)
.432(k)
R
Adjusted
Square R Square
.362
.362
.358
.355
.351
.339
.326
.310
.277
.207
.187
-.050
.008
.054
.097
.135
.159
.179
.195
.190
.146
.157
Std. Error
of the
Estimate
.35283
.34291
.33484
.32714
.32017
.31568
.31193
.30884
.30977
.31819
.31617
R Square
Change
.362
.000
-.004
-.003
-.004
-.012
-.014
-.015
-.033
-.070
-.020
Change Statistics
F
Change df1 df2
.878 11 17
.001
1 17
.116
1 18
.091
1 19
.114
1 20
.388
1 21
.456
1 22
.527
1 23
1.151
1 24
2.432
1 25
.659
1 26
Details from Table B13 are presented below:

a. Predictors: (Constant), Available number of IS staff, Strategic usage of IS, Managed
Healthcare, EHR Supporting Technology Application Status, Physician's Usage of HIS,
Affiliation Status of Facility, Status of clinical Data Security Issues, Utilization of Patient Safety
Software Applications, HIS Connectivity, Available number of PC, and Available number of
servers.
b. Predictors: (Constant), Available number of IS staff, Strategic usage of IS, Managed
157
Sig. F
Change
.577
.970
.737
.766
.739
.540
.506
.475
.294
.131
.424

Affiliation Status of Facility, Utilization of Patient Safety Software Applications, HIS
Connectivity, Available number of PC, and Available number of servers.
c. Predictors: (Constant), Available number of IS staff, Strategic usage of IS, Managed
Utilization of Patient Safety Software Applications, HIS Connectivity, Available number of PC,
and Available number of servers.
d. Predictors: (Constant), Available number of IS staff, Strategic usage of IS, Managed
Utilization of Patient Safety Software Applications, Available number of PC, and Available
number of servers.
e. Predictors: (Constant), Available number of IS staff, Strategic usage of IS, Managed
Healthcare, EHR Supporting Technology Application Status, Utilization of Patient Safety
Software Applications, Available number of PC, and Available number of servers.
f. Predictors: (Constant), Available number of IS staff, Managed Healthcare, EHR
Supporting Technology Application Status, Utilization of Patient Safety Software Applications,
Available number of PC, and Available number of servers.
g. Predictors: (Constant), Available number of IS staff, Managed Healthcare, Utilization
of Patient Safety Software Applications, Available number of PC, and Available number of
servers.
h. Predictors: (Constant), Available number of IS staff, Utilization of Patient Safety
Software Applications, Available number of PC, and Available number of servers.
158
i. Predictors: (Constant), Available number of IS staff, Utilization of Patient Safety

Software Applications, and Available number of servers.
j. Predictors: (Constant), Available number of IS staff and Utilization of Patient Safety
Software Applications.
k. Predictors: (Constant), Utilization of Patient Safety Software Applications.
Table B14
Small Bed Size Model Summary After Removing Information Systems Staff and Information
Systems Servers
Log Transformed HIS cost:
Model
.601(a)
R
Adjusted
Square R Square
.361
Std. Error
of the
Estimate
R Square
Change
.28543
.361
.192
Change Statistics
F
Change df1 df2
2.133
9 34
Sig. F
Change
.050
a. Predictors: (Constant), Available number of PC, EHR Supporting Technology Application

Status, Affiliation Status of Facility, Managed Healthcare, HIS Connectivity, Status of clinical
Data Security Issues, Physician's Usage of HIS, Strategic usage of IS, and Utilization of Patient
Safety Software Applications.
Analysis of Variance (ANOVA) (b)
Sum of
Model
Squares
1
Regression
1.564
Residual
2.770
Total
4.334
df
9
34
43
Mean
Square
.174
.081
F
2.133
Sig.
.050(a)
a. Predictors: (Constant), Available number of PC, EHR Supporting Technology Application

