Itamar Shabtai Ph.D. and Yossi Lichtenstein Ph.D. itamar@colman.ac.il ; yossil@colman.ac.il College of Management Academic Studies In collaboration with: Irena Milstein Ph.D., Holon Institute of Technology Moshe Leshno M.D., Ph.D., Tel-Aviv University Orna Blondheim M.D., Clalit Healthcare Services המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009 1
Economies of scale in production, distribution and marketing are the hallmark of the industrial economy, resulting in large corporations dominating their sectors. In addition to these supply side economies of scale, the digital economy has economies of scale related to demand, that are called network externalities. The value of technology is typically increased when it's network of customers is large. 2 המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009
Telephones/Fax machines - The more people own telephones/faxes, the more valuable the telephone/fax is to each owner The popularity of the Windows operating system created many applications, increasing it's value, and making Microsoft a near monopoly in this market. Google - The more users and search activities the better results. 3 המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009
Academic In spite of the importance of network externalities to modern economies, and the substantial analytical research on their characteristics (Katz and Shapiro, 1985; Farrell and Saloner, 1985; Milstein and Tishler, 2007), there are few empirical analyses and actual measurements of the extent of network externalities (for a review see Gandal, 2000). Practice managers need to understand Network Externalities and techniques to manage Externalities. Opportunity We have access to a unique, large data-set of the intensity of usage of a medical information system (Shabtai et al., 2007). 4 המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009
Are there network externalities in the healthcare information system under study? What is their extent? 5 המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009
The OFEK system The medical information system that has been chosen for the study, namely the OFEK, was provided by the dbmotion Company. Integrating medical information and interoperability using a health information network (HIN) 6
7 Clalit Hospitals All ER Admissions All ER Units, February 2004 November 2007 Total Admissions and Discharges 800,000 Clalit hospitals: January 2004 November 2007 600,000 226,214 Number of Admissions Number of Discharges Percentage of Admissions 20% 172,045 400,000 134,647 113,276 145,107 200,000 535,241 405,266 344,672 362,398 318,689 83,401 221,547 46,696 10% 0 Soroka Meir Beillinson Emek Kaplan Carmel 110,711 Golda 0% 1/21/2009 7
7 Clalit Hospitals All ER Admissions All ER Units, February 2004 November 2007 Total Admissions and Discharges distributed by insurance All Referrals distributed by insurance 2,500,000 2,000,000 698,198 Number of Admissions Number of Discharges Percentage of Admissions 80% 1,500,000 60% 1,000,000 1,660,698 223,188 40% 500,000 637,826 20% 0 0% Clalit Non-Clalit 1/21/2009 8
Prior Results Percentage of Single-Day Admissions when Medical History was Not Viewed Percentage of Single-Day Admissions when Medical History was Viewed A Decrease in the number of Single-Day Admissions p-value All Insurances 20.9% (146,643) 17.3% (37,882) 17.22% <0.001 Clalit 20.1% (104,854) 16.4% (28,876) 18.41% <0.001 Non-Clalit 23.1% (41,789) 21.1% (9,006) 8.66% <0.001 9
The current study will test if the decision to access historical data for a specific patient, is also related to the availability and use of various types of historical data by the same physician for all other patients : The Probability of Physician (i) Accessing Data for Patient (j) at Admission (t) = α1unit (i) + α2 Insurance Type (j) + α3 Diagnosis (i,j,t) + β Number_Of_Types_Historical-Data-Viewed (i, all other j, all previous t) We expect β to be positive. Namely, we expect the physician to be induced to use the system, if his/her experience is that historical data is generally available. 10 המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009
Variable Coefficient t Comment Unit -0.35-51.68 As expected (Interim uses more data) Insurance Type 0.05 4.178 Surprising Diagnosis -5E-007-13.03 Unclear Number of Types of Historical Data Viewed 0.258 687.67 As expected Should be interpreted more carefully (Innate attitude vs. experience) 11 המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009
Possibly the first theoretically-anchored discussion of network externalities in medical information systems. Public policy implications - If network externalities exist, wide access for the information increases social welfare. Currently, the contract between Clalit and dbmotion excludes other Israeli HMS from using Ofek; this may need to be disallowed by the regulator. 12 המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009
dbmotion (2008) http://www.dbmotion.com/site/content/t1.asp?pid=284&sid=69 Farrell, J. and Saloner, G. (1985). Standardization, Compatibility and Innovation, RAND Journal of Economics, Vol. 16, 70-83. Gandal, N. (2000). Quantifying the Trade Impact of Compatibility Standards and Barriers: An Industrial Organization Perspective, Tel Aviv University, mimeo. Gowrisankaran, G. and Stavins, J. (2004). Network Externalities and Technology Adoption: Lessons from Electronic Payments, RAND Journal of Economics, Vol. 35, 260-276. Katz, M. L. and Shapiro, C. (1985). Network Externalities, Competition, and Compatibility, American Economic Review, Vol. 75, 424-440. Milstein, I. and Tishler, A. (2007). R&D and Product Compatibility in Markets with Network Externalities, Submitted for Publication. Shabtai, I., Leshno, M., Blondheim, O., and Kornbluth., J. (2007). Value of Information for Decision-Making in the Healthcare Environment, Medical and Care Compunetics 4, IOS Press. Shabtai, I., Leshno M., Kornbluth J., Blondheim O., "Realistic value of information in the decision process at the healthcare environment", ILAMI - The Israel Association for Medical Informatics, May 2005, Tel-Aviv, Israel 13 המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009
Thank You for Your Attention! המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009 14
We study Ofek a system that allows access to medical records and diagnostic data (dbmotion, 2008). Ofek is used by Clalit Healthcare Services at its hospitals, as well as community care services. The system is also used by other independent hospitals (e.g., Hadasa), but not the other Israeli health maintenance systems (HMS). The dataset include 922,079 records of admissions in 7 hospitals between February 2004 and November 2007. The records include demographic and clinical data about the patient, as well as the number and type of historical medical data that exist, and those that the physician viewed through the Ofek system. 15 המסלול האקדמי המכללה למינהל, יום המחקר 13.1.2009