26 Chapter 2 METHODS For themeasurement of the level of implementation of information systems, the concept of maturity of information systems has been developed. There is a large number of methods or models available to measure the level of implementation of IT. 14 This study will use the EMRAM scoring approach developed by HIMSS Analytics. 15 EMRAM is an eight-stage maturation model reflecting the EMR capabilities in hospitals, ranging from a completely paper-based environment (Stage 0) to a highly advanced digital patient record environment (Stage 7). The EMRAMmodel 16 is perhaps one of themost commonly cited EMR maturation models in the world, as its scoring approach has been applied to over 10,000 hospitals in the U.S., Canada, Europe, the Middle and Far-East, and Australia. To adjudicate a hospital’s EMRmaturation, the CEOs of every hospital in the Netherlands (93) were invited to participate in this study. Seventy-two hospitals (77.4%) joined the study. The scoring process was done by identifying the software used in the different functional areas of the hospital. Depending on the level of maturity, each hospital CEO was presented with approximately 150 questions (available from the authors) to focus on varied issues to include demographics, software functionalities, processes, integration standards, and usage in percentage by physicians and nurses. In order to monitor the quality of the scoring process, the authors conducted site visits on selected hospitals. Validation was done by the quality assurance department of HIMSS Analytics Europe and the scoring by a proprietary scoring algorithm (HIMSS Analytics North America). If a hospital received an EMRAM Stage 6 score, an additional 59 questions were asked by a validation team of international peer inspectors mostly from Stage 6 or 7 hospitals in the EU. Stage 6 hospitals can apply for a Stage 7 validation, consisting of a 2-day visit of peer inspectors. EMRAM scores lower than Stage 6 are not publicly shared by HIMSS Analytics. The Netherlands was awarded its first EMRAM Stage 7 hospital in February 2015. This outcome is outside the scope of this project (2012-2014). RESULTS Non-Response analysis A profile of the 21 Dutch hospitals that did not participate in the study is reflected in Table 1.
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