Electronic health record

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For information on local computerised records in a specific health care organization, see Electronic medical record.
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Sample patient record view from an image-based electronic health record (VistA)

An electronic health record (EHR) (also electronic patient record or computerised patient record) is an evolving concept defined as a longitudinal collection of electronic health information about individual patients or populations[1]. It is a record in digital format that is capable of being shared within across different health care settings, by being embedded in network-connected enterprise-wide information system. Such records may included a whole range of data in comprehensive or summary form, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, and billing information.

It is important to note that an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office. [2]

Its purpose can be understood as a complete record patient encounters that allows to automate and streamline workflow in health care settings and to increase safety through evidence-based decision support, quality management, and outcomes reporting.[3]

Contents

[edit] Advantages of electronic medical records

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EHR systems increase physician efficiency and reduce costs, as well as promote standardization of care. Even though EMR systems with computerized provider order entry (CPOE) have existed for more than 30 years, fewer than 10 percent of hospitals as of 2006 have a fully integrated system.[4]

[edit] Reduce healthcare costs

One of the major sources of rapid growth in healthcare costs comes from medical imaging. Medicare Part B spending on imaging rose from $6.80 billion in 2000 to $14.11 billion in 2006.[5] Access to a patient's images in an EHR is an effective way to avoid duplicating expensive imaging procedures. Other cost savings include the reduction of medical errors that can otherwise lead to further expensive care.

[edit] Improve quality of care

An EHR system can help reduce medical errors by providing healthcare workers with decision support. Fast access to medical literature and current best practices in medicine enable proliferation of ongoing improvements in healthcare efficacy.

[edit] Promote evidence-based medicine

EHRs provide access to unprecedented amounts of clinical data for research that can accelerate the level of knowledge of effective medical practices.

These benefits may be realized in a realistic sense only if the EHR systems are interoperable and wide spread (e.g. national) so that various systems can easily share information. Also, to avoid failures that can cause injury to the patient and violations to privacy, the best practices in software engineering and medial informatics must be deployed.[6]

EHRs also have the advantages of electronic medical records (EMR). In general, medical records may be on "physical" media such as film (X-rays), paper (notes), or photographs, often of different sizes and shapes. Physical storage of documents is problematic, as not all document types fit in the same size folders or storage spaces. In the current global medical environment, patients are shopping for their procedures. Many international patients travel to US cities with academic research centers for specialty treatment or to participate in Clinical Trials. Coordinating these appointments via paper records is a time-consuming procedure.

Physical records usually require significant amounts of space to store them. When physical records are no longer maintained, the large amounts of storage space are no longer required. Paper, film, and other expensive physical media usage (and therefore cost) is also reduced with electronic record storage. When paper records are stored in different locations, furthermore, collecting and transporting them to a single location for review by a healthcare provider is time-consuming. When paper (or other types of) records are required in multiple locations, copying, faxing, and transporting costs are significant, as are the concerns of HIPAA compliance.

In 2004, an estimate was made that 1 in 7 hospitalizations occurred when medical records were not available. Additionally, 1 in 5 lab tests were repeated because results were not available at the point of care. Electronic medical records are estimated to improve efficiency by 6% per year, and the monthly cost of an EMR is offset by the cost of only a few unnecessary tests or admissions.[7][8]

Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors.[9] Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies.

In contrast, EMRs can be continuously updated. The ability to exchange records between different EMR systems ("interoperability"[10]) would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.[11]

[edit] Disadvantages of electronic medical records

Critics point out that while EHRs may save the "health system" money, physicians, those who buy the systems, may not benefit financially. EHR price tags range widely, depending on what's included, how robust the system is, and how many providers use it. Asked what they paid in an online survey, about a third of respondents paid between $500 and $3,000 per physician. A third paid between $3,001 and $6,000, and 33 percent paid more than $6,000 per physician for their EHR.[12] Physicians do tend to see at least short-term decreases in productivity as they implement an EHR. They spend more time entering data into an empty EHR than they used to spend updating a paper chart with a simple dictation. Such hurdles can be overcome once the software has some data, as physicians learn to use easy templates for data entry, and as workflow in the practice changes, but not every practice gets that far[citation needed].

Studies also call into question whether, in real life, EHRs improve quality.[13]

[edit] Lack of adoption of EHRs in the United States

US medical groups' adoption of EHR (2005)

As of 2000, adoption of EHRs and other health information technology (HITs) (such as computer physician order entry (CPOE)) was minimal in the United States (outside of the VA system). Fewer than 10% of American hospitals had implemented HIT,[14] while a mere 16% of primary care physicians used EHRs.[15] In 2001-2004 only 18% of ambulatory care encounters utilized an EHR system.[16][17] In 2005, 25% of office-based physicians reported using fully or partially electronic medical record systems (EMR), an almost one-third increase from the 18.2% reported in 2001.[17] However, less than one-tenth of these physicians actually had a "complete EMR system" (with computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes).[18]

The healthcare industry spends only 2% of gross revenues on HIT, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%.[19][20][21]

[edit] Incentives in the United States

Until recently, with the American Recovery and Reinvestment Act of 2009, providers were expected to take the full risk of investing in healthcare IT. Notably, healthcare payers, such as the government through Medicare, also have potential for significant cost savings if providers adopt EHR systems.