Status, Affiliation Status of Facility, Managed Healthcare, HIS Connectivity, Status of clinical
Data Security Issues, Physician's Usage of HIS, Strategic usage of IS, and Utilization of Patient
Safety Software Applications.
b. Dependent Variable: Log10(IS Cost)
159
Table B14
Small Bed Size Model Summary After Removing Information Systems Staff and Information
Systems Servers (Continued)
Small Bed Size Model Coefficients (a)
B
1
(Constant)
Managed Healthcare
HIS Connectivity
EHR Supporting
Technology
Application Status
HIS
Facility
Safety Software
Applications
Status of clinical
Available number of
pc
Tolerance
VIF
5.856
-.186
-.329
.895
.902
1.117
1.109
-.139
.795
1.258
-.035
.609
1.641
-.008
.699
1.431
.016
.841
1.188
.199
.551
1.814
.091
.823
1.215
.000
.665
1.504
a. Dependent Variable: Log10(IS Cost)
160
Table B15
Medium Bed Size Model Summary
Log 10 IS cost
Model
R
Adjusted
Square R Square
.522(a)
.273
Std.
Error
of the
Estimate
.245
R Square
Change
.28741
.273
Change Statistics
F
Change df1 df2
9.658 11
283
a. Predictors: (Constant), Available number of IS staff, Affiliation Status of Facility, Strategic

Usage of IS, EHR Supporting Technology Application Status, Physician's Usage of HIS,
Managed Healthcare , HIS Connectivity, Utilization of Patient Safety Software Applications,
Available number of PC, Status of clinical Data Security Issues, and Available number of
servers.
Medium Bed Size ANOVA (b)
Model
1
Regression
Residual
Total
Sum of
Squares
df
8.776 11
23.378 283
32.153 294
Mean
Square
.798
.083
F
9.658
Sig.
.000(a)
a. Predictors: (Constant), Available number of IS staff, Affiliation Status of Facility, Strategic

Usage of IS, EHR Supporting Technology Application Status, Physician's Usage of HIS,
Managed Healthcare, HIS Connectivity, Utilization of Patient Safety Software Applications,
Available number of PC, Status of clinical Data Security Issues, and Available number of
servers.
b. Dependent Variable: log_iscost
161
Sig. F
Change
.000
Table B15
Medium Bed Size Model Summary (Continued)
Medium Bed Size Model Coefficients (a): Dependent Variable: log_iscost
(Constant)
Managed Healthcare
HIS Connectivity
EHR Supporting
Technology
Application Status
HIS
Facility
Safety Software
Applications
Security Issues
Available number of
pc
Available number of
servers
Available number of
IS staff
B
5.374
.027
-.017
Tolerance
VIF
.963
.941
1.038
1.063
-.009
.974
1.026
.010
.949
1.054
.005
.927
1.078
.000
.936
1.068
.041
.905
1.105
.044
.872
1.147
.000
.892
1.122
.000
.777
1.287
.000
.781
1.281
162
Table B16
Large Bed Size Model Summary
Model
1
Adjusted
R
R Square R Square
.269(a)
.072
-.020
Std. Error
of the
Estimate
.31040
a. Predictors: (Constant), Available number of IS staff, HIPAA Compliance, Available number

