SIMULATION MODELING OF ELECTRONIC HEALTH
RECORDS ADOPTION IN THE U.S. HEALTHCARE SY STEM
NADIYE O. ERDIL
Ph.D.
Department of Systems Science and Industrial Engineering
State University of New Y ork (SUNY ) at Binghamton
PO Box 6000 Binghamton, NY 13902
607-768 2809
nadiye@ binghamton.edu
C. ROBERT EMERSON
Professor
Department of Systems Science and Industrial Engineering
State University of New Y ork (SUNY ) at Binghamton
PO Box 6000 Binghamton, NY 13902
607-777 7663
remerson@ binghamton.edu
ABSTRACT
Increasing the efficiency of the healthcare system in the United States is an important subject
due to rapidly rising costs. Among many propositions to improve the operation of the system,
adoption of Electronic Health Records is widely discussed. This study uses a system dynamics
methodology to develop a simulation model of the adoption process that will allow for the
exploration of policies. This paper presents the development and the preliminary findings of this
model.
Keywords: Electronic Health Records, System Dynamics, Simulation, Causal-loop Diagram
INTRODUCTION
The United States has the largest and the most costly healthcare system in the world [1].
Quality and cost of healthcare services are affecting peoples’ lives, the country’s population
health, and the economy. In searching for ways to improve delivery of healthcare services, better
integration and effective utilization of Health Information Technology (HIT) with an emphasis
on Electronic Health Records (EHRs) is one of the propositions that the healthcare industry has a
near consensus on [2, 3,4,5]. However, EHR adoption in the United States healthcare system
moves slowly [6,7, 8, 9, 10].
Healthcare systems are complex systems. The United States healthcare system, furthermore,
is highly fragmented and has an intricate economic structure. Under these conditions, it is a
challenge to understand how EHR adoption progresses in the system, and to evaluate what kind
of interventions could speed up the process. The objectives of this study are to understand the
factors influencing the adoption decision, how the dynamics of the system affects the adoption
patterns and what kind of interventions can accelerate the adoption. To achieve these objectives,
this research uses a System Dynamics (SD) approach. The SD methodology provides tools to
uncover the dynamics of a system and to explore policy options through simulation. In [11], we
developed a causal loop diagram of the EHR adoption process in the United States. In this
paper, we continue with the development of a simulation model. First, we describe the general
structure of the model, which consists of five sections. Then, we unfold the model by exploring
each of these sections. Lastly, we present the preliminary findings of this simulation model.
METHODOLOGY
System Dynamics (SD) is a methodology that involves simulation modeling used in the
analysis of complex systems. It focuses on the underlying reasons for changes over time. The
cause and effect relationships and the feedback loops are the two fundamental concepts used to
explain a change in a state of a variable. As opposed to discrete-event simulation models that
constitute a large portion of simulation modeling, system dynamics simulation models are
continuous simulation models. Continuous simulation modeling focuses on an aggregated view
of a system, while discrete-event modeling involves detailed modeling of systems.
Introduced in the early 1960s by Jay W. Forrester to study urban dynamics problem, today
SD has a wide range of application areas including healthcare. Applications of SD within the
healthcare are also broad ranging from market analysis, feasibility assessment, chronic disease
management, public health policy evaluations, planning ambulatory services, etc.
MODEL DEVELOPMENT
The main objective of this study is to develop an understanding of the EHR adoption process
and to evaluate various policy options. A simulation model will provide grounds to attain this
objective. The development process of this simulation model is the focus of this paper. This
model is not intended to be a statistical forecasting tool, but rather to be a tool used for
understanding of system behavior and the underlying dynamics. With this tool, policy options
can be tested to assess the response of the system.
To build a stock-flow simulation model, first, the cause and effect relationships (feedback
loops) among factors influencing the adoption process need to be revealed. The causal loop
model explained in the following section captures these feedback loops.
