113 General discussion still needs to be found. The lack of interconnection of systems (in the hospital) is also seen as an important limitation. CONCLUSION OF THE SUBQUESTION 3. The eleven medical specialists interviewed shared positive experiences of EMR use in comparison with the former recordings on paper. But it takes a lot of effort and time to keep the patient file up to date. The only result is a non-paper file, which they appreciate, but is ultimately not enough to motivate them. It is tempting to make encoding medical data mandatory. STRENGTHS, WEAKNESSES, AND LIMITATIONS OF THE STUDY A strength of this study is the broad scope. Quality of care information from multiple sources (IGJ, ZIZO, Elsevier, NIVEL, DSCA) is used. The maturity of EMR-systems was repeatedly (for some hospitals three times) measured. Hospitals have been visited during about a four-hour visit and not interviewed by phone as usual at HIMSS. The factors (determinants) affecting this maturity are analyzed. And in addition, medical specialists are asked for their experiences about the influence of maturity on the quality of care. And finally, the 72 hospitals that did participate provided a fairly good representation of the total population of the 93 hospitals in the Netherlands. But there are also weaknesses of this study. The Netherlands is small, so numbers are small, and difficult to find significant confounding factors. Small hospitals and hospitals located in the northern part of the Netherlands were underrepresented in the study. Although a 77% response rate was achieved, the hospitals that did not respond to the survey differed from those that did respond. Given those nonresponding hospitals were more likely to have characteristics associated with lower maturity levels, a residual bias may have led us to overestimate adoption levels. Furthermore, although we adjusted for many factors, unknown confounding factors could still be present such as the lack of active involvement of professionals and management. The main disadvantage of the qualitative analysis among medical specialists is that their findings cannot be extended to broader populations with the same degree of certainty as quantitative analyses. The main objective of this qualitative study was to detect possible factors why the previous quantitative studies did not show a relation. Assessing the 8
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