of pc, Strategic usage of IS, Affiliation Status of Facility, Managed Healthcare, Utilization of
Patient Safety Software Applications, Status of clinical Data Security Issues, Physician's Usage
of HIS, EHR Supporting Technology Application Status, and Available number of servers.
Table B17
Large Bed Size Model Summary After Removing Information Systems Staff and Information
Systems Servers
Model
.245(a)
R
Adjusted
Square R Square
.060
-.001
Std.
Error
of the
Estimate
R Square
Change
.40281
.060
Change Statistics
F
Change df1 df2
.978
8
122
Sig. F
Change
.457
a Predictors: (Constant), Available number of PC, Status of clinical Data Security Issues,
Physician's Usage of HIS, Utilization of Patient Safety Software Applications, Managed
Healthcare, Strategic usage of IS, Affiliation Status of Facility, and EHR Supporting Technology
Application Status.
163
Table B17
Large Bed Size Model Summary After Removing Information Systems Staff and Information
Systems Servers (Continued)
Model Coefficients (a): Dependent Variable: Log10 (IS Cost per staffed bed)
(Constant)
Managed Healthcare
EHR Supporting
Technology
Application Status
HIS
Facility
Safety Software
Applications
Status of clinical
Available number of
pc
B
5.292
.246
Tolerance
VIF
.952
1.051
-.059
.797
1.254
.029
.922
1.084
-.007
.914
1.094
.010
.868
1.152
.062
.907
1.103
-.045
.891
1.123
1.15E005
.872
1.147
164
Table B18
Large Bed Size Model Summary Using Stepwise Regression/Backward Regression
ANOVA (k)
Model
1
10
Regression
Residual
Total
Regression
Residual
Total
Regression
Residual
Total
Regression
Residual
Total
Regression
Residual
Total
Regression
Residual
Total
Regression
Residual
Total
Regression
Residual
Total
Regression
Residual
Total
Regression
Residual
Total
Sum of
Squares
.818
10.608
11.426
.818
10.608
11.426
.815
10.611
11.426
.809
10.617
11.426
.781
10.645
11.426
.753
10.674
11.426
.686
10.740
11.426
.615
10.812
11.426
.497
10.929
11.426
.356
11.070
11.426
df
10
111
121
9
112
121
8
113
121
7
114
121
6
115
121
5
116
121
4
117
121
3
118
121
2
119
121
1
120
121
Mean Square
.082
.096
F
.856
Sig.
.576(a)
.091
.095
.960
.477(b)
.102
.094
1.085
.379(c)
.116
.093
1.241
.286(d)
.130
.093
1.407
.218(e)
.151
.092
1.636
.156(f)
.172
.092
1.868
.121(g)
.205
.092
2.236
.088(h)
.249
.092
2.707
.071(i)
.356
.092
3.861
.052(j)
Details from Table B18 are presented as follows.

a. Predictors: (Constant), Available number of IS staff, Affiliation Status of Facility,
Strategic usage of IS, Available number of PC, Managed Healthcare, Utilization of Patient
165
Safety Software Applications, Status of clinical Data Security Issues, Physician's Usage of HIS,
EHR Supporting Technology Application Status, and Available number of servers.
b. Predictors: (Constant), Available number of IS staff, Affiliation Status of Facility,
Safety Software Applications, Status of clinical Data Security Issues, EHR Supporting
Technology Application Status, and Available number of servers.
c. Predictors: (Constant), Available number of IS staff, Affiliation Status of Facility,
Safety Software Applications, EHR Supporting Technology Application Status, and Available
number of servers.
d. Predictors: (Constant), Available number of IS staff, Affiliation Status of Facility,
Strategic usage of IS, Available number of PC, Managed Healthcare, EHR Supporting
Technology Application Status, and Available number of servers.
e. Predictors: (Constant), Available number of IS staff, Affiliation Status of Facility,
Available number of PC, Managed Healthcare, EHR Supporting Technology Application Status,
and Available number of servers.
f. Predictors: (Constant), Available number of IS staff, Affiliation Status of Facility,
Available number of PC, Managed Healthcare, and EHR Supporting Technology Application
Status.
g. Predictors: (Constant), Available number of IS staff, Affiliation Status of Facility,
Available number of PC, and EHR Supporting Technology Application Status.
166
h. Predictors: (Constant), Available number of IS staff, Available number of PC, and

