Cross-sectional Survey
Jiban Khuntia 1; Xue Ning 1; Rulon Stacey
CU Business School, University of Colorado Denver, Denver, CO, United States
Published on 16.8.2021
Credit to the image on top: whatnextglobal
Acknowledgements: Naser Shekarian, PhD candidate
Key messages:
- The challenges and uncertainties that the COVID-19 pandemic presented to health systems in the United States were unprecedented.
- Almost all health systems have adopted customer-facing digital technologies to enable remote and virtual care deliveries.
- Finally, health systems in the midwest and south, along with low-revenue and noninvestor-owned health systems are more likely to adopt futuristic and growth-oriented digital technologies.
- The response to the disruption of the COVID-19 pandemic highlights the significance of digital technologies.
- We give the clarion call to form a top-level US health systems digital strategy and plan to shape the development blueprints for all health systems and the nation.
Background:
- Almost all health systems have developed some form of customer-facing digital technologies and have worked to align these systems to their existing electronic health records to accommodate the surge in remote and virtual care deliveries during the COVID-19 pandemic.
- Others have developed analytics-driven decision-making capabilities.
- However, it is not clear how health systems in the United States are embracing digital technologies and there is a gap in health systems’ abilities to integrate workflows with expanding technologies to spur innovation and futuristic growth.
- There is a lack of reliable and reported estimates of the current and futuristic digital orientations of health systems.
- Periodic assessments will provide imperatives to policy formulation and align efforts to yield the transformative power of emerging digital technologies.
Objective:
The aim of this study was to explore and examine differences in US health systems with respect to digital orientations in the post-COVID-19 “new normal” in 2021.
Differences were assessed in four dimensions:
- analytics-oriented digital technologies (AODT),
- customer-oriented digital technologies (CODT),
- growth and innovation-oriented digital technologies (GODT), and
- futuristic and experimental digital technologies (FEDT).
The former two dimensions are foundational to health systems’ digital orientation, whereas the latter two will prepare for future disruptions.
Methods:
- We surveyed a robust group of health system chief executive officers (CEOs) across the United States from February to March 2021.
- Among the 625 CEOs, 135 (22%) responded to our survey.
We considered the above four broad digital technology orientations, which were ratified with expert consensus.
Secondary data were collected from the Agency for Healthcare Research and Quality Hospital Compendium, leading to a matched usable dataset of 124 health systems for analysis.
We examined the relationship of adopting the four digital orientations to specific hospital characteristics and earlier reported factors as barriers or facilitators to technology adoption.
Results:
See appendix 2
Conclusions:
- Almost all health systems have some current foundational digital technological orientations to glean intelligence or service delivery to customers, with some notable exceptions.
- Comparatively, fewer health systems have growth or futuristic digital orientations.
- The transformative power of digital technologies can only be leveraged by adopting futuristic digital technologies.
- Thus, the disparities across these orientations suggest that a holistic, consistent, and well-articulated direction across the United States remains elusive.
- Accordingly, we suggest that a policy strategy and financial incentives are necessary to spur a well-visioned and articulated digital orientation for all health systems across the United States.
- In the absence of such a policy to collectively leverage digital transformations, differences in care across the country will continue to be a concern.
FULL VERSION
Introduction
Background
The COVID-19 pandemic aggravated the perennial issues of cost, quality, and delivery challenges of health care in the United States.
Simultaneously, the COVID-19 pandemic has also opened up newer directions to solve some of these challenges.
Digital technologies have come to the forefront in solving many of the challenges.
The critical role of technology in fighting the pandemic through effective tracking of the virus across the world is undeniable.
Health systems have used existing health record systems along with surveillance and monitoring applications to gather, collate, analyze, and present information to the government to make meaningful and valuable decisions to help in the pandemic.
Several technologies played an essential role in informing health systems and frontline health professionals to fight the crisis.
The scope of health information technologies has traditionally been limited to electronic health or medical records, with sporadic examples of data and intelligence-based decision-making using the recorded data.
Digital records have been touted to increase the potential to improve health care providers’ efficiency and effectiveness.
Key functionalities of electronic health records such as computerized provider order entry for medications, electronic prescribing, or using clinical decision support systems have helped to achieve some of the objectives [].
Industry sectors other than health care have leveraged the transformative potential of digital technologies beyond the capture, archiving, and use of data using digital records only.
The increasing prevalence of digital technology is fundamentally transforming how businesses create value.
