Collective Bargaining and Technological Investment: The Case of Nurses’ Unions and the Transition from Paper‐Based to Electronic Health Records

Published date01 December 2017
Date01 December 2017
DOIhttp://doi.org/10.1111/bjir.12249
British Journal of Industrial Relations doi: 10.1111/bjir.12249
55:4 December 2017 0007–1080 pp. 802–830
Collective Bargaining and Technological
Investment: The Case of Nurses’ Unions
and the Transition from Paper-Based to
Electronic Health Records
Adam Seth Litwin
Abstract
Does the presence of a unionized nursing workforce retard US hospitals’
transition from paper-based to electronic health records (EHRs)? After tying
archivaldata on hospitals’ structural features and health information technology
(IT) investment patterns to self-gathereddata on unionism, I find that hospitals
that bargain collectively with their registered nurses (RNs) appear to delay
or forego the transition away from paper, consistent with existing theory
and research in industrial relations and institutional economics. However, this
relationship is fully mediated by a hospital’s payer mix: those serving a larger
share of less lucrative, elderly, disabled and indigent patients are more likely to
adopt EHRs if they are unionized than if they are not, a result that holds even
at the median payer mix. Indeed, this accords with research on the interplay
of labour and technology as the aforementioned dynamics are driven entirely
by RN-exclusive bargaining units for whom the new IT serves as a complement
rather than as a substitute in production. Giventhe outsized role that unions play
in the US healthcare sector, the overall sluggish performance of the sector, and
the expectations that policymakers have for EHRs, evidence that these unions
are welfare-enhancing should be welcome news.
1. Introduction
The question of whether or not unions and collective bargaining inhibit
business investment once captured the fascination of researchers and the
concern of politicians and policymakers (Simons 1944; Slichter et al. 1960).
After all, to the extent that unions could be credibly blamed for hindering
Adam Seth Litwin is at Cornell University.
C
2017 John Wiley & Sons Ltd.
Collective Bargaining and Technological Investment 803
capital accumulation, one could also reasonably accuse them of slowing
economic growth and erodingcompetitiveness writ large (Metcalf 2003)—not
to mention sowing the seeds of their own demise by curtailing the number of
unionized employers (Menezes-Filho and VanReenen 2003). Yet,with private
sector union density in the United States below 7 per cent, one can imagine
many other more viable culprits for most of the country’s and the developed
world’s economic ills.
Despite the apparent evaporationof an urgent need for a ‘grand theory’ to
explain the influence of collective bargaining on investment, those concerned
with the performance of one sector, in particular—healthcare—would be
remiss to discharge this issue as purely academic. Close observers of the
US healthcare sector have noted two parallel phenomena. First, despite
the structural, economy-wide decline in collective bargaining, healthcare
unionism has proven resilient and, in fact, a bright spot for union organizers
(Avgar et al. 2016). While union membership declined by about 200,000
workers nationwide over the period 2012–2014, the healthcare sector added
47,000 new union members (Bloomberg/BNA 2015). Moreover, the insurance
mandate embedded in the Obama-era AordableCare Act (ACA) is expected
to exacerbate existing unmet demand for skilled healthcare workers—
registered nurses (RNs), in particular—extending the period of relative labour
market power for the largest single group of employees in US hospitals (Clark
2013; Juraschek et al. 2012).
Second, whereas nearly every sector in the United States embraced the
digital revolution of the latetwentieth century, healthcare long persisted as the
singular holdout (Porter and Teisberg 2006). Recordkeeping in US hospitals
remained largely paper-based until the federal government as part of its
2009 economic stimulus package started favouring those hospitals adopting
electronic health record (EHR) systems with more generous reimbursement
rates for Medicare and Medicaid, the social welfare programs that fund care
for the elderly, disabled and indigent. Consequently,even as late as 2012, fewer
than half of the nation’s general acute care hospitals claimed to have installed
what Adler-Milstein et al. (2015) and Jha et al. (2009), among others, define
as a ‘basic’ EHR system.
Taken together, these two stylized facts beg the question: has collective
bargaining, particularly on the part of registered nurses, eectively retarded
hospital investments in EHRs? Indeed, if this were the case, then one can
still reasonably point to collective bargaining as the culprit for the sector’s
abysmal performance over time relative to other others domestically and to
the healthcare systems of other nations.And, given the centrality of this sector
to a high-functioning civil society and economy, this accusation could not be
ignored.
I attempt to answer this question by drawing on theory from seminal work
in labour relationsas well as from more recent, economics-oriented research to
predict the mechanisms by which the union statusof nurses in a given hospital
should influence whether and when it adopts an EHR system, controlling for
structural characteristics of the hospitals themselves. In the aggregate, these
C
2017 John Wiley& Sons Ltd.

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