114 Chapter 8 conclusions of this qualitative study requires quantitative confirmation. In the qualitative study, only medical specialists were interviewed from hospitals with an EMRAM score 2 in 2012. These hospitals found themselves in low maturity according to the EMRAM model but with significant potential to improve effectiveness and in a position to have learned fromother hospitals before the interviews. However, this qualitative study might still have been too early in the hospital’s implementation of EMR to identify relevant factors for the mature use of EMRs. And finally, the age of the interviewed medical specialists varies between 42 and 62 years. These are medical specialists with a great deal of experience in the field. A question is whether the perception of younger medical specialists corresponds with those of their older colleagues. The younger medical specialist usually does an essential part of the work. ANSWERING THE CENTRAL RESEARCH QUESTION WITH A MAIN CONCLUSION. The central question of this thesis is: What is the relation between thematurity of hospital EMR systems and the quality of care. The three quantitative sub-studies showed little or no association between maturity and quality of care. We found that implementing clinical documentation, especially nursing documentation, ‘Closed Loop Medication Administration’, and intelligent pathways including CDSS, present as a challenge to create an impulse for quality improvement. The interviewed medical specialists prefer digital over the old paper records. The fact that the involved health professionals can access the patient data at any time they need it, is considered important. DISCUSSION OF THE MAIN CONCLUSION Two discussion points arise from this main conclusion: 1. The five studies give rise to the hypothesis “Potential quality improvement lags behind as long as decision support cannot be applied by lack of a fully coded patient record”. However, we could not test this this hypothesis. For this it is necessary to have comparable hospitals: One group with a fully coded patient record with decision support and one group without it. The first group meets the EMRAM stage 7 score: They should achieve an effect with regard to the quality of the care provided. In the Netherlands only two hospitals acquired the EMRAM stage 7 status in 2020. The follow-up time was too short to do a not-randomized comparable case study.
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