Research has postulated that technology and strategy align together to drive proper digital transformation and ultimately provide a competitive advantage.
In this context, we sought to address the following questions:
1.What are the digital orientations of health systems in the post COVID-2019 new normal?
2.How can such orientations be measured and compared across health systems to provide a systemic evaluation across the United States?
3.What are the factors that may influence the digital orientations of health systems?
2.With anticipated health care spending to reach US $5.7 trillion by 2026, the time is right to enhance public policy understanding of digital technologies and to build the strategic imperatives around those technologies.
However, to change the current standard practices and install improved digital-based technologies into health systems while leveraging these improvements throughout the industry, a comprehensive assessment of the health systems’ digital orientations in 2021 is needed to inform research and practice.
Literature Review: Digital Orientations
Digital orientation as a strategic direction exhibits superior performance by using and leveraging technology in different ways and through different means while maintaining a view of current and futuristic options [].
A specific digital orientation can be examined from perspectives such as technology scope and capabilities [].
Different digital orientations shape the way organizations create and adapt behaviors and resources [,], similar to market orientation (eg, []) and entrepreneurial orientation (eg, []), which have been extensively studied as sources of competitive advantage [].
- Analytics-oriented digital technologies (AODT),
- Customer-oriented digital technologies (CODT),
- Growth and innovation-oriented digital technologies (GODT), and
- Futuristic and experimental digital technologies (FEDT).
1.Analytics-oriented digital technologies (AODT),
The basic step of digital orientation starts with the technologies that support the existing functions of an organization on a day-to-day basis [,].
Given that electronic health records have been well disseminated in US health care, the data-driven clinical and administrative decision-making based on
- mining applications and
- tools to analyze the data captured along with data available from the records encompass such an orientation.
We coin this category of basic orientation as analytics orientation.
2.Customer-oriented digital technologies (CODT),
Another category is customer-oriented digital technologies (CODT), which involve technical interfaces through which customers can access services that enable standardized delivery of services [,] to provide increased flexibility of access [,].
- Mobile technologies are an example of tools that provide such access.
- Social media-integrated tools and applications result in different avenues for the customer to reach these services [,].
3.Growth and innovation-oriented digital technologies (GODT), and
A set of emerging technologies helps health systems to foster growth and innovation orientation.
These technologies help to reevaluate and reengineer several business functions, similar to the enterprise resource planning applications [].
The underlying concept for this orientation is to be innovative in changing business functions and processes, and extending these innovations across partnering businesses to change the value chain.
For instance, information exchange with organizations helps to provide just-in-time care effectively while extending care provisions across health systems [].
Similarly, virtual and remote care models require that the diagnosis and treatment involving physician and patient interactions be redesigned and aligned to newer value-based models relative to the earlier fee-based models.
4.Futuristic and experimental digital technologies (FEDT).
Finally, futuristic and experimental digital technologies (FEDT) are being trialed or experimented with in terms of their potential to change the practice and delivery of health care [].
These may not be widely disseminated, and the value may not be predictably assessed as is the case for the growth-oriented technologies.
Examples of this category would include
- robotics applications,
- wearable chips, and
- tracking devices [].
- Artificial intelligence and machine learning applications are also being introduced to health care, with some value potential, but are waiting for broader dissemination [].
Delineating the current stage of the four digital orientations described above will aid in guiding strategies and policies in health care.
The US health care systems need an overarching digitally enabled strategic orientation to holistically mirror the heightened, transfunctional role of digitalization across the sector.
Assessment of these four orientations in 2021 is a first step to guide future actions in this direction.
Study Aims, Methods, Statistical Analysis and Results
See the full version of the paper.
Discussion
Principal Findings
This study first explored the digital orientations of health systems across the United States and then examined the factors that may influence the digital orientations of health systems, comparing across the current analytics and customer-oriented technologies, and the growth and futuristic-oriented technologies [].
The main findings suggest that:
- health systems in the midwest and southern states, along with low-revenue and noninvestor-owned health systems have growth or futuristic digital orientations (ie, GODT or FEDT); and
- Small-sized, nonteaching, and less burdened health systems are still focusing on current digital technologies such as analytics or customer-oriented technologies (ie, AODT or CODT).
The first set of results suggests the impacts of size, teaching status, and burden of a health system on its digital orientations.
More specifically, the smaller-sized health systems are more likely to adopt analytics and customer-oriented digital technologies.
Plausibly, smaller health systems are constrained by the complexities of digital technologies to explore advanced digital technologies such as artificial intelligence and robotics [].
