Information technology and the employment relationship : an examination of the adoption and use of electronic health records

Abstract

This dissertation advances theory on the interplay of workplace technological change and features of the employment relationship to inform an active policy debate. In particular, many connect US healthcare's lackluster economic performance -- both historically and relative to other industries -- to its apparent reluctance to adopt electronic health record (EHR) systems. Drawing on management and employment relations theory as well as a multi-method field study of a large-scale healthcare provider, I first demonstrate that performance improvements depend not on the technology per se, but rather on the concomitant adoption of both the information technology (IT) and the rest of its reinforcing work system. In line with prior research, the work system includes workplace-level employment practices like teamwork and training. However, I advance our understanding of these complementarities by showing that their emergence depends on the scope of participatory structures included in the work system. Irrespective of how engaged workers are in the IT initiative, participation only complements the effectiveness of the EHR system where workers could 1.) renegotiate IT-engendered changes in the terms and conditions of employment, and 2.) influence the configuration and deployment of the technology. Based on these findings, IT adoption does not ensure improved performance, implying a shortcoming in policies promoting the diffusion of EHRs rather than the adoption of EHR-inclusive work systems. Drawing once again on both theory and the field study, I propose that only certain medical practices -- most notably, those that finance patient care on a prepaid or "capitated" basis -- internalize the benefits of EHR investment.

(cont.) Therefore, physicians affiliated with such organizations are more likely to report that their practice adopted the technology along with financial incentives to encourage its optimal use. Those practices whose IT adoption cannot be explained by their business strategy will be less likely to introduce the requisite incentives. Econometric evidence derived from a nationwide sample of physicians finds strong support for these hypotheses. Therefore, this dissertation warns of the imminent decoupling of EHR technology from its work system while advancing management and employment relations theory.