CAUSAL LOOP MODEL (CLM)
Since the complete details of the CLM are in [11], only key points of the model are presented
here. Factors included in the CLM, shown in Figure 1, have been identified through a literature
review and the authors’ prior studies in healthcare. Topics that are frequently discussed and
issues that are stressed by the experts are the main sources. The system includes more factors
than shown in the figure. However, to keep the model at a manageable level the number of
factors is limited.
The focus of the model is the number of providers using EHR systems, represented by the
factor Adopted Population. Although stocks and flows are not commonly used in causal loop
models, population factors are included in the model in that format to emphasize the focus. The
flow adopting indicates the number of providers adopting per year.
The plus/minus signs on the arrows, in Figure 1, indicate how one factor changes because of
a change in the other. The plus sign represents change in the same direction, while the minus
sign corresponds to the opposite direction. The reinforcing and the balancing loops are shown
with letters R and B, respectively.
FEEDBACK LOOPS
Feedback loops shown in Figure 1 capture the major issues in the EHR adoption process.
Interactions of these loops determine the system behavior. Overall, the model focuses on the
factors that influence the adoption decision of the non-adopted population in the provider sector.
For example, increasing presence of EHR systems attracts the non-adopted population. This
causal relationship is captured by the reinforcing Loop R1 in the figure, where the factor
fraction_of population_adopted is an input to the attractiveness for potential adopters. The
complete loop is shown in Figure 2.
EHR implementation cost is another factor that effects the non-adopted population in their
decision to acquire EHR systems. Implementation costs increase as the market matures. While
one would expect these costs to decline in a mature market, considering how fast the digital
technology advances, and thus new and improved structures are needed to support the
advancements, implementation costs increase as more enhanced products are released. With
increased costs, attractiveness of EHR systems declines and fewer providers adopt. This
feedback loop, shown in Figure 3, is Loop B1. The interested reader should refer to [11] for
detailed discussions of all feedback loops shown in Figure 1.
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Figure 1 EHR adoption process in the U.S. Healthcare System - the Causal Loop Model
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Figure 2 Loop R1 ‘more adopters attract non-
adopters’ Figure 3 Loop B1 ‘increasing implementation costs
with mature products”
SD MODEL
The simulation captures most of the feedback loops revealed in the causal loop study. Each
feedback loop involves a number of interacting factors although only the top-level factors are
displayed. By using a top-down approach, the feedback loops of the causal loop model steer the
identification of factors included in the model. Some loops such as B5 and R8 “risk of
purchasing a product obsolete in future” in the CLM shown in Figure 1 are currently eliminated
due to the lack of data.
SD MODEL DESCRIPTION
In this section, first, assumptions of the model are reviewed. Later, the structure of the model
is presented.
MODEL ASSUMPTIONS
The model is based on inpatient setting only which mainly consists of hospitals for two
reasons. As opposed to outpatient setting, there is more data on hospitals’ use of Health
Information Technology; and studying one type of setting reduces model complexity, which is
helpful in development of a starter model.
The model does not distinguish the classification of hospitals, which are the type, the
location, the ownership, and the size. This study assumes that all hospitals are approximately the
same size, and uses the American Hospital Association’s statistics on the total number of
hospitals and the total number of beds in the United States healthcare system to calculate the
average.
The model does not represent providers in transition to EHR systems separately, but includes
them in the non-adopter population.
EHR product and maintenance costs as well as costs of healthcare services are exogenous
variables of the model.
The assumptions of the model at the factor level are the following: Once a provider starts
using an EHR system, it does not abandon the system. Therefore, there is no outflow from the
factor Adopted_Population.
The factor EHR_maintenance_costs represents the expenses associated with maintaining an
EHR system. It includes several factors such as software updates, machine maintenance, user
training, etc. These factors are not separately included in the model for simplicity; but are
aggregated under EHR_maintenance_costs.
Although the total number of hospitals is a dynamic variable, a fixed number' is used in the
model.
