49 The Association between eHealth Capabilities and the Quality and Safety of Health Care experience of care scores were calculated by the American Hospital Association (AHA) by using data fromHospital Compare. Before adjusting for hospital characteristics (#beds, system status, teaching hospital, profit, and geographic region) EMRAM stage 7 users had significant higher clinical process scores and significant lower experience of care scores. After controlling for hospital characteristics, EMRAM stage 7 advanced EMR use was associated with significantly higher process of care scored than both EMRAM stage 6 advanced users and non-advanced users. There was no difference in process of care scores between EMRAM stage 6 advanced use and non-advanced use. After adjusting for hospital characteristics, there was no difference in experience of care scores by level of advanced use. These findings may support our conclusion that EMRAM stage 6 may not be a good enough indicator for advanced EMR use, because hospitals could qualify as a stage 6 hospital if the required functionalities and facilities are implemented in only one patient care service area in the hospital even though other parts of the hospital reflect the capabilities of lower EMRAM stages. Only at stage 7 the required functionalities and facilities are implemented in every patient care service area in the hospital. The number of hospitals in the NL (67) may not be enough to adjust for hospital characteristics in our study. No significant difference between hospital characteristics and EMRAM score was found in our study (Data available at the first author). CONCLUSION The hypothesis of this study, that there is a positive association between advanced electronic medical record (EMR) capabilities and quality and safety of hospital care in the Netherlands, was not supported by the findings of this study at this point in time. This outcome may be caused by a multiplicity of factors (such as the characteristics of the models being used, the varied EMR implementation strategies employed by hospital leaders in the Netherlands, and/or the mastery of the staff in using these technologies) leading one to conclude that future research efforts should give careful consideration to these variables. 3
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