Smaller health systems may not have a research and development team or an independent information technology department to steer and improve future technologies and align them to create value.
Third, health systems including hospitals with a lower uncompensated care burden are apt to choose AODT or CODT.
According to a prior study, uncompensated care decreased at hospitals when there was Medicaid expansion []. A
low uncompensated care burden health system presumably has higher revenue, and has no strong motivation to be future-thinking.
In other words, such health systems are satisfied with the revenue from traditional care avenues through the current basic analytics and customer-oriented digital technologies.
Similarly, health systems with a low revenue are also more likely to adopt futuristic and growth-oriented digital technologies.
Although it appears counterintuitive, leaders of low-revenue systems have strong motivation to explore and leverage futuristic digital technology to grow rather than risk failure by sustained low revenue.
In other words, low-revenue systems are aspiring that the futuristic technologies will help them to be efficient and cost-effective on the digital transformative path.
Implications
These findings have several practice and policy implications.
- There are strong indications that small-sized and low-revenue health systems need financial incentives to bridge the digital gap.
- Although their aspirations are high, current revenues may not allow the investment needed to create a competitive advantage.
- On a similar note, it is possible that health systems’ aspirations will end in unmet expectations unless those expectations are used to guide the health system through effective adoption and utilization of appropriate digital technologies.
Earlier failures of electronic health record implementations by several health systems indicate that digital technology adoption and implementation is a risky venture.
Given past failures, evidence suggests that some health systems are either not disciplined enough or financially prepared for such an implementation.
We suggest that policymakers pay attention to these past failures and formulate a well-orchestrated, incentive-based approach for these health systems to succeed in the future.
A point of concern here is the observed significant variations of health systems’ digital orientations.
Although it may be realistic to expect that some variations are unavoidable, such significant variations are of some concern, particularly when all health systems are engaged in similar operations, businesses, and service delivery approaches.
This again points to the lack of consensus and specific public policy in the health care sector regarding the development of digital technologies across the health system.
It is clear that a top-level US health systems digital strategy and plan, driving all health systems with similar implementation criteria is desperately needed.
Once an appropriate public policy is in place, we believe that the market will drive relevant training opportunities, improve organizational capabilities, and focus the attention of CEOs necessary to drive regional developments.
Additionally, we believe that such a process will successfully drive financial, operational, and strategic support for nondigital health systems that cannot thrive in the absence of such support.
At present, it appears that there are only a few senior leaders of health systems who can, without hesitation, state that their system has a health care technology plan and program.
Some wonder if they even have a program at all. As these leaders can adapt to a more significant industry-wide policy of digital technology, their systems will be better positioned to move toward the future to help overcome employee-level resistance to these changes.
Limitations and Directions for Future Research
We acknowledge some limitations of this study.
First, although we examined the impacts of revenue on digital orientations, we could not capture the actual digital expenditures, which is a more significant factor for health systems’ digital options. In the future, we plan to collect data to reflect this factor.
Furthermore, there are several significant barriers to adopting futuristic digital technologies, such as security concerns. Future studies may focus on how these barriers and orientations are aligned.
We also recognize that the underlying tone in this study is that the growth and futuristic orientation is more important than the customer and analytic orientation for health systems, following prior research [4,27]. However, in the current US health care industry, we acknowledge that customer orientation and analytics-driven intelligence also play significant roles in improving quality and efficiency while reducing care delivery costs. Independent of this perspective, a future study may correlate the digital technology orientations with the performance of health systems to justify this assumption. Moreover, we have only focused on the influences of objective factors on digital orientations in this study due to the nature of using secondary data. Future studies may consider other subjective factors such as senior leadership support and strategic alignment–relevant factors.
Conclusions
The challenges and uncertainties that the COVID-19 pandemic presented to health systems in the United States were unprecedented.
The pandemic propelled the transformative and disruptive powers of digitalization to the forefront.
The unprecedented surge of telehealth with remote and virtual care reshaped delivery models, which changed the relationship between patients and care providers.
Further, the pandemic relatively quickly reshaped the acceptance of virtual technology.
More than ever before, health care was provided virtually, and patients who used to have to come to a hospital or clinic were free from that burden.
Given this change, senior leaders need to understand the digital orientations in their health systems to address the challenges and prepare for the uncertainties.
Almost all health systems have adopted customer-facing digital technologies to enable remote and virtual care deliveries.
