109 General discussion reached stage 6 and have implemented ‘close loop medication’ so the ‘five rights of medication administration’ 1 are guaranteed, in addition to ‘intelligent’ care pathways. In most cases, discussions in the investigated 72 hospitals focused on two themes. The first relates to how the hospital in question has arranged ‘closed-loop medication’. 2 The second theme is how intelligent care pathways are applied. This last concept means that the system supports the treating clinician by using decision support or artificial intelligence functionality of the EMR combined with evidence-based practices (what (and why) might be the next step in the treatment). The second objective of this subquestion was to identify organizational, environmental factors, and IT factors associated with maturity. This identifying process was based on the ‘Resource dependence theory’.3 This theory builds on the premise that organizations are not in control of all of the resources they need to survive and therefore attempt to reduce their dependence on external resources in times of uncertainty. Since the maturity of EMR systems may lead to better hospital performance and outcomes and increased efficiency 4, hospitals may use it as a strategy to combat this environmental uncertainty. By considering a wide array of relevant variables 5, determinants investigated during this study were population density, hospital density, financial stability, hospital size, hospital type, and IT capabilities (number of ICT employees and ICT budget). The results of this study 6 do not strongly support the general assertion that maturity is influenced by organizational and environmental factors, nor IT capabilities. However, comparison of the variables on a descriptive scale suggests a consistently positive effect for hospital size, hospital type, and IT capabilities. The multivariate analysis did not find any independent association between the EMRAM-score and the selected factors. These results are somewhat unexpected and give rise to the idea that other (confounding) factors may exist in the Netherlands. CONCLUSIONS OF THE SUBQUESTION 1 Of the 72 hospitals measured of a total of 93 hospitals in the Netherlands, 27 (37.5%) did not reach stage 3 because of lacking a digital nursing record. Hospitals that took this challenge, the full implementation of ‘closed-loop medication and intelligent pathways proved to be a significant next obstacle. No significant relation was found between the selected influencing factors and the degree of maturity. 8
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