EHR Supporting Technology Application Status.
i. Predictors: (Constant), Available number of PCand EHR Supporting Technology
Application Status.
j. Predictors: (Constant), Available number of PC.
k. Dependent Variable: Log10 (IS Cost per staffed bed).
Logistic Regression Model for Health Insurance Portability and Accountability Act Compliance
Table B19
Small Bed Size: Health Insurance Portability and Accountability Act (HIPAA) Compliance
Model Summary
B
Step
Constant
1.910
0
Variables not in the Equation
Step
0
Variables
Overall Statistics
S.E.
.536
mng_hcare
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Wald
df
12.703
Score
.721
.317
.492
1.525
.213
.317
.043
2.526
.319
.043
.452
11.382
167
Sig.
1
.000
1
1
1
1
1
1
1
1
1
1
1
11
Sig.
.396
.574
.483
.217
.645
.574
.835
.112
.572
.836
.501
.412
df
Exp(B)
6.750
Table B20
Small Bed Size Health Insurance Portability and Accountability Act (HIPAA) Compliance
Model: Standardized Canonical Discriminant Function Coefficients
Managed Healthcare
HIS Connectivity
EHR Supporting
Technology
Application Status
HIS
Facility
Safety Software
Applications
Security Issues
Available number of
pc
Available number of
servers
Available number of
IS staff
Function
1
-.201
-.095
.392
1.068
.406
.156
-.505
.955
-.041
-.898
1.240
168
Table B21
Small Bed Size Health Insurance Portability and Accountability Act (HIPAA) Compliance Model
Summary Using Block One Backward Stepwise (Conditional) Method
Step
1
-2 Log
likelihood
.000(a)
Cox &
Snell R
Square
.537
Nagelkerke
R Square
1.000
a. Estimation terminated at iteration number 23 because a perfect fit is detected. This solution is
not unique.
Step
1
Chisquare
.000
df
4
Sig.
1.000
169
Table B22
Medium Bed Size Health Insurance Portability and Accountability Act (HIPAA) Compliance
Model Summary

