115 General discussion This hypothesis finds also some support in the experiences in American level 7 hospitals which show a higher quality of care in single case studies. 10 11 . However, these case studies are not conducted with comparable hospitals without decision support. 2. The five studies give also rise to the hypothesis: “Expanding digitization of a hospital improves only quality of care when professionals are able to change easily clinical pathways within the hospital” 10,11 . Clinical pathways are professional, multidisciplinary agreements for treating and caring a patient group with the same diagnosis. 12 Expanded digitization could offer quality data which give rise to evaluation which inspires to change a clinical pathway. In Figure 3 we show this missing link. If this is only possible in the organization and in the IT system of the hospital with a delay of a couple of years and with high costs-of-change, the relation between expansion of digitization and quality improvement will stay weak, because in that case many medical specialists are unwilling or unable to comply. Implementing new systems requires technological rethinking and organizational and even social rethinking. 13 14 The significance of technological transition-related problems is clear. 15 In our study we were not able to investigate the relation between the EMRAM score, the quality of care and changes in the clinical pathways. 8
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