Under normal conditions, it is assumed that one percent of the population adopts EHR
systems every year. This number is an average calculated from the adoption rates observed
between the first time the term Computerized Patient Record was used in a publication - 1991,
and 2005. During this period, over eleven percent of the population had acquired EHR systems.
MODEL STRUCTURE
The model’s focus is the adopted population. The factor effecting the adopted population is
the adoption rate multiplier, and thus, is the core of the model. Figure 4 shows the factors
affecting the adoption rate. The model is designed to simulate the EHR adoption rate that is
influenced by these factors.
Providers’
financial gain
SN
Cultural Adoption Rate
Barriers Multiplier
I VarN
Current EHR HIPPA, Privacy issues,
adoption ———}_ confidentiality, other
prevalence regulations, etc.
Costof EHRS —————ey
Insurers’
financial gain
Figure 4 Factors affecting EHR adoption rate
By using the feedback loops identified in the CLM, the process of EHR adoption in the U.S.
healthcare system is divided into five sections, as Figure 5 shows. To unfold the simulation
model, these sections are used for guidance.
The main section includes the backbone of the model, the stock-flow structure that is the
focus of the simulation. The whole population is divided into two categories: providers with and
without EHRs, Adopted_Population and Not_Yet_Adopted_Population respectively. The model
assumes that a certain percentage of non-adopters move into the adopters’ pool each year. The
attractiveness of EHR systems to the non-adopters, which is represented by the factor
adoption_rate multiplier, influences this number. Multiple factors influence the attractiveness.
The provider section contains one of the factors that influence the attractiveness of EHR
systems, provider multiplier. This part of the model computes an average annual retum on
' The total number of hospitals in 2005.
investment (ROI) for an average size hospital, given that an EHR system is in use. High annual
ROI in provider facilities with EHRs attracts the non-adopter population to EHR systems.
Similar to the provider section, the insurer\payer section calculates a multiplier that
represents the insurers and payers approach to the electronic health record systems. The model
computes the financial impacts of EHR systems to the insurer\payers. If a positive impact is
observed, then the insurer\payer supports the acquisition of such systems at provider locations
and establishes transaction systems with the providers that would encourage this acquisition, and
vice versa.
The cost section integrates EHR implementation and maintenance costs into non-adopters’
decision-making on whether to acquire EHR systems. It calculates an average implementation
and maintenance costs based on the number of beds in a facility.
The environment section includes non-financial factors that effect the non-adopted
population, such as cultural barriers, security and privacy issues, etc.
Cost Section
i [ Provider Section ]
[_ Main Secton EHR implementation i
multiplier
provider multiplier
Not Yet Adopted
Population Insuren\Payer Section
adoption rate
multiplies = “==>
insuren\payer multiplier
adopting
security & privacy
cultural barriers ;
adopted population ue issues multiplier
multiplier multiplier
Adopted Mopulation
Environment Section
Figure 5 Main factors in the EHR adoption process in the U.S. Healthcare System — Sections
MODEL VALIDATION AND ANALYSIS
This section begins with the explanation of the model validation process. Then, the results of
the base run simulation and the sensitivity analysis are discussed.
VALIDATION
Of the three test types — structure, behavior, and policy, - the structure tests have been
extensively applied to the simulation model developed for this study. These tests are listed
below. Behavior and policy implications tests, that judge whether a model generates plausible
behavior, were not formally explored. The system that was modeled is fairly young, and thus it
was difficult to interpret the patterns of behavior in terms of their plausibility. Among behavior
tests, only the behavior-sensitivity test was performed. The details of this test are given in the
Sensitivity Analysis section.
Structure verification test: The structure verification test assesses whether the model structure
is consistent with the knowledge about the real system being modeled. The organization of
model variables of this study was verified by walkthroughs of each section explained in the
Model Structure section and comparisons with the causal loop diagram in Figure 1. Mental
model verification included reviews of the model by professionals in the healthcare field.