The 2009 economic stimulus package (HITECH Act) passed by the US Congress aims at incenting more physician to adopt EHR. The act promises incentive payments to those who adopt and use "certified EHRs" and, eventually, reducing Medicare payments to those who do not use an EHR. In order to receive the EHR stimulus money, the HITECH act (ARRA) requires doctors to also show "meaningful use" of an EHR system.[22]

In 2004, the Office of the National Coordinator for Health Information Technology (ONC) was created. Under the ONC, Regional Health Information Organizations (RHIOs) have been established in many states in order to promote the sharing of health information.

[edit] Standards

  • ANSI X12 (EDI) - transaction protocols used for transmitting patient data. Popular in the United States for transmission of billing data.
  • CEN's TC/251 provides EHR standards in Europe including:
    • EN 13606, communication standards for EHR information
    • CONTSYS (EN 13940), supports continuity of care record standardization.
    • HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
  • Continuity of Care Record - ASTM International Continuity of Care Record standard
  • DICOM - an international communications protocol standard for representing and transmitting radiology (and other) image-based data, sponsored by NEMA (National Electrical Manufacturers Association)
  • HL7 - a standardized messaging and text communications protocol between hospital and physician record systems, and between practice management systems
  • ISO - ISO TC 215 provides international technical specifications for EHRs. ISO 18308 describes EHR architectures

[edit] Long-term preservation and storage of records

An important consideration in the process of developing electronic health records is to plan for the long-term preservation and storage of these records. The field will need to come to consensus on the length of time to store EHRs, methods to ensure the future accessibility and compatibility of archived data with yet-to-be developed retrieval systems, and how to ensure the physical and virtual security of the archives.

Additionally, considerations about long-term storage of electronic health records are complicated by the possibility that the records might one day be used longitudinally and integrated across sites of care. Records have the potential to be created, used, edited, and viewed by multiple independent entities. These entities include, but are not limited to, primary care physicians, hospitals, insurance companies, and patients. Mandl et al. have noted that “choices about the structure and ownership of these records will have profound impact on the accessibility and privacy of patient information.”[23]

The required length of storage of an individual electronic health record will depend on national and state regulations, which are subject to change over time. Ruotsalainen and Manning have found that the typical preservation time of patient data varies between 20 and 100 years. In one example of how an EHR archive might function, their research "describes a co-operative trusted notary archive (TNA) which receives health data from different EHR-systems, stores data together with associated meta-information for long periods and distributes EHR-data objects. TNA can store objects in XML-format and prove the integrity of stored data with the help of event records, timestamps and archive e-signatures."[24]

In addition to the TNA archive described by Ruotsalainen and Manning, other combinations of EHR systems and archive systems are possible. Again, overall requirements for the design and security of the system and its archive will vary and must function under ethical and legal principles specific to the time and place.

While it is currently unknown precisely how long EHRs will be preserved, it is certain that length of time will exceed the average shelf-life of paper records. The evolution of technology is such that the programs and systems used to input information will likely not be available to a user who desires to examine archived data. One proposed solution to the challenge of long-term accessibility and usability of data by future systems is to standardize information fields in a time-invariant way, such as with XML language. Olhede and Peterson report that “the basic XML-format has undergone preliminary testing in Europe by a Spri project and been found suitable for EU purposes. Spri has advised the Swedish National Board of Health and Welfare and the Swedish National Archive to issue directives concerning the use of XML as the archive-format for EHCR (Electronic Health Care Record) information."[25]

[edit] Synchronization of records

When care is provided at two different facilities, it may be difficult to update records at both locations in a co-ordinated fashion.

Two models have been used to satisfy this problem: a centralized data server solution, and a peer-to-peer file synchronization program (as has been developed for other peer-to-peer networks).

In the United States, Great Britain, and Germany, the concept of a national centralized server model of healthcare data has been poorly received. Issues of privacy and security in such a model have been of concern.[26][27]

Synchronization programs for distributed storage models, however, are only useful once record standardization has occurred.

Merging of already existing public healthcare databases is a common software challenge. The ability of electronic health record systems to provide this function is a key benefit and can improve healthcare delivery.[28][29][30]

[edit] Privacy Concerns

Privacy concerns in healthcare apply to both paper and electronic records. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also.[31] Recent revelations of "secure" data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location.[32] Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet.

The Health Insurance Portability and Accountability Act (HIPAA) was passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. However, there are concerns as to the adequacy of implementation of these standards.

In the European Union (EU), several Directives of the European Parliament and of the Council protect the processing and free movement of personal data, including for purposes of health care.[33]

Personal Information Protection and Electronic Documents Act (PIPEDA) was given Royal Assent in Canada on April 13, 2000 to establish rules on the use, disclosure and collection of personal information. The personal information includes both non-digital and electronic form. In 2002, PIPEDA extended to the health sector in Stage 2 of the law's implementation.[34] There are four provinces where this law does not apply because its privacy law was considered similar to PIPEDA: Alberta, British Columbia, Ontario and Quebec.

