34 Chapter 2 to why so many hospitals in the Netherlands have been apparently slow to implement a nursing documentation system but do question if it has something to do with the value placed on nurses in Dutch hospitals. While nurses play a significant role in patient care in a hospital, their role (and by extension perceived value) are often times secondary to the role of the attending physician. If true, then it is possible IT leaders are placing a greater emphasis on EMRAM applications targeted towards physicians than nurses. A notable observation: physician related applications (Computerized Physician Order Entry; Physician Documentation) are higher order applications in EMRAM. This hypothesis certainly warrants further exploration as there is a strong argument to be made in prioritizing the automation of nursing documentation, especially as a means of reducing the transmission of erroneous patient information. Once EMRAM Stage 3 requirements are met, the EMRAM profile then suggests NL hospitals are likely to be challenged in meeting the requirements of EMRAM Stage 6 (Closed loopmedication administration [CLMA] and advanced decision support [CDSS]), with 43.1% of the hospitals in EMRAM Stage 5. The CLMA process includes ePrescribing, medication dispensing and tracking, and administration and documentation in the electronic Medication Administration Record (eMAR). A CDSS function (i.e., alerts) must be available at the point of care immediately prior to administration to ensure the five rights of administration check (right patient, right medication, right dose, right route, and right time). Especially the guarantee of the right medication and the right dose is a challenge in the NL, as bar coded unit doses are not always readily available from the pharmaceutical industries by lack of European bar code standards for drugs. The other class of variables influencing EMR adoption in NL hospitals involves organizational and environmental forces. By considering a wide array of relevant variables, the results of this study support the general assertion that EMR adoption is influenced by organizational and environmental forces. More specifically, variances in EMR adoption rates varied notably by hospital size and hospital type. The same holds for smaller hospitals. Smaller hospitals are unlikely to have the financial or human resource means to implement and use an EMR system. This is consistent with previous research that has identified cost as the greatest barrier to EMR adoption and use. 2,18 When hospitals make an investment in an EMR system and when the implementation is successful, the payers and purchasers also benefit. This misalignment of incentives represents perhaps the single most important barrier to moving ahead. Additionally, it is possible that a smaller hospital may not have the human resources available to run such a system. If this is the case, these smaller hospitals may need to form a coalition to investigate the feasibility of a
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