Indeed, several health systems have analytics-driven decision-making capabilities. Nevertheless, not many health systems use technologies for workflow alignments to spur innovation and futuristic growth.
On the one hand, smaller-sized, nonteaching, and low-burdened health systems tend to adopt analytics and customer-oriented digital technologies.
The rationale for their choice may be financial constraints, lack of capability, and lack of support with respect to policy or technical support.
Finally, health systems in the midwest and south, along with low-revenue and noninvestor-owned health systems are more likely to adopt futuristic and growth-oriented digital technologies.
The underlying reasons can be very complex, but this finding indicates the development pattern regarding location, financial performance, and ownership status.
Some traditionally underrepresented health systems are making efforts to grow by leveraging disruptive digital technologies.
While this is excellent progress, such efforts need to be supported at the highest echelons of the policy level.
With guidance, these policies can better ensure that future failures are avoided.
The response to the disruption of the COVID-19 pandemic highlights the significance of digital technologies.
In the post COVID-19 era, we believe that more and more health systems will see the value of digital transformation.
However, some health systems may fall back in this process due to resource constraints, including tangible resources such as budget and intangible resources such as information technology capabilities [].
It is crucial to provide policy and technical assistance to support the future-oriented digital transformation efforts in health systems.
We give the clarion call to form a top-level US health systems digital strategy and plan to shape the development blueprints for all health systems and the nation.
We give the clarion call to form a top-level US health systems digital strategy and plan to shape the development blueprints for all health systems and the nation.
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Appendix 1: Results
Health systems showed
- a lower level of customer-oriented digital technologies (CODT), (mean 4.70)
- or growth and innovation-oriented digital technologies (GODT), and)(mean 4.54) orientations
- compared with analytics-oriented digital technologies (AODT), (mean 5.03),
- and showed the lowest level of futuristic and experimental digital technologies (FEDT) (mean 4.31).
The ordered logistic estimation results provided nuanced insights. Medium-sized ( P<.001) health systems, major teaching health systems ( P<.001), and systems with high-burden hospitals ( P<.001) appear to be doing worse with respect to analytics-oriented digital technologies (AODT),raising some concerns.
Health systems of medium ( P<.001) and large ( P=.02) sizes, major teaching health systems ( P=.07), those with a high revenue ( P=.05), and systems with high-burden hospitals ( P<.001)
- have less customer-oriented digital technologies (CODT),
Health systems in the midwest ( P=.05) and southern ( P=.04) states
- are more likely to adopt growth and innovation-oriented digital technologies (GODT), and, whereas high-revenue ( P=.004) and investor-ownership ( P=.01)
- health systems are deterred from growth and innovation-oriented digital technologies (GODT).
Health systems of a medium size, and those that are in the midwest ( P<.001), south ( P<.001), and west ( P=.01)
- are more adept to futuristic and experimental digital technologies (FEDT),
Whereas medium ( P<.001) and high-revenue ( P<.001) health systems, and those with a high discharge rate ( P=.04) or high burden ( P=.003, P=.005)
- have subdued futuristic and experimental digital technologies (FEDT).
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About the authors
Jiban Khuntia 1, PhD; Xue Ning 1, PhD; Rulon Stacey 1, PhD
1 CU Business School, University of Colorado Denver , Denver, CO, US
Acknowledgments
The authors thank Naser Shekarian, PhD candidate in the CSIS Business program at the University of Colorado Denver, for help in compiling the addresses of CEOs for the climate study data collection.
This research is part of the Health Systems’ Climate Study of 2021 conducted by the Health Administration Research Consortium.
The Climate Study aims to understand the current state of health systems in the United States following the COVID-19 pandemic.
We extend our sincere thanks to the CEOs from 135 health systems for their active and candid participation.
The authors thank Naser Shekarian, PhD candidate in the CSIS Business program at the University of Colorado Denver, for help in compiling the addresses of CEOs for the climate study data collection.
The authors appreciate the support from the Business School at the University of Colorado Denver for this project, specifically the Health Administrations and the CSIS Business PhD Program for the time and efforts of the authors involved with this study.
Conflicts of Interest
None declared.
Originally published at https://www.jmir.org on August 16, 2021.
Citation
Khuntia J, Ning X, Stacey R
Digital Orientation of Health Systems in the Post–COVID-19 “New Normal” in the United States: Cross-sectional Survey
J Med Internet Res 2021;23(8):e30453
doi: 10.2196/30453PMID: 34254947
