44 Chapter 3 per hospital were asked about demographics, software functionalities, processes, integration standards, usage in percentage by physician and nurses, depending on the available software in the hospital. In order to monitor the quality of the scoring process closely and distances in the Netherlands are never more than 200 km it was decided to do onsite visits. Depending on the complexity of the software environment, visits took between 1.5 and 4 h. For instance, in the case of software frommultiple vendors instead of one vendor identification of how the software is interconnected and integrated took more time. Validation was done by the quality assurance department of HIMSS Analytics Europe, and the scoring was done by a proprietary scoring algorithmby HIMSS Analytics North America (Table 1). 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 or7 hospitals in the EU. Stage6 hospitals can apply for a stage 7 validation, consisting of a 2-day visit of peer inspectors. One day will be used for presentations of predefined issues and one day for hospital visits to check life processes and the paperless status of the hospital. Until stage 5 the achieved score is secret to make participation to this study easy to decide. Two consecutive measurements with an interval of 18 months were taken. No stage 7 hospital was measured in the NL until to date (Dec 2014). One of the senior researchers of HIMSS Analytics is co-author of this study. Table 1 Frequency distribution of EMRAM scores EMRAM Score Frequency Percent Cumulative Percent 7 0 0 0 6 7 10 10 5 32 48 58 4 2 3 61 2 25 37 99 1 1 1 100 0 0 0 100 Total 67 100 To measure the quality and safety of healthcare in Dutch Hospitals we used select data from the publicly available basic set and the safety set of the Health Care Inspectorate (IGZ) and the Dutch Health Care Transparency Program ‘Zichtbare Zorg’ (ZIZO) program (both sets survey year 2013). The quality and safety measures selected reflect the measures used to score Dutch hospitals as presented in Elsevier’s annual ‘The Best Hospitals’ publication. As the discussions about the transparency of the healthcare
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