81 Level of digitization in Dutch hospitals and the lengths of stay (PDMS), is most of the time not integrated with the EMR system of the entire hospital. So the management of the LOS in the ICU may differ from the management of the LOS in the hospital. Only at EMRAM stage 6 and 7 the integration of the EMR system with the PDMS system is mandatory. It may also be a side effect of the diversity of hospitals in the EMRAM high group. In this group, hospitals with basic clinical facilities are present, but also hospitals with more advanced digital processes and evidence-based intelligence. If in future more hospitals will reach the highest, full digital, stage 7 level a third group (EMRAM>=6) can be added to look for the association with more advanced (outcome) indicators in the DSCA database. Further research is suggested to look for this relationship. 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. Small hospitals and hospitals located in the northern part of the Netherlands were underrepresented in the study. The 72 hospitals that did participate provided a fairly good representation of the total population of the Netherlands 93 hospitals. Given that nonresponding hospitals were more likely to have characteristics associated with lower levels of adoption of electronic health records, residual bias may have led us to overestimate adoption levels. Furthermore, although we adjusted for an extensive number of patient and tumor factors, unknown confounding factors could still be present. CONCLUSION We found a significant association between the level of digitalization of hospitals and the length of stay after colorectal cancer surgery, consistent with shorter length of stay in hospitals with higher levels of digitization. 5
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