OBJECTIVE. The purpose of this study was to examine the adoption of health information technology by children's hospitals and to document barriers and priorities as they relate to health information technology adoption.
METHODS. Primary data of interest were obtained through the use of a survey instrument distributed to the chief information officers of 199 children's hospitals in the United States. Data were collected on current and future use of a variety of clinical health information technology and telemedicine applications, organizational priorities, barriers to use of health information technology, and hospital and chief information officer characteristics.
RESULTS. Among the 109 responding hospitals (55%), common clinical applications included clinical scheduling (86.2%), transcription (85.3%), and pharmacy (81.9%) and laboratory (80.7%) information. Electronic health records (48.6%), computerized order entry (40.4%), and clinical decision support systems (35.8%) were less common. The most common barriers to health information technology adoption were vendors' inability to deliver products or services to satisfaction (85.4%), lack of staffing resources (82.3%), and difficulty in achieving end-user acceptance (80.2%). The most frequent priority for hospitals was to implement technology to reduce medical errors or to promote safety (72.5%).
CONCLUSION. This first national look at health information technology use by children's hospitals demonstrates the progress in health information technology adoption, current barriers, and priorities for these institutions. In addition, the findings can serve as important benchmarks for future study in this area.
- health information technology
- children's hospitals
- National Association of Children's Hospitals and Related Institutions
The use of health information technology (HIT) by hospitals has increased significantly over the past decade.1 The increase in use has corresponded to mounting evidence2–4 suggesting the diverse benefits that can be realized when hospitals implement information systems. These benefits include improved clinical,5,6 operational,7 and financial8,9 performance. Studies have highlighted the specific benefits,10–12 as well as the risks,13 of HIT for pediatric patients, who are more susceptible to potential harm from medical errors.14
For example, the use of electronic order entry by physicians in a pediatric critical care unit was associated with almost-complete elimination of medication prescribing errors.15 The use of electronic tools was associated with error reduction in pediatric chemotherapy.16 Given the frequency with which patient safety events,17 including adverse drug events12 and medication errors,18,19 affect pediatric care, many experts have advocated the increased use of HIT by pediatric providers.18–21 However, some researchers have identified adverse outcomes related to the implementation of HIT.13
Most children who require hospital care are seen at either acute-care community facilities or specially designated children's hospitals (CHs). CHs, which are devoted exclusively to the care of children, include freestanding acute-care facilities, freestanding rehabilitation or long-term care facilities, freestanding psychiatric facilities, and joint pediatric hospitals operating within larger medical centers. Each year, CHs receive ∼2.3 million emergency department visits and 13 million outpatient visits.22 In addition, CHs consistently provide the vast majority of highly specialized care for children with complex and rare conditions. CHs are also essential providers of care for the 38% of all children who are uninsured or depend on Medicaid and other public insurance sources for their care.22,23 Therefore, CHs provide a significant proportion of care to our nation's most vulnerable patients.
Despite the growing body of research examining HIT use by hospitals in general and the potential benefits of HIT to pediatric patients, little is known about the use of HIT by CHs. The purpose of the current study was to examine the adoption of HIT by CHs and barriers and priorities as they relate to HIT adoption. Moreover, we investigated whether organizational factors may be associated with HIT use. To our knowledge, this is the first study of its kind to document the use of HIT in a national sample of pediatric hospitals.
Primary data collection was conducted in conjunction with the National Association of Children's Hospitals and Related Institutions (NACHRI). NACHRI is a not-for-profit organization of CHs, large pediatric units in medical centers, and related health systems, including those that specialize in rehabilitative care of children with serious chronic or congenital illnesses.24 Of the ∼250 CHs in the United States, 199 (80%) were members of the NACHRI in 2005, the time of data collection. The chief information officers (CIOs) at each of these 199 hospitals were targeted with a survey designed to collect information about hospital HIT priorities, barriers, and usage. The survey and a cover letter signed by NACHRI leaders were mailed in the spring of 2005. The survey was remailed to nonrespondents in the summer of 2005. CIOs had the option of completing an Internet-based version of the survey during the same time period.
The survey was adapted from previous work examining information technology (IT) adoption by acute-care hospitals.25–27 The original survey questions were carefully developed and extensively pilot-tested with a group of hospital IT experts. With the help of pediatric HIT specialists, the current survey was tailored to the specific HIT environment unique to CHs. In brief, the 10-page survey included questions about current and future use of a variety of clinical and nonclinical HIT applications (eg, electronic health records, bar-coded medication management, and telemedicine). In addition, the survey included questions regarding organizational priorities and barriers to the use of HIT, as well as hospital characteristics and CIO demographic features.
