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.
In general, the findings of this study sup-
If EMRs do in fact improve hospital quality or
efficiency, policymakers should take steps to
encourage hospital EMR use.