B
Step
0
Constan
t
S.E.
3.055
.273
Wald
df
124.754
Sig.
1
.000
1
1
1
1
1
1
1
1
1
1
1
Sig.
.535
.571
.197
.398
.595
.182
.066
.033
.509
.356
.899
Variables not in the Equation(a)
Step
0
Variables
mng_hcare
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Score
.386
.321
1.668
.715
.283
1.782
3.387
4.555
.436
.853
.016
df
a. Residual Chi-Squares are not computed because of redundancies.
170
Exp(B)
21.214
Table B23
Model Using Block One and Backward Stepwise Likelihood Ratio Method
Model Summary
Step
1
2
3
4
5
6
7
8
9
10
-2 Log
likelihood
94.050(a)
94.253(a)
94.870(a)
95.450(a)
96.248(a)
97.766(a)
99.150(a)
100.836(a)
103.170(b)
105.352(b)
Cox &
Snell R
Square
.063
.062
.060
.058
.056
.051
.047
.042
.035
.028
Nagelkerke
R Square
.204
.202
.196
.190
.182
.167
.154
.137
.113
.091
a. Estimation terminated at eighth iteration because parameter estimates changed by less than
.001.
b. Estimation terminated at seventh iteration because parameter estimates changed by less than
.001.
ChiStep
square
df
1
6.964
2
2.944
3
10.318
4
14.472
5
3.748
6
9.365
7
5.836
8
1.990
9
2.205
10
4.013
8
8
8
8
8
7
7
4
4
2
Sig.
.541
.938
.243
.070
.879
.227
.559
.738
.698
.134
171
Table B23
Model Using Block One Backward Stepwise Likelihood Ratio Method (Continued)
Step
1(a)
Step
2(a)
Step
3(a)
Step
4(a)
Variables
mng_hcare
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Constant
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Constant
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
Constant
connct
tech_appl
strat_usage
p_his_usage
affil_status
B
1.008
1.923
-1.323
-.313
-.150
-.222
-1.564
2.326
.001
-.003
.003
2.819
1.898
-1.317
-.333
-.148
-.223
-1.564
2.315
.001
-.003
.003
3.631
1.998
-1.303
-.344
-.127
-.219
-1.566
2.257
.001
-.001
3.575
2.171
-1.263
-.353
-.124
-.203
S.E.
2.226
1.302
.645
.272
.141
.154
1.074
1.138
.001
.002
.005
2.589
1.304
.644
.268
.141
.154
1.075
1.137
.001
.002
.005
1.897
1.284
.639
.269
.137
.154
1.069
1.132
.001
.002
1.866
1.259
.637
.267
.137
.151
Wald
.205
2.180
4.200
1.325
1.128
2.070
2.120
4.181
2.962
1.297
.527
1.185
2.117
4.186
1.544
1.108
2.091
2.118
4.144
3.021
1.311
.506
3.665
2.423
4.150
1.631
.867
2.021
2.145
3.973
2.851
.667
3.671
2.971
3.933
1.758
.817
1.793
172
df
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Sig.
.651
.140
.040
.250
.288
.150
.145
.041
.085
.255
.468
.276
.146
.041
.214
.292
.148
.146
.042
.082
.252
.477
.056
.120
.042
.202
.352
.155
.143
.046
.091
.414
.055
.085
.047
.185
.366
.181
Exp(B)
2.739
6.841
.266
.731
.861
.801
.209
10.241
1.001
.997
1.003
16.763
6.671
.268
.717
.862
.800
.209
10.121
1.001
.997
1.003
37.763
7.376
.272
.709
.880
.804
.209
9.551
1.001
.999
35.700
8.765
.283
.702
.884
.817
Table B23
Model Using Block One and Backward Stepwise Likelihood Ratio Method (Continued)
Step
5(a)
Step
6(a)
Step
7(a)
Step
8(a)
Step
9(a)
Step
10(a)
p_safety
d_security
struct_pc
Constant
.
connct
tech_appl
strat_usage
affil_status
p_safety
d_security
struct_pc
Constant
connct
tech_appl
affil_status
p_safety
d_security
struct_pc
Constant
connct
tech_appl
p_safety
d_security
struct_pc
Constant
tech_appl
p_safety
d_security
struct_pc
Constant
tech_appl
p_safety
d_security
Constant
p_safety
d_security
Constant
-1.544
2.337
.001
3.229
1.069
1.144
.001
1.803
2.086
4.171
2.862
3.207
1
1
1
1
.149
.041
.091
.073
.213
10.347
1.001
25.260
S.E
Wald
df
Sig.
Exp(B)
2.103
1.249
2.834
092
8.188
-1.204
-.320
-.200
-1.605
2.206
.001
2.826
1.976
-1.213
-.178
-1.567
2.256
.001
2.129
1.830
-1.233