Privacy and Security of the Electronic Health Record: As the ever-changing healthcare industry evolves, one key topic within the electronic health record (EHR) is privacy. The Federal government has set guidelines that all healthcare organizations will have to comply with in regards to electronic health transactions. Most supporters believe that the EHR will improve care and reduced costs, while transforming the health care system, but whether the privacy of the records will be upheld is yet to be determined. A successful partnership for administrative health data standards can promote the development of clinical data standards and their application in computer based patient record systems.[35]

One major issue that has risen on the privacy of the U.S. network for electronic health records is the strategy to secure the privacy of patients. Former US president Bush called for the creation of networks, but federal investigators report that there is no clear strategy to protect the privacy of patients as the promotions of the electronic medical records expands throughout the United States. In 2007, the Government Accountability Office reports that there is a “jumble of studies and vague policy statements but no overall strategy to ensure that privacy protections would be built into computer networks linking insurers, doctors, hospitals and other health care providers.”[36]

The privacy threat posed by the interoperability of a national network is a key concern. One of the most vocal critics of EMRs, New York University Professor Jacob M. Appel, has claimed that the number of people who will need to have access to such a truly interoperable national system, which he estimates to be 12 million, will inevitable lead to breaches of privacy on a massive scale. Appel has written that while "hospitals keep careful tabs on who accesses the charts of VIP patients," they are powerless to act against "a meddlesome pharmacist in Alaska" who "looks up the urine toxicology on his daughter's fiance in Florida, to check if the fellow has a cocaine habit."[37] This is a significant barrier for the adoption of an EHR. Accountability among all the parties that are involved in the processing of electronic transactions including the patient, physician office staff, and insurance companies, is the key to successful advancement of the EHR in the U.S. Supporters of EHRs have argued that there needs to be a fundamental shift in “attitudes, awareness, habits, and capabilities in the areas of privacy and security” of individual’s health records if adoption of an EHR is to occur.[38]

According to the Wall Street Journal, the DHHS takes no action on complaints under HIPAA, and medical records are disclosed under court orders in legal actions such as claims arising from automobile accidents. HIPAA has special restrictions on psychotherapy records, but psychotherapy records can also be disclosed without the client's knowledge or permission, according to the Journal. For example, Patricia Galvin, a lawyer in San Francisco, saw a psychologist at Stanford Hospital & Clinics after her fiance committed suicide. Her therapist had assured her that her records would be confidential. But after she applied for disability benefits, Stanford gave the insurer her therapy notes, and the insurer denied her benefits based on what Galvin claims was a misinterpretation of the notes. Stanford had merged her notes with her general medical record, and the general medical record wasn't covered by HIPAA restrictions.[39]

Within the private sector, many companies are moving forward in the development, establishment and implementation of medical record banks and health information exchange. By law, companies are required to follow all HIPAA standards and adopt the same information-handling practices that have been in effect for the federal government for years. This includes two ideas, standardized formatting of data electronically exchanged and federalization of security and privacy practices among the private sector.[38] Private companies have promised to have “stringent privacy policies and procedures.” If protection and security are not part of the systems developed, people will not trust the technology nor will they participate in it.[36] So, the private sector know the importance of privacy and the security of the systems and continue to advance well ahead of the federal government with electronic health records.

[edit] Legal issues

[edit] Liability

Legal liability in all aspects of healthcare was an increasing problem in the 1990s and 2000s. The surge in the per capita number of attorneys[40] and changes in the tort system caused an increase in the cost of every aspect of healthcare, and healthcare technology was no exception.[41]

Failure or damages caused during installation or utilization of an EHR system has been feared as a threat in lawsuits.[42]

This liability concern was of special concern for small EHR system makers. Some smaller companies may be forced to abandon markets based on the regional liability climate.[43] Larger EHR providers (or government-sponsored providers of EHRs) are better able to withstand legal assaults.

In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital's software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers.[44] In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.[45][46]

[edit] Legal Interoperability

In cross-border use cases of EHR implementations, the additional issue of legal interoperability arises. Different countries may have diverging legal requirements for the content or usage of electronic health records, which can require radical changes of the technical makeup of the EHR implementation in question. (especially when fundamental legal incompatibilities are involved) Exploring these issues is therefore often necessary when implementing cross-border EHR solutions.[47]

[edit] Costs

Most practitioners and healthcare organizations will agree that both quality healthcare and medical error reduction take precedence over many other healthcare concerns. Common knowledge to most, the U.S. allocates a vast amount of funds towards the health care industry—more than $1.7 trillion per year.[48] The implementation of electronic health records (EHR) can help lessen patient sufferance due to medical errors and the inability of analysts to assess quality.[48] Obviously, these savings can lead to healthcare quality promotion. In addition, these savings are not limited to businesses alone: If savings are allocated using the current level of spending from the National Health