36 Chapter 2 competition in the classic sense may not be an important factor in the way hospitals act. In general, the findings of this study support the conclusions found in other studies in the U.S. A ‘leadership and culture’ hypothesis was not a part of this research project. It is our feeling that this might be an important factor for the level of digitalization in hospitals in the Netherlands. This may be a subject for subsequent research. LIMITATIONS OF THE STUDY AND SUGGESTIONS FOR FURTHER RESEARCH There are limitations to our study. First, although we achieved a 77% response rate, the hospitals that did not respond to our survey were somewhat different from those that did respond. Given those non-responding hospitals were more likely to have characteristics associated with lower levels of adoption of EHRs, residual bias may have led us to overestimate adoption levels. Little is known about governance characteristics and organizational performance for EMR adopters. 20,21 As pressures about healthcare quality and related costs increases dramatically in the Netherlands, it may be of value to examine hospitals with a sophisticated EMR and compare those hospitals to similar hospitals (with a less sophisticated EMR) to understand the association between EMR capabilities and IT governance characteristics. Presence and length of stay of key ICT players like CMIO and CIO in the hospital organization may be a good indicator to investigate and test a related hypothesis. We did not measure presence and length of stay of key ICT players in this project. So, testing of this hypothesis was not part of this study.
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