Journal Of Healthcare Information Management

mission of erroneous patient information.

Once EMRAM Stage 3 requirements are met, the EMRAM profile then suggests NL hospitals are likely to be challenged in meeting the requirements of EMRAM Stage 6 (Closed loop medication administration [CLMA] and advanced decision support [CDSS]), with 43.1% of the hospitals in EMRAM Stage 5. The CLMA process includes ePrescribing, medication dispensing and tracking, and administration and documentation in the electronic Medication Administration Record (eMAR). A CDSS function (i.e., alerts) must be available at the point of care immediately prior to administration to ensure the five rights of administration check (right patient, right medication, right dose, right route, and right time). Especially the guarantee of the right medication and the right dose is a challenge in the NL, as bar coded unit doses are not always readily available from the pharmaceutical industries by lack of European bar code standards for drugs.

The other class of variables influencing
EMR adoption in NL hospitals involves
organizational and environmental forces.
By considering a wide array of relevant
variables, the results of this study support
the general assertion that EMR adoption is
influenced by organizational and environ-
mental forces. More specifically, variances
in EMR adoption rates varied notably by
hospital size and hospital type. The same
holds for smaller hospitals. Smaller hos-
pitals are unlikely to have the financial or
human resource means to implement and
use an EMR system. This is consistent
with previous research that has identified
cost as the greatest barrier to EMR adop-
tion and use. 18, 19 When hospitals make an
investment in an EMR system and when
the implementation is successful, the pay-
ers and purchasers also benefit. This mis-
alignment of incentives represents perhaps
the single most important barrier to moving
ahead.
Additionally, it is possible that a smaller
hospital may not have the human resources
available to run such a system. If this is the
case, these smaller hospitals may need to
form a coalition to investigate the feasibility
of a group purchase and implementation of
EMRs. Because EMRs are expensive, and
larger hospitals have begun using EMRs
more than smaller hospitals, it is possible
that without greater economies of scale
for implementation, EMRs are too costly
for the smaller hospitals. If EMRs do in
fact improve hospital quality or efficiency,
policymakers should take steps to encour-
age hospital EMR use. These steps could
include programs that aid hospitals in
implementing and using EMRs with EMR
hardware and software, as well as train-
ing and personnel to help with implemen-
tation. These programs will be especially
important to smaller hospitals.
Policymakers may also, at some point,
offer greater financial reimbursement
for hospitals that use EMRs as a way to
encourage hospital use. Additionally, more
regulations from payer groups and policy-
makers can ensure that hospital EMR use
is practiced. These regulations may be in
the form of requirements for certification,
endorsements, or accreditation. Previous
research has concluded similar incentives
are necessary for more widespread EMR
adoption. 20
Three of the six university hospitals
represented in this study (total of eight
university hospitals in the Netherlands)
have full EMR systems in use in at least one
clinical unit. University hospitals have far
more resources than non-university hos-
pitals and have a different financial model
with more government funding. They have
more IT budget and more ICT employees.
Teaching hospitals are well represented
in the group that is implementing addi-
tional functionalities, which also reflects
other findings. They have higher and bet-
ter resources. Hospitals with higher ICT
budgets were expected to do better, which
is the case.

CONCLUSION

Although small hospitals and hospitals located in the northern part of the Netherlands were underrepresented in the study, the 72 hospitals that did participate provided a fairly good representation of the total population of the Netherland’s 93 hospitals. Although the group is relatively small, and no robust statistical significant conclusions could be drawn, three of the six hypotheses were supported. Adoption and use of the EMR tends to be positively associated with larger hospitals and teaching hospitals. Not found was a relationship between hospital density and population density, as a measure for the competition level, and the EMRAM score.

According to the Resource Dependence theory, resources in areas with low density populations are scarcer in areas of lower population, (potential) patients have less choice, and hospitals feel less urgency to adopt advanced technologies like EMRs. No proof was found for this statement in the Netherlands in this study. Competition in the Netherlands is a new and developing phenomenon. The healthcare insurance companies and the Government play a dominant role. So competition in the classic sense may not be an important factor in the way hospitals act.