-1.636
2.334
.001
1.979
-1.139
-1.621
2.060
.001
3.785
-.952
-1.545
1.919
4.141
-1.501
1.761
3.995
.628
.261
.151
1.064
1.123
.001
1.729
1.233
.627
.149
1.063
1.134
.001
1.614
1.220
.618
1.064
1.132
.000
1.600
.606
1.058
1.079
.000
1.058
.572
1.056
1.060
1.031
1.051
1.049
1.018
3.670
1.507
1.754
2.274
3.861
2.589
2.671
2.570
3.748
1.426
2.171
3.958
2.087
1.741
2.251
3.975
2.365
4.248
1.684
1.529
3.528
2.350
3.645
1.473
12.804
2.766
2.142
3.273
16.121
2.042
2.820
15.403
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
.055
.220
.185
.132
.049
.108
.102
.109
.053
.232
.141
.047
.149
.187
.134
.046
.124
.039
.194
.216
.060
.125
.056
.225
.000
.096
.143
.070
.000
.153
.093
.000
.300
.726
.819
.201
9.077
1.001
16.879
7.217
.297
.837
.209
9.541
1.001
8.409
6.236
.292
.195
10.315
1.001
7.237
.320
.198
7.845
1.001
44.039
.386
.213
6.811
62.881
.223
5.821
54.325
173
In Table B23, 'a' indicates variable(s) entered on step one as: mng_hcare, connct,
tech_appl, strat_usage, p_his_usage, affil_status, p_safety, d_security, struct_pc, struct_server,
struct_staff.
174
Table B24
Model if Terms Removed
Variable
Step 1 mng_hcare
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Step 2 connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Step 3 connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
Model Log
Likelihood
-47.127
-47.869
-48.701
-47.695
-47.577
-48.031
-48.569
-50.489
-49.354
-47.601
-47.348
-47.949
-48.800
-47.909
-47.669
-48.142
-48.670
-50.550
-49.518
-47.706
-47.435
-48.357
-49.085
-48.260
-47.858
-48.418
-49.007
-50.707
Change in 2 Log
Likelihood
.203
1.688
3.352
1.340
1.105
2.012
3.089
6.927
4.659
1.152
.646
1.645
3.346
1.564
1.085
2.031
3.086
6.847
4.783
1.159
.617
1.843
3.299
1.650
.846
1.966
3.145
6.543
df
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
175
Sig. of the
Change
.652
.194
.067
.247
.293
.156
.079
.008
.031
.283
.421
.200
.067
.211
.298
.154
.079
.009
.029
.282
.432
.175
.069
.199
.358
.161
.076
.011
Table B24
Model if Terms Removed (Continued)
Hipaa Medium bed Size
Variables
Step 4
Model Log
Likelihood
Change in 2 Log
Likelihood
d.f.
Sig. of the
Change
struct_pc
struct_server
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
-49.719
-47.725
-48.812
-49.294
-48.616
-48.124
-48.594
-49.247
-51.180
-50.031
4.568
.580
2.174
3.137
1.781
.798
1.739
3.044
6.910
4.611
1
1
1
1
1
1
1
1
1
1
.033
.446
.140
.077
.182
.372
.187
.081
.009
.032
connct
tech_appl
strat_usage
affil_status
p_safety
d_security
struct_pc
connct
tech_appl
affil_status
p_safety
d_security
struct_pc
connct
tech_appl
p_safety
d_security
struct_pc
-49.162
-49.593
-48.883
-48.974
-49.825
-51.297
-50.203
-49.832
-50.386
-49.575
-50.497
-52.152
-50.584
-50.418
-51.129
-51.365
-53.158
-50.906
2.077
2.938
1.518
1.700
3.402
6.346
4.158
1.898
3.007
1.384
3.227
6.538
3.402
1.686
3.109
3.580
7.166
2.663
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
150
.086
.218
.192
.065
.012
.041
.168
.083
.240
.072
.011
.065
.194
.078
.058
.007
.103
..
Step 5
Step 6
Step 7
176
Table B24
Model if Terms Removed (Continued)
Step 8
Step 9
Step
10
tech_appl
p_safety
d_security
struct_pc
tech_appl
p_safety
d_security
p_safety
d_security
-51.800
-52.207
-53.434
-51.585
-52.676
-53.193
-54.257
-54.204
-54.936
2.765
3.579
6.032
2.334
2.183
3.217
5.344
3.055
4.520
1
1
1
1
1
1
1
1
1
.096
.059
.014
.127
.140
.073
.021
.080
.034
The Cut Value is 0.500
Table B25
Function
1
Managed Healthcare
HIS Connectivity
Application Status
-.144
-.329
.239
.137
.308