We were interested in identifying the overall trends in HIT adoption among CHs and in determining whether certain organizational characteristics were related to the use of clinical HIT applications. Clinical HIT applications include any information system designed to assist directly in the care of patients. We investigated whether organizational size, measured as the number of beds at each CH, was related to HIT adoption. Moreover, we examined whether differences in HIT adoption were present among different CH types (eg, freestanding acute-care CH, specialized CH, or CH operating within a larger medical center). In addition, we examined tax status and geographic location, to determine whether these factors were related to HIT adoption among CHs. Tax status refers to either a for-profit or not-for-profit designation, and geographic location was based on the US Census tract region.28
The study protocol regarding data collection was approved by the Florida State University institutional review board. We used standard descriptive statistics and SPSS 13.0 (SPSS, Chicago, IL) to analyze the data, first using univariate techniques (χ2 test or independent-sample t test as appropriate) and then using multivariate models (ordinary least-squares regression analyses) to identify differences among groups. Differences were considered to be statistically significant at the P = .05 level.
A total of 109 CHs responded to our survey, yielding a 55% participation rate. Demographic characteristics of the responding hospitals and their CIOs are presented in Table 1. Of the 109 hospitals that responded to the survey, a majority (52.6%) were CHs operating within a larger hospital. The mean bed size was 373, and almost all respondents reported that their hospital had a not-for-profit tax designation. CIOs were mostly male (73.1%), had been in their current position for an average of 5.6 years, and had an average of 21.9 years of experience in the IT field. Only 4 CIOs were licensed physicians.
Clinical Information Systems
Respondents were asked to indicate which of 24 clinical IT applications and 9 telemedicine applications were available at their CH (Table 2). If a given clinical system was not currently in use, then respondents were asked to indicate whether their organization was planning to implement that system within the next 2 years. No statistically significant differences (eg, all P > .05) in HIT adoption were noted when results were compared according to hospital type (eg, freestanding CH, system-affiliated CH, CH within a hospital, or specialty CH), bed size, tax status, or geographic Census region, in both univariate and multivariate analyses.
Among all CHs, common applications included clinical scheduling (86.2%), transcription (85.3%), and pharmacy (81.9%) and laboratory (80.7%) information systems. Electronic health records (48.6%), computerized order entry (40.4%), and clinical decision support systems (35.8%) were less common. However, 35.8% to 44.0% of the respondents who had not already implemented the applications indicated their intention to adopt these patient safety-related applications within the next 2 years.
The most commonly used telemedicine applications were teleradiology (51.4%) and telecardiology (20.2%). Tele-emergency systems, which involve the transmission of vital statistics and other clinical indicators by emergency medical services (eg, ambulances), were in use at 12.8% of CHs. However, 22 respondents (20.2%) indicated an intention to adopt a tele-emergency system within the next 2 years. This reflected the largest proportion of intended adoption among telemedicine applications.
HIT Priorities and Barriers
CIOs were asked to indicate, from a list, their top 5 current IT priorities (Table 3). Only 2 items were selected by one half or more of respondents (Table 3). The most frequent priority of CHs was to implement technology to reduce medical errors or to promote patient safety (72.5%). In addition, 54.1% of respondents indicated that replacing or upgrading inpatient clinical systems was a current priority for their CH.
Respondents were also asked to indicate how each potential barrier, from a list, affected their organization's ability to implement HIT successfully at their CH (Table 4). No single barrier was rated as major by a majority of respondents. The most common barrier, rated as either major or minor by 85.4% of CIOs, was a vendor's inability to deliver the product or service to satisfaction. More than 40% of respondents reported this as a major barrier. Other common barriers, rated as major or minor, included lack of staffing resources (82.3%) and difficulty in achieving end-user acceptance (80.2%). With the use of the χ2 test to examine trends, no statistically significant differences in priorities or barriers were noted for CHs of different types, sizes, tax statuses, or Census regions.
Regional Health Information Organizations
Regional health information organizations (RHIOs) are local collaborative efforts that attempt to share clinical and other patient information among competing providers in an area. A total of 50 hospitals (50% of those answering this question) reported that their CH was part of a RHIO within the past year. No differences in RHIO participation were detected according to hospital type, tax status, or geographic Census region. However, CHs that were involved in RHIOs were significantly larger, in terms of bed size, than were those that were not (413 beds vs 272 beds; P = .035).
Of the CHs involved in RHIOs, 28 indicated that they had shared patient-level data with other organizations and 20 had received patient data from other organizations. Of CHs that have not yet participated in a RHIO, 31 facilities would consider joining such an effort if one existed in their region. An additional 13.6% suggested that they would not participate, and 4.5% had declined the opportunity to join a RHIO.