Parameter verification test: The parameter verification test checks whether all parameters in
the model have real world correspondence and that their values are consistent with the numerical
knowledge of the system. All factors of the model in this study have been extracted from the
literature about the real system and the author’s prior studies in healthcare. Values of all
parameters were derived from studies in the literature about the real system.
Extreme condition test: The extreme condition test examines whether the model exhibits a
realistic behavior when subjected to extreme values. In this study, cost was identified as one of
the significant factors effecting the adoption decision; therefore, extreme condition tests were
performed with factors that were cost related. The response of the model to these tests was
neither unexpected nor unrealistic.
Dimensional consistency test: The dimensional consistency test checks whether all equations
and the dimension of all the variables in the model are specified and balanced. The “Check
Units” feature in Stella that performs a unit consistency check on all model variables was used to
verify the dimensional consistency in the model.
Boundary adequacy test: The boundary adequacy test assesses whether all relevant structure of
the system being modeled is included in the model and the important concepts used to address
the problem are endogenous to the model. In this study, the benefits of EHR systems and
barriers of the adoption process formed the general structure of the model; and consistent with
the purpose of the model, all major factors were generated endogenously.
ANALYSIS - BASE RUN
The simulation starts from 2005. The base run is executed under the assumptions explained
in the Model Assumptions section. It is important to understand that much can be gained by
further studies and variation of the assumptions used. With the current set of data, EHR adoption
patterns from the model output are shown in Figure 6. An S-shape growth is observed on the
number of EHR users indicated by the blue line marked with a 1 on the graph. According to this
output, in about fifty-five years, ninety percent of the provider population would be using EHR
systems. The number adopting follows a slow growth in the beginning, accelerates in the
middle, starts to slow down as saturation begins, and finally stops at maturity. This S-shape
growth behavior is common in new product markets.
Figure 7 shows the EHR usage performance pattern and the expected financial gains and
losses to the provider attributed to EHR system usage. The factor EHR usage_performance
represents the maturity level of EHR systems in a given time period. Indicated by the purple line
marked with a 3 on the graph, EHR products mature over time. Since EHR usage performance
effects the operation of the system functions, its impact on these functions increases as the usage
performance improves. Thus, pattems of expected financial gain and loss follow the EHR usage
performance pattern. The graph indicates that once the EHR products enter a mature state
(middle section of the S-curve), the net financial gain considerably increases, creating an
attractiveness to potential adopters.
® 1: Adopted Population 2: adopting
1 5000:
2 800
1 2500,
2 400"
0.00 25.00 50.00 75.00 100.00
Page 1 Years
NS ? Adoption Pattern
Figure 6 EHR adoption pattem - Base Run
® 1: provider gain 2: provider loss 3: EHR Usage performance
1 18000000" HRS cE Kear, RCE
3: 4.00
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2 2000000 3.
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2 System Performance & Provider Income
Figure 7 Provider Income Pattems — Base Run
SENSITIVITY ANALYSIS
The parameter sensitivity test assesses how robust the model is to uncertain decisions or
assumptions about the data. For the SD model, nine factors were varied one at a time by +20
percent to analyze the effects on the outcome of the model. The nine factors chosen for
sensitivity analysis were related to the adoption rate, system costs, length of stay, utilization of
services, medical mistakes, and the organization size.
Adoption Rate: The model assumes that under normal conditions, one percent of the non-
adopted population acquires EHR systems. This is represented by the factor
adoption_rate normal. With higher values of this factor, a shorter time span to full adoption
was expected. Figure 8 shows the results of varying this factor. As expected, run #3 — with the
highest adoption rate normal, gave the shortest time. Judging by the gap between each output, it
was concluded that the model was sensitive to this factor.
® Adopted Population: 1-2-2
1 000: petaapeaey
pes
‘Input Variables
Runt adoption cate normal
1 0.008
2 0.010
3 0.012
1 2o00
y
eee
‘too 7600 e000 Teo 700.00
Paget ‘yous
2 ‘Adoption Pattome
Figure 8 Sensitivity Analysis - adoption_rate_normal
System C osts-Implementation C ost per Bed: Cost of EHR systems is one of the major barriers
to adoption; therefore, it was expected that the model was sensitive to cost related factors.
