Prior to the interviews the extent of EMR use of all selected hospitals was recalibrated. This shows that some hospitals remained at EMRAM score 2 since 2014, particularly because they do not use a digital nursing record. Others rose to higher levels. Some hospitals merged, resulting in fifteen hospitals meeting the selection criteria for the present study, additionally including the hospital that reached EMRAM level 7, while starting at level 4 in 2012. Twelve hospitals (Table 1) subsequently agreed to participate in this qualitative study. Three hospitals (one regional and two teaching hospitals) were not willing or not able to participate.
Each participating hospital nominated one medical specialist to be interviewed, representing 10 different medical areas and between 5 to 27 years of experience in their current hospital (Table 2). In total, respondents mentioned 160 factors that influence the relation between the extent of EMR use and the quality of care. 122 factors were characterised as ‘barrier’ and 38 as ‘facilitator’ (Table 3).
The technical factors
The ‘technical factors’ are mentioned most often (96 times), of which 65 times as ‘barrier’ and 31 times as ‘facilitator’. Table 4 therefore shows a subdivision of the technical factors (11), followed by exemplary quotes from respondents to provide more insight in the underlying insights.
Customisability
Within the category ‘technical’, ‘customisability’ is mentioned most often (55 times), more often as ‘facilitator’ than as ‘barrier’. A medical specialist of a local hospital (respondent 7) observes: “Back in the day, the paper records often got lost. Lab results are available more quickly now and the medical specialist can quickly see the daily reports of the nurses (facilitator)”. And another says “innumerable positive points; accessible everywhere, even at home. No more illegible notes (facilitator)” (respondent 10). And because no paper file anymore but “It is digital, but that about says it all. Leaves much to be desired, though (barrier)” (respondent 9). And a medical specialist of a University Medical Centre adds (respondent 2) “Not intuitive. Terrible user interface. Unpleasant system, it clearly hasn’t been primarily designed for doctors and paramedics. An originally administrative system that has been reshaped into a medical system (barrier)”. “We can see the added value, but these systems are shoddy. Not intuitive (barrier)” (respondent 8). And respondent 2 “Negative: preoperative polio. Supplementary lab research takes 1-2 days. If you want to change policy based on the results, the EMR system shows that this is impossible because the patient has not been hospitalised but is not present at the outpatient clinic either (barrier)”.
Interconnectivity/standardisation’
The ‘interconnectivity/standardisation’ of the system is also an important topic. It is mentioned 15 times, of which 13 times as ‘barrier’.
A gynaecologist from a local hospital (respondent 9) states: “Gynaecologists work with 4 systems (safety risk), because systems are not interlinked (barrier)”. And respondent 11 states: “Using many separate systems poses a great risk because they are not linked to our EMR system regarding the transfer of records (barrier)”. But also, “Positive: back in the day, there was no background information available if the GP’s notification read ‘diarrhoea’, now there is (facilitator)” (respondent 5).
Limitation of the system
The ‘limitation of the system’ is mentioned 15 times of which 14 times as a ‘barrier’. According to the respondents, these systems promise a great deal but offer little more than the old situation. Respondents particularly point to the promised additional intelligence, the help the system could offer so-called ‘evidence-based’ material based on the individual and combined patient data available in the system (12). About this, respondent 4 states: “Intelligence systems fall short. Before the transformation, paper records would have a yellow post-it: pay attention! Responsibilities in the system are becoming increasingly regulated. Overabundance of authorisations is necessary because system demands this (e.g. medication). System should be able to make its own decisions (compare yellow post-it). Medical specialist becomes overworked, because support has disappeared due to EMR use (barrier)”. An internist from a teaching hospital (respondent 5) is more positive: “There is a little bit of decision support for medication (prescriptions) (facilitator)”. But respondent 10 states: “Frustration: patient comes to me with additional info (e.g. Fitbit). Cannot enter data into system (barrier)”. An oft-heard theme is the lack of analytic tools to analyse the entered data (analytics). A surgeon (respondent 8) from a local hospital, who also operates on patients referred by him to a University Medical Centre and who performed his own analyses on the countrywide available data by ‘hand’, states about the potential of good analytic tools: “Quality potentially improves through registration, but it is not used yet. Take, for example, cancer registrations: gastrointestinal surgery was compared with other hospitals; too many complications; painkillers scrapped; this provides lower mortality, now we are best of class (barrier)”. And respondent 9, who addressed the same issue of the unavailability of good analytic tools by end users adds: “Executing the analysis was very time consuming. Analytics have to be carried out by an IT-specialist. This makes it a hopeless affair. These tools should be included in the EMR (barrier)”.