.379

Security Issues
.443
-.585
-.305
.290
-.209
177
Table B26
Large Bed Size Health Insurance Portability and Accountability Act (HIPAA)
Variables in the
B
S.E.
Equation
Step
Constant
4.227
.712
0
Variables not in the Equation(a)
Step Variables
mng_hcare
0
connct(1)
tech_appl
tech_appl(1)
tech_appl(2)
strat_usage
strat_usage(1)
strat_usage(2)
strat_usage(3)
strat_usage(4)
p_his_usage
p_his_usage(1)
p_his_usage(2)
p_his_usage(3)
p_his_usage(4)
p_his_usage(5)
p_his_usage(6)
p_his_usage(7)
affil_status
affil_status(1)
affil_status(2)
affil_status(3)
affil_status(4)
p_safety(1)
d_security(1)
struct_pc
struct_server
struct_staff
Wald
df
35.218
Score
Sig.
1
df
Exp(B)
.000
68.500
Sig.
.212
.645
.015
7.373
6.030
7.373
14.032
.709
.614
.321
.909
15.879
.030
1.943
6.348
.092
.535
.030
.264
1.289
1.289
.045
.157
.763
.763
1.369
.189
.006
.000
1
2
1
1
4
1
1
1
1
7
1
1
1
1
1
1
1
4
1
1
1
1
1
1
1
1
1
.903
.025
.014
.007
.007
.400
.433
.571
.340
.026
.863
.163
.012
.762
.465
.863
.607
.863
.256
.832
.692
.382
.382
.242
.664
.940
.985
Note. 'a' indicates residual Chi-Squares are not computed because of redundancies.
178
Table B27
Large Bed Size Health Insurance Portability and Accountability Act (HIPAA) Compliance Model
Summary with Block One Backward Stepwise Likelihood Ratio Method
Step
1
2
3
4
5
6
7
8
9
-2 Log
likelihoo
d
.000(a)
.000(a)
.000(a)
.000(a)
.000(a)
.000(a)
.000(a)
.000(a)
.000(a)
Cox &
Snell R
Square
.140
.140
.140
.140
.140
.140
.140
.140
.140
Nagelkerke
R Square
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
a. Estimation terminated at 20th iteration because maximum iterations have been reached.
Final solution cannot be found.
Hosmer and Lemeshow Test:
ChiStep
df
square
1
.000
2
.000
3
.000
4
.000
5
.000
6
.000
7
.000
8
.000
9
.000
3
3
2
2
1
2
2
2
2
Sig.
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
179
Table B28
if Terms Removed
Variable
Step mng_hcare
1
connct
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Step mng_hcare
2
tech_appl
strat_usage
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Step mng_hcare
3
tech_appl
p_his_usage
affil_status
p_safety
d_security
struct_pc
struct_server
struct_staff
Model Log
Likelihood
Change in
-2 Log
Likelihood
.000
.000
.996
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
1
2
4
7
4
1
1
1
1
1
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
.000
.000
995
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
2
4
7
4
1
1
1
1
1
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
1.000
.000
.000
.989
-5.033
.000
.000
.000
.000
.000
.000
.000
10.066
.000
.000
.000
.000
.000
.000
.000
2
7
4
1
1
1
1
1
.007
1.000
1.000
1.000
1.000
1.000
1.000
1.000
180
Sig. of the
Change
df
Table B28
if Terms Removed (Continued)
Step
4
.000
.000
.992
-5.033
.000
.000
.000
10.066
.001
.000
.000
2
7
1
1
.007
1.000
1.000
1.000
.000
.000
1.000
.000
.000
1.000
1.000
.000
.000
.000
.000
.993
tech_appl
p_his_usage
d_security
struct_pc
struct_server
struct_staff
mng_hcare
-5.492
-5.257
.000
.000
.000
.000
10.983
10.515
.000
.000
.000
.000
2
7
1
1
1
1
.004
.161
1.000
1.000
1.000
1.000
.000
.000
.989
tech_appl
p_his_usage
struct_pc
struct_server
struct_staff
mng_hcare
-5.814
-5.817
.000
.000
.000
11.628
11.633
.000
.000
.000
2
7
1
1
1
.003
.113
1.000
1.000
1.000
-2.183
4.367
.037
tech_appl
p_his_usage
struct_server
struct_staff
mng_hcare
-5.941
-6.909
.000
.000
11.881
13.819
.000
.000
2
7
1
1
.003
.055
1.000
1.000
-2.247
4.494
.034
tech_appl
-5.962
11.924
.003
mng_hcare
tech_appl
p_his_usage
p_safety
d_security
Step struct_pc
4
struct_server
struct_staff
Step
5
Step
6
Step
7
Step
8
mng_hcare
181
Table B28
if Terms Removed (Continued)
Step p_his_usage
8
struct_staff
Step mng_hcare
9
tech_appl
p_his_usage
-7.034
14.068
.050
.000
.000
1.000
-2.249
4.499
.034
-6.002
12.004
-7.105
14.209
.002
.048
a. Variable(s) removed on step 2: connct.