Figure 9 shows the response of the model to changing values of the factor
implementation_cost_per_bed. The model output indicated that as the per bed cost increases the
time to full adoption lengthens.
@ Adooted Population: 1-2-2
1 ‘000 Pa ee ee ee
Input Variables}
gun implementation cost oer bea|
1 2800. } 1 ‘aa
2 5500
3 6600
too 7500 5000 75.00 720.00
Paget ‘years
2 ‘Adoption Patter
Figure 9 Sensitivity Analysis - implementation_cost_per_bed
System C osts- Maintenance C ost Per Bed: Results similar to the implementation costs per bed
were expected with the sensitivity analysis on the maintenance costs. The model output, shown
in Figure 10, exhibited the same patterns as in the previous case.
® scoptad Poputaton: 1-2 3-
1 5000: see en oeere
| Tnput Variables
1 2500- + Pe j i Run# maintenance _cost_per bed
1 3086
2 #1358
3 13029
a
| nesta
1 0.
000 2500 e000 7a00 120.00
Page! Years
: 2 ‘Adoption Pattorn
Figure 10 Sensitivity Analysis - maintenance_cost_per_bed
System Costs-Annual Price Increase on EHR_ products: The factor
EHR_implementation_normal reflects the annual price increase on EHR products. Similar to the
factor per bed costs, the model was expected to be sensitive to this factor since it was a cost
related parameter. The model output, shown in Figure 11, asserted this argument. Moreover, the
results indicate that this cost factor is one of the most sensitive factors in the model. The run #3,
representing +20 percent change in annual price increase, shows almost no new adoptions in the
system.
© Acopien Poulain 1-2-3-
1 s000- 4 oper eee
Input Variables
Run EHR implementation _normal
1 2600 | ‘ —<
2 1.010
3 1.212
gol a ea
boo 25.00 50000 76.00 7100.0
fPsoe 1 Years
st 2 Adoption Pattern
Figure 11 Sensitivity Analysis - EHR_implementation_normal
System C osts-A nnual Price Increase on maintenance: The factor EHR_maintenance_normal
reflects the annual price increase on the maintenance of EHR products. Shown in Figure 12, the
output of the model indicates that this is another sensitive factor. Comparing Figure 11 to
Figure 12, increase in implementation costs vs, maintenance costs, it was interesting to see that
while higher implementation costs results in longer time to full adoption, lower maintenance
costs accelerates the adoption. This indicates that the higher initial (short term) and the lower
10
long term expenses are more influential in adopting decision than the lower initial and the higher
long term expenses.
Adopted Population: 1-2-2
1 sno
R 500 = Input Variables
Run # EHR maintenance normal
q 0.8008
2 1.0010
2
ie
00 2500 e000 fn 700.00
Faget years
2 ‘Adoption Pattorn
Figure 12 Sensitivity Analysis -EHR_maintenance_normal
Length of Stay: The factor LOSMPB represents per bed cost of length of stay. Since this factor
positively effects both the provider and the insurer\payer multiplier, a change in its value was
expected to impact the model output. The time gaps between the base run and the alternatives
confirmed that the model was sensitive to this factor.
@ Adopted Population: 1-2-9
1 000: % feeree ee
1 200+ ; Tnput Variables]
Runt LosMips}
326224]
/ 7
3 7 z 482855}
= —_ - 5 579426
neat
=
‘00 700 enn 7800 “ona
Praue1 Years
2 aciption Pattern
Figure 13 Sensitivity Analysis -LOSMPB
Utilization of Services: The factor uos mult denotes a utilization of services multiplier that
represents the fraction of service utilization costs lost to the provider. It is a cost related factor;
however, compared to the other cost related factors its impact on the provider multiplier is not
considerable. Therefore, the model was not expected to respond significantly to the changing
values of this factor. As anticipated, the model output, shown in Figure 14, did not show a
noticeable change of pattern.