Over the past decade, investments in HIT by US hospitals have tripled.1 During this time, researchers have linked increased HIT use to improved outcomes and to certain characteristics among acute-care hospitals. For example, larger hospitals,29–31 those that are not for profit,32,33 and those in an urban location25 seem to adopt HIT more readily than their counterparts. Moreover, membership in a multihospital system has correlated with increased HIT adoption among some acute-care hospitals.27,31 Despite these trends, no study has examined the adoption of HIT by CHs.
In the current study, we found that none of the aforementioned hospital characteristics was associated with HIT adoption among CHs. Surprisingly, hospital size and CH type did not correlate with clinical HIT adoption. Moreover, because most CHs (97%) indicated a not-for-profit tax designation and no CH was located in a rural area, these factors, which were related to HIT use in general acute-care facilities, were not associated with HIT adoption by CHs. In addition, geographic location, based on US Census classifications, did not relate to HIT adoption by CHs. In sum, none of the factors examined was associated with HIT adoption among participating CHs.
Experts have noted that CHs are not merely hospitals that serve children. Instead, they differ in many ways. For example, in comparison with acute-care hospitals that serve children, CHs treat sicker children and have higher charges per admission34 but also have higher quality of care and shorter lengths of stay for certain conditions.35,36 With respect to the factors related to HIT use, the findings for the current study seem to confirm the idea that CHs differ significantly from their adult-serving counterparts. More research is needed for a better understanding of the factors that influence HIT adoption in the exclusively pediatric hospital setting.
At the time of data collection for the present study, >5 years had passed since the publication of the landmark Institute of Medicine report on patient safety.4 That report, which was followed by a series on quality and HIT,2,3 began to advocate for the widespread use of information systems in all clinical settings. The findings of the current study suggest that a significant number of CHs still are not using clinical HIT applications to their fullest. For example, electronic health record systems and computer-based practitioner order entry systems were each used in less than one half of responding CHs. The electronic health record adoption rate was similar to that in a 2003 survey of general acute-care hospitals but was significantly greater than the ∼13% rate of computer-based practitioner order entry system use in that setting.26 It is unclear whether the differences in adoption reflect true differences or normal diffusion of a highly publicized37,38 technology over time.
It is important to note that the most common HIT priority, identified by >70% of CH respondents, was to implement technology to reduce medical errors and/or to promote patient safety. This is consistent with the fact that 35% to 45% of responding CIOs suggested an intention to adopt either an electronic health record or computer-based practitioner order entry system (or both) within the next 2 years. Although almost all respondents either had already adopted or expressed an interest in adopting these technologies, several barriers will need to be overcome before these systems become universally used in CHs.
The most common major barrier to HIT adoption by CHs was vendors' inability to deliver products or services to satisfaction. Lack of adequate financial resources did not rank high, with only approximately one fourth of respondents rating this issue as a major barrier. Health care delivered in CHs is highly tailored to the needs of children. As a result, clinical HIT applications used by CHs must be able to provide certain functionalities (eg, weight-based dosing) that similar systems in general acute-care hospitals may lack. The dissatisfaction with vendors' products, an issue that is not as prominent in the general acute-care literature,27 may reflect the frustrations of CHs with the lack of availability of pediatrics-specific HIT systems in the marketplace. HIT vendors should continue to work with pediatric experts to address this issue.
Despite the new information provided by the present study, several limitations are important to note. First, consistent with survey research, data collection was based on the willingness and ability of individuals to respond to each survey question, as well as their desire to give correct answers. Despite the relatively high response rate, we recognize that response bias is always present in surveys that do not achieve a perfect participation rate. Moreover, given the overall sample size, the relatively small cell sizes in some analyses (especially tax status) might have made it difficult to find differences among groups.
The current HIT study provides baseline data regarding barriers, priorities, and adoption of clinical information systems among CHs. The data can serve as a benchmark for future studies of pediatric settings, as well as comparative studies of other hospitals. More research that focuses on HIT use among providers and organizations that serve children is needed.
This work was supported in part by grants from the All Children's Hospital Foundation, the Pediatric Clinical Research Center of All Children's Hospital and the University of South Florida, and the Maternal and Child Health Bureau (grant R60 MC 00003-01).
- Accepted September 11, 2008.
- Address correspondence to Nir Menachemi, PhD, MPH, UAB School of Public Health, Ryals Building, Room 330, 1530 3rd Ave South, Birmingham, AL 35294. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
- ↵Aspden P. Patient Safety Achieving a New Standard for Care. Washington, DC: National Academies Press; 2004
- ↵Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001
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- ↵Han YY, Carcillo JA, Venkataraman ST, et al. Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics.2005;116 (6):1506– 1512
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- ↵National Association of Children's Hospitals and Related Institutions. All Children Need Children's Hospitals. Alexandria, VA: National Association of Children's Hospitals and Related Institutions; 2007
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