A total of 889 surveys were collected from 870 hospitals. Two hundred four of them were excluded because they are repeated submissions. The number of distinct hospitals included in the study is 685 (78.7%). Similarly, 85 of the surveys were also excluded because of poor quality data and some severe inconsistencies. Overall, 600 verified, acceptable surveys (68.9%) were analyzed in this study. The distribution of the hospitals and their size, type, and level of healthcare are shown in Table 2.
The distribution of the number of hospitals in each EMRAM stage is shown in Figure 1. It is exciting to see that most of the hospitals (72.66%) are either Stage 2 or 6. It is logical to suggest that the barrier requirements of Stage 3, such as having PACS, eMAR, and adopting nursing documents, act as a kind of threshold. It seems, once hospitals achieve Stage 3, the remaining technologies can be adopted relatively easily and so that their adoption level regularly increases.
3.1. Availability of Applications and Electronic Health Record Functions
This section provides the results of the availability of information systems and EHR functions in hospitals.
3.1.1. Hospital Information Systems, Laboratory Information Systems, and Patient Administration Systems
The availability of HIS, LIS, and PAS is listed in Table 3 concerning the hospital sizes. The results show that 100% of hospitals have a HIS suite. Similarly, 94% of hospitals have PAS, and 93% of hospitals have LIS integrated with HIS. It is also evident that the hospital size does not have a role in having HIS, LIS, and PAS.
3.1.2. Clinical Documents and Computerized Physician Order Entry
The clinical documentation is also provided in Table 4, along with hospital sizes. The results show that 98.6% of hospitals have a CDR, and 79.7% of hospitals have a hospital-wide CDR. Recall that the CDR was one of the requirements of EMRAM Stage 2. Physician and nursing documents, as requirements of EMRAM Stage 3, have very similar availability percentage across hospital sizes. Although 86.2% of hospitals have physician documents, the nursing documents are available in 84.8% of all hospitals. Those high percentages can be explained by the national healthcare quality standard (SKS), which makes it mandatory to have clinical document infrastructure since 2009 in Turkey. However, CPOE is not functional in 13.8% of hospitals. The size of the hospital has no significant relationship with the availability of clinical documents and CPOE systems.
3.1.4. Medication Administration
Pharmacy and medication administration are essential functions of HIS. As depicted in Table 5, the surveys indicate that 99.5% of all hospitals have a pharmacy management system, even though three (0.5%) of them receive this service from an external source. The medications applied to the patient are recorded during the time of application in 66% of the hospitals, but 29.2% of them do not record those applications. The high availability of pharmacy management systems can be explained by the MoH regulations about stock management and efficiency criteria in the pharmacies of public hospitals since 2013. Despite the high availability of the information systems, the lack of recording the medication application shows that the information systems still focus the institutional purposes more than the clinical services.
3.1.5. Image Management
As depicted in Table 6, the surveys show that 89% of hospitals have a PACS system; however, the PACS systems in 14.5% of hospitals are not integrated with HIS and may only the by the radiology department. On the other hand, 9.5% of hospitals have a dictation and speech recognition system, which helps the radiologists write their reports more efficiently. That is to say that technology has not penetrated to the reporting process.
3.1.5. Image Management
As depicted in Table 6, the surveys show that 89% of hospitals have a PACS system; however, the PACS systems in 14.5% of hospitals are not integrated with HIS and may only the by the radiology department. On the other hand, 9.5% of hospitals have a dictation and speech recognition system, which helps the radiologists write their reports more efficiently. That is to say that technology has not penetrated to the reporting process.
Electronic ordering also has a similar prevalence. The usage of CPOE is 72.5% for medication and 62.7% for non-medication orders, respectively. However, orders for nurses in inpatient care facilities have a slightly higher proportion of 79%. By considering the prevalence of CPOE, Table 9 shows that the percentage of CPOE usage for inpatient medication orders is 66.6% and 70.5% for non-medication orders in more than 50% of the hospital.
Although there is no significant relationship between hospital size and the usage of electronic ordering (Table 8), the prevalence of electronic ordering has a significant relationship with hospital size (Table 9). The results show that small hospitals are better than medium-sized and larger hospitals in adopting electronic ordering capabilities. The verbal order is not allowed by regulations in Turkish public hospitals. However, it seems that the managers can apply this rule better in smaller hospitals.
3.2.2. Clinical Decision Support
As shown in Table 10, the hospitals have access to clinical decision support systems (CDSS). Correctly, CDSS was used in 69% of physician/nursing documents, 71.7% of medication orders, and 57.3% of non-medication orders. Additionally, although there is no significant relationship between hospital size and the usage of CDSS in clinical documents and non-medication orders, the usage of CDSS in medication orders has a significant relationship with hospital size. Small hospitals are better than medium-sized and larger hospitals in adopting CDSS for medication orders. Considering Tables 5, 9, and 10 together, we can claim that despite nearly all hospitals have pharmacy management systems and drug databases; the small hospitals are quickly adopting e-order and CDSS for medications to larger hospitals.
3.2.2. Clinical Decision Support
As shown in Table 10, the hospitals have access to clinical decision support systems (CDSS). Correctly, CDSS was used in 69% of physician/nursing documents, 71.7% of medication orders, and 57.3% of non-medication orders. Additionally, although there is no significant relationship between hospital size and the usage of CDSS in clinical documents and non-medication orders, the usage of CDSS in medication orders has a significant relationship with hospital size. Small hospitals are better than medium-sized and larger hospitals in adopting CDSS for medication orders. Considering Tables 5, 9, and 10 together, we can claim that despite nearly all hospitals have pharmacy management systems and drug databases; the small hospitals are quickly adopting e-order and CDSS for medications to larger hospitals.
Table 12 shows the items or persons (i.e., patient and nurse) to be identified using technology (RFID and barcode) during the application of medication at the bedside. The results show that the technology is used more frequently to identify medications and patients than identifying nurses. However, although those percentages are high in large and medium hospitals, the percentages are significantly lower in small hospitals. Moreover, the p-value indicates that there is a significant relationship between the auto-identified target (medication, nurse, and patient) and usage of technology. This result can be evaluated that the nurses do not consider a necessity to validate themselves and patients since they believe that they can do it well enough even manually, but they validate the drugs at the bedside by using technology.
3.2.4. Image Management
Image management systems (IMS) are stand-alone applications that are required to be integrated with EHR or HIS for practical usage. Table 13 shows that 74.7% of hospitals integrated their IMS with EHR. When we consider the prevalence of IMS in hospitals, we can see that 37.3% of hospitals are using IMS in greater than 50% of the entire facility. There is no significant relationship between hospital size and the percentage of IMS integration with EHR nor the prevalence of IMS. This situation can be explained by a nation-wide teleradiology system of Turkish MoH, which has been applicable since 2008 (45).