a
® scoptad Population: 1-2-3
1 000:
seca So
Input Variables
Run # uos mult
1 2000 : : $ | 1 0.16
; } 2 0.20
woot. 3 0.24
_— —_—-
1 of
too B00 s000 700 Tooad
fecet Years
bse 2 Adantion Pate
Figure 14 Sensitivity Analysis — uos_mult
Cost of Medical Mistakes per Bed: Cost of medical mistakes per bed is represented by the
factor MMMPB in the model. This factor is an input to the provider loss computations. An
increase in the value of this factor increases the financial loss for the provider. Therefore, a
delay in reaching a full EHR adoption was expected with higher values of this factor. However,
results shown in Figure 15 indicated otherwise. This was attributed to the reason that the factor
was also an input in the insurer\payer gain computations. The more financial gain there was for
the insurer, the greater the incentive programs were for the providers to use EHR systems.
Therefore, for providers on one hand there is the financial incentives generated by the
insurer\payers encouraging the use of EHR systems, and on the other, there is the financial loss
caused by the use of the system. The output of this sensitivity analysis showed that the effect of
the factor MMMPB from the insurer section balanced the effects from the provider section.
Therefore, the model did not show sensitivity to the factor MMMPB.
© scsopto Popuaton 1-9-3
1 s000: mes
Input Variables
Run # MMMPB
1 3490
2 4362
3 5234
i 2500 a0 Ta 00.09
Paget Years
ES 2 adoption Pater
Figure 15 Sensitivity Analysis - MMMPB
Billing-C oding-Charging Errors: The factor BCCEMPB represents per bed cost of billing,
coding, and charging. Similar to other cost related factors, the model was expected to respond to
changes in this factor. However, the response of the model, shown in Figure 16, indicated
otherwise. The reason is similar to the case explained in the previous test. This is a factor
affecting both the provider and insurer\payer, in the opposite direction. Thus, a change in one
2
balances the change in the other; and the net change is not significant enough to alter the model
behavior.
® Adopted Popul
1 so00 sis
Input Variables
Run # BCCEMPB
1 246913
A 2500 i 2 308642
y 2 370370
ee
ie
bos t
too moo a Tab Toot
panes vets
LE D Acton Patern
Figure 16 Sensitivity Analysis - BBCEMPB
Total Number of Beds: Total number of beds in the system is represented by the factor TNB.
This factor is an input to all financial calculations. Thus, the model was expected to be sensitive
to this factor. Since, cost becomes a major impediment as the size of the organization gets
smaller [1, 2], a slower adoption pattem was expected with smaller values of TNB. Moving from
the line marked with a 1 to the line marked with a 3 in Figure 17, deceleration in the adoption
patterns were encountered with decreasing number of beds.
adopted Population: 1 2-3-
1 S000:
=
Thput Variables
Bunt IN
1 691849
2 802311
3 962773
i 2600:
00 25100 #000 78100 100.00
Paget Years
Is 2 ‘Adoption Pattern
Figure 17 Sensitivity Analysis - TNB
MODEL IMPLICATIONS
The EHR adoption process in the United States healthcare system follows a common trend
seen in new technology-product markets. An s-shape pattern is projected by the model. Until
approximate forty percent adoption rate is reached, a slow growth is displayed. Then
acceleration in adoption is observed which leads to almost a full adoption in ten years. After
13
ninety-six percent adoption rate is attained, the growth slows down again. The number adopting
reaches its peak around when the adoption rate is seventy percent.
Factors directly affecting the EHR adoption, shown in Figure 18, also exhibit similar
behaviors. Despite that fact that the input functions for these factors are not all s-shape; all
factors, except system cost, show an s-shape output pattern following the trend in the current
adoption rate. System cost, displayed in Figure 18b, presents a different pattern, because it is not
dependent on the current adoption rate. It is based on the assumption that costs increase annually
by one percent [18]. The decreasing trend, which indicates that the negative influences on the
adoption patterns get worse, is due to the consistent increase in the systems cost.
© soon. muir ®proader umer 3 caine
lee ears fesse ‘es
| 2 Fass reat tect adept ater 2 Beoncost
(a) (b)
Figure 18 Factors directly affecting adoption pattem - BASE RUN
The factor provider_multiplier that represents the willingness of the non-adopter population
to adopt EHR systems is indirectly dependent on the EHR system performance, which in tum, is
dependent on the maturity level of the market. Shown in Figure 19, market maturity and
EHR_usage_performance exhibit almost identical behaviors, while the provider_multiplier
behavior is slightly different. The reason is that there are other factors influencing
provider multiplier. Sophisticated EHR products, a result of a mature market, improve
performance metrics. However, enhanced products require enhanced support structure, which
increases the cost of acquiring and maintaining the systems. Since cost is a factor also effecting
provider_multiplier, a slight change in behavior is observed.
Based on the analysis presented in the Sensitivity Analysis Section, the model is sensitive to
cost related parameters, both implementation and maintenance. Among the factors that are
affecting both providers and insurer\payers financial gains, the model is not responsive to factors
that generate effects in the opposite direction.
MODEL LIMITATION AND FUTURE WORK
In our earlier work [11], we presented a causal loop model (CLM) of the EHR adoption
process in the United States healthcare system. In this paper, we discuss a simulation model
developed from this CLM. This model as it stands focuses on the providers’ side of the adoption
process, and includes the insurer\payers partially. Including other stakeholders such as vendors,
patients, etc. would improve the model. Second, these stakeholders’ input should be taken in the
model development and verification phases. Without these, the model is limited and theoretical.
In addition, the model needs rigorous data to strengthen its implications even though it is not
designed to serve as a statistical based inference tool.
14
There are some simplifying assumptions of the model that are not consistent with the real
world situation. For example, in the model, there is no going back to the non-adopted population
once entered in the adopted population. Considering the financial costs of acquiring EHR
systems, it is unexpected to see a move from the adopted population to the non-adopter
population. However, it still is possible. These assumptions, given that data becomes available,
could be altered.
With a complete simulation model, future work lies in the exploration of policy options.
This analysis will help us understand what type of interventions can accelerate the EHR adoption
process, how these interventions can be integrated in the current system, and given that a
policy(s) is executed what the outlook will be.
@ +: rmarkot msturity 2: EHR Ucaye porformanca 2 provider multiplier
1 1.00 rae
y A
3 00
0560,
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|)
3.00 25.00 50.00 7500 100.00
Page 1 Years
Ise 2 System Performace & Market Meturity & Provider Behavior
Figure 19 Market - Performance Metrics - Non-adopter Behavior - BASE RUN
CONCLUSION
This study focuses on the EHR adoption process in the United States healthcare system. The
goal is an understanding of the factors influencing the adoption process, how the dynamics of the
system effects the adoption patterns, and what kind of interventions can accelerate the adoption.
To address this problem, a System Dynamics (SD) methodology is followed. This approach has
provided grounds to bring systems perspective on the topic, something that has yet to be
exploited in the literature. First, a causal loop model of the system is developed. Then, an SD
simulation model is developed. This simulation model is the focus of this paper. The model
represents the general structure of the system from the providers’ perspective. Nonetheless, it
offers a theoretical foundation to gain insights about the dynamics of the system. Future work is
to evaluate various policy and regulatory decisions by using the model.
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About the Authors
Nadiye O. Erdil, (B.S., Computer Science — M.S., Industrial Engineering) received her Ph.D. in
Industrial and Systems Engineering from Binghamton University in Spring 2009. Her research
interests include health systems and health information systems.
C. Robert Emerson is professor of Industrial and Systems Engineering at Binghamton
University. His research interests include finding solutions to policy questions within complex
systems. The applications range from manufacturing to healthcare.
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