24 Chapter 2 potentially scarcer and placing hospitals under more pressure to distinguish themselves from competitors, thus securing their market share of patients. If patients have more choices, they may elect where to go for healthcare and will likely choose a hospital that offers new or better services such as EMRs. Hospitals may reason that EMRs will make them more appealing to the patient population in an area of high competition where patients have choices of where to receive care. In the Netherlands the bargaining of hospital services is done exclusively by the healthcare insurance companies. In some areas certain healthcare insurance companies have a prevalent position. H3: Larger hospitals are more likely to have advanced EMR capabilities. Perhaps the greatest barrier to hospital EMR adoption is the cost of implementation and maintenance. With adequate financial resources, hospitals are likely more able to purchase the often-expensive EMR systems and equipment. However, not all hospitals have the financial means to implement and use complete EMR systems. Those with smaller operating margins are less likely to have the funds to buy and implement EMRs. Organizational power is often associated with organizational size since larger organizations tend to have greater impact on a community than smaller organizations. More powerful organizations may also be those that control vital resources in an environment, and for this reason, these organizations may be in a better position to name the terms of exchange. The power associated with size allows hospitals to more easily achieve economies of scale for services, and larger purchases will likely lead to more negotiation power with suppliers. H4: Academic affiliated hospitals are more likely to have advanced EMR capabilities. University and top teaching hospitals provide a great deal of specialized care andmedical research, as well as provide the training and education of many of the nation’s healthcare workforce. According to Retchin and Wenzel, 13 university health centers, as top teaching hospitals, can easily adapt to the use of EMRs because they “have the expertise to resolve remaining software issues, the components necessary for the integrated delivery, a culture for innovation in clinical practice, and a generation of future providers that can be acclimated to the requisites for computerized records” (p.493). Another reason for this increased likelihood is that medical training occurs in these hospitals, and younger medical trainees tend to be more comfortable with computers as they have recently used them in school. Because of this, the staff resistance to EMR use may not be as great as in other hospitals.
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