Impact of Digitalization on Performance of Dutch Hospitals: Longitudinal Quantitative Study
Journal of Medical Internet Research ·
Background: Hospitals continue to invest heavily to increase their level of digitalization. While advanced digital maturity is assumed to improve hospital performance, empirical evidence remains mixed. This tension is mirrored by the productivity paradox of IT, whereby investments in digital technologies do not consistently translate into observable performance gains. Objective: This study aims to examine the relationship between the Healthcare Information and Management Systems Society (HIMSS) Electronic Medical Record Adoption Model (EMRAM) score and hospitals’ financial, operational, and workforce-related indicators. Methods: This longitudinal observational study used routinely collected hospital-level annual report data from the Dutch National Annual Healthcare Reports Database (CIBG) for Dutch hospitals from 2017 to 2023. Hospital-year records were linked at the institutional level to publicly available HIMSS EMRAM stage 6 or 7 certification information and operationalized dichotomously (stage 6 or 7 vs ≤5). The sample included 66 to 74 hospitals per year (mean 70.4, SD 2.8), corresponding to up to 498 hospital-year observations. Outcome measures were financial (profit margins, return on assets, asset-turnover ratio, and personnel-expense ratio), operational (length of stay and number of patients treated), and workforce (absenteeism) performance indicators. Linear mixed-effects models were estimated while controlling for hospital size, teaching status, staff-to-patient ratio, time trends, and COVID-19 effects. Results: Advanced digital maturity was not significantly associated with improved financial, operational, or workforce performance after adjustment for multiple testing. For financial outcomes, high digital maturity showed no significant association with profit margin, return on assets, personnel-expense ratio, or asset-turnover ratio. Digitally mature hospitals initially appeared to treat more patients annually ( β =31,664.318; 95% CI 8392.095-54,936.540; P =.008), but this association was not statistically significant after Holm-Bonferroni correction (adjusted P =.44). No significant associations were observed for length of stay or absenteeism. Conclusions: In a highly digitalized health system with near-universal electronic health record adoption, advanced technical digital maturity alone was not associated with measurable improvements in aggregated hospital-level financial, operational, or workforce performance. These findings provide longitudinal empirical support for the IT productivity paradox in hospital digitalization, suggesting that technical maturity is a necessary but insufficient condition for performance gains. Trial Registration:
Background: Hospitals continue to invest heavily to increase their level of digitalization. While advanced digital maturity is assumed to improve hospital performance, empirical evidence remains mixed. This tension is mirrored by the productivity paradox of IT, whereby investments in digital technologies do not consistently translate into observable performance gains. Objective: This study aims to examine the relationship between the Healthcare Information and Management Systems Society (HIMSS) Electronic Medical Record Adoption Model (EMRAM) score and hospitals’ financial, operational, and workforce-related indicators. Methods: This longitudinal observational study used routinely collected hospital-level annual report data from the Dutch National Annual Healthcare Reports Database (CIBG) for Dutch hospitals from 2017 to 2023. Hospital-year records were linked at the institutional level to publicly available HIMSS EMRAM stage 6 or 7 certification information and operationalized dichotomously (stage 6 or 7 vs ≤5). The sample included 66 to 74 hospitals per year (mean 70.4, SD 2.8), corresponding to up to 498 hospital-year observations. Outcome measures were financial (profit margins, return on assets, asset-turnover ratio, and personnel-expense ratio), operational (length of stay and number of patients treated), and workforce (absenteeism) performance indicators. Linear mixed-effects models were estimated while controlling for hospital size, teaching status, staff-to-patient ratio, time trends, and COVID-19 effects. Results: Advanced digital maturity was not significantly associated with improved financial, operational, or workforce performance after adjustment for multiple testing. For financial outcomes, high digital maturity showed no significant association with profit margin, return on assets, personnel-expense ratio, or asset-turnover ratio. Digitally mature hospitals initially appeared to treat more patients annually ( β =31,664.318; 95% CI 8392.095-54,936.540; P =.008), but this association was not statistically significant after Holm-Bonferroni correction (adjusted P =.44). No significant associations were observed for length of stay or absenteeism. Conclusions: In a highly digitalized health system with near-universal electronic health record adoption, advanced technical digital maturity alone was not associated with measurable improvements in aggregated hospital-level financial, operational, or workforce performance. These findings provide longitudinal empirical support for the IT productivity paradox in hospital digitalization, suggesting that technical maturity is a necessary but insufficient condition for performance gains. Trial Registration: