71 Level of digitization in Dutch hospitals and the lengths of stay INTRODUCTION Implementations of potentially transformative eHealth technologies throughout the world frequently have a significant impact on national health expenditures. Such largescale efforts and investments have been justified on the grounds that the EMR, picture archiving and communication systems (PACS), electronic prescribing (ePrescribing) and associated computerized provider (or physician) order entry systems (CPOE), and computerized decision support systems (CDSS) are supposed to help to address the problems of variable quality and safety in modern health care1–6. However, the scientific basis of such claims, which are repeatedly made and seemingly uncritically accepted, remains to be firmly established. For the measurement of the level of implementation of information systems a concept of maturity of these systems has been developed. There is a large number of methods or models available tomeasure the level of implementation of information technology7. One of these methods is the so-called Electronic Medical Record Adoption Model (EMRAM) scoring approach developed by Healthcare Information and Management Systems Society (HIMSS) Analytics8. EMRAM is an eight-stage maturation model reflecting the EMR capabilities in hospitals, ranging froma completely paper-based environment (Stage 0) to a highly advanced paperless and digital patient record environment (Stage 7). The scoring process is done by identifying the software used in the different functional areas of the hospital. At least 150 questions per hospital are included about demographics, software functionalities, processes, integration standards, usage in percentage by physician and nurses, depending on the available software in the hospital. Previous studies on this model in the Netherlands show that EMRAM stage 3, the first stage in which clinical functionalities (nursing) become available, presents as the first notable challenge to Dutch hospitals; 37.5% of the hospitals in this study have yet to satisfy the requirements of this stage. The basic andmore advanced clinical capabilities should help to increase the quality, safety and efficiency of the treatment of patients in the hospital9. The Dutch surgical colorectal audit (DSCA), started in 2009, is a nationwide audit used to monitor, evaluate, and improve quality of care of primary colorectal cancer surgery. It provides feedback to all hospitals in the Netherlands on a set of quality measures and indicators. While EMRs may lead to better hospital performance and outcomes, hospitals may use EMRs to improve the quality of care. This paper has the objective to contribute to the scientific discourse on the relationship between the digitalization of hospital data and the effect on quality of care, with colorectal cancer as a guiding example 10,11. 5
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