b. Variable(s) removed on step 3: strat_usage.
c. Variable(s) removed on step 4: affil_status.
d. Variable(s) removed on step 5: p_safety.
e. Variable(s) removed on step 6: d_security.
f. Variable(s) removed on step 7: struct_pc.
g. Variable(s) removed on step 8: struct_server.
h. Variable(s) removed on step 9: struct_staff.
i. Residual Chi-Squares are not computed because of redundancies.
The Cut Value is 0.500
182
Table B29
Large Bed Size Health Insurance Portability and Accountability Act (HIPAA) Compliance
Managed Healthcare
HIS Connectivity
EHR Supporting
Technology
Application Status
HIS
Facility
Safety Software
Applications
Security Issues
Available number of
pc
Available number of
servers
Available number of
IS staff
Function
1
.099
.026
.706
.315
.438
-.260
.315
.142
-.407
-.140
.042
183

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IMPLEMENTATION OF ELECTRONIC HEALTH RECORDS:

MODELING AND EVALUATING HEALTHCARE INFORMATION SYSTEMS FOR

A Dissertation Presented in Partial Fulfillment

Vinata Kulkarni, 2006

Introduction to the Problem

Background of the Study

Statement of the Problem

Purpose of the Study

Significance of the Study

Definition of the Terms

Nature of the Study

Assumptions and Limitations

Organization of the Remainder of the Study

CHAPTER 2: LITERATURE REVIEW

The U.S. Healthcare Systems Background

Review of the U.S. Healthcare Information Systems

Electronic Health Record through Healthcare Information Systems for Managed

Theoretical Development and Information Systems Models for Healthcare Information

Healthcare Information Systems and Electronic Health Record Modeling

Summary of the Literature Review

Research Design with the Conceptual Model

Measurement of the Variables

Validity of the Secondary Survey Data Instrument

Log Transformed Linear and Logistic Regression Model

Possible Research Study Implications and Recommendations

CHAPTER 4: DATA COLLECTION AND ANALYSIS

Hypothesis Testing of Healthcare Quality Profiles

Hypothesis Testing of Critical Success Factors' Profiles

Log Transformed Linear and Logistic Regression Models

Summary of the Predictive and Significant Variables

Recommendations for Further Study

A. Definition and Description of the Data Variables

B. Output from Statistical Package for Social Sciences-Graduate Pack

Table 2: Secondary Survey Responses By Bed Size

Table 10: Log Transformed Linear Regression Model Summary

Table B3: Dependent/Explanatory Variables: Descriptive Statistics

Table B4: Test of Homogeneity of Variances

Table B6: Discriminant Analysis: Physicians' Usage of Healthcare Information Systems

Table B7: Discriminant Analysis: Affiliation Status

Table B8: Discriminant Analysis: Strategic Usage of Healthcare Information Systems

Table B9: Discriminant Analysis: Healthcare Information Systems Connectivity

Table B10: Discriminant Analysis: Electronic Health Record Supporting Technology

Table B11: Discriminant Analysis: Utilization of Patient Safety Software Applications

Table B12: Discriminant Analysis: Status of Clinical data security issues

Table B13: Small Bed Size Model Summary

Table B16: Large Bed Size Model Summary

Figure 2: The conceptual model of Electronic Health Record-centric healthcare quality

Figure 7: Normal approximation of log transformed healthcare information systems annual

Many accreditation agencies, state governments, business coalitions, and U.S.

Purpose of the Study

Acute care hospital. As per the description in Dorenfest database, it is a healthcare

In this study, a non-experimental longitudinal design with multivariate data was

CHAPTER 2. LITERATURE REVIEW

As healthcare organizations grew in size and complexity of operational procedures,

Clinical health is described as traditional biomedical and physiological health

Functional health is described as quality of life and general well-being is

Healthcare satisfaction is described as consumers' attitude and responses to the

Healthcare cost is related to acquiring the desired level of health outcome.

Several IT developments evolved in the U.S. healthcare system through government,

organizational size, resources, managerial perspectives, technological developments and

Healthcare Information Systems and Electronic Health Record Modeling

provide a comprehensive understanding of current performance of the organization (Ward &

particularly daily operational information for monitoring the organizational performance