The ‘change process’
The ‘change process’ is mentioned 30 times of which two times as ‘facilitator’. The role of the IT specialists and the software providers is mentioned frequently. “………. (EMR supplier mentioned) does not listen to the customer (barrier)” (respondent 4). And with regards to the role of the medical specialists themselves: “Before, medical specialists were individual, had their own working methods. By now, a technological revolution has taken place (paper records are now electronic records). But people do not want to change (95%). They have to get out of their comfort zone. You have to invest in that. Now: medical specialists’ approach EMR as if it were paper (barrier)” (respondent 10). A central theme for almost all interviewed medical specialists is the coded or non-coded recording of obtained information. A number of hospitals have initially started out with the recording of this information by medical specialists, but have later abolished this system because the medical specialist want to keep their options open as trained, “80-90% was filled out in the check box ‘other’ (plain text)”, “in other words, doctors should not be the one to fill out these structured questionnaires, this should be left to the nursing specialist, or an outpatient clinic assistant together with a patient, since they know exactly what to ask” “Conclusion: recording by medical specialist is undesirable, but it is necessary to enable systems to ‘offer help’ on a more advanced level. This process should be structured differently by giving supporting staff a role in it (barrier)” (respondent 8).
The factor ‘psychological’
The factor ‘psychological’ is mentioned 11 times. One of the respondents states that “Doctors are stubborn and have seldom put their needs down on paper (barrier)” (respondent 2). A paediatric neurologist also sees a distinction between old and young medical specialists, whereby he states, “there is a contrast between old and young specialists: I think the older ones accept a system more easily, their demands are less high (barrier)” (respondent 7). Some things are perceived as positive, though: “enforces a certain treatment and that is positive (facilitator)” (respondent 10). Apparently, this treatment has been agreed within the professional group of the medical specialists concerned.
The factor ‘time’
The factor ‘time’ is mentioned 11 times, of which twice as ‘facilitator’. Key focus lies on a remark from a University Medical Centre (respondent 2): “….it costs five extra hours of work a week (barrier)”. Nevertheless, the factor ‘time’ is also experienced in a positive sense. A paediatric neurologist (respondent 7) states “Productivity increases (facilitator)” and a pharmacist (respondent 11) says “Fewer staff, saves us 2 minutes per patient (facilitator)”.
The factor ‘social’
Medical specialists perceive the factor ‘social’ mainly as a barrier (eight times) and twice as facilitator. A paediatric neurologist of a local hospital states that he has to see the patient intensively: “Anamnesis is very important for a neurologist; head-turning-syndrome, for instance, can only be recognised through observation of the patient (barrier)” (respondent 7). A side effect is articulated by a radiologist of a teaching hospital “Back in the day, photos sometimes disappeared (dangerous), but medical specialists came to radiology because there was only one photo, this meant people knew each other, radiology was the centre, people walked in, it used to run more smoothly, now there is multidisciplinary consultation, but people don’t know each other anymore (barrier)” (respondent 4).
The focus lies on the relationship with the patient, which a cardiologist (respondent 10) expresses as follows “Negative influence on doctor-patient relationship through administrative burden (barrier)”. Politics also play a role, says respondent 2 of an academic hospital: “I am unhappy about the bad influence of politics/the government (barrier)”. And the same respondent also states about the role of management: “Hospital boards have insufficient insight into the needs of physicians and paramedics (barrier)”.
The factor ‘financial’
The factor ‘financial’ is mentioned twice. Two respondents of small hospitals note: “…… (EMR supplier mentioned) is ‘sexy’ but expensive (barrier)” (respondent 12) and “we have not looked at ……….. (EMR supplier mentioned), it is too expensive (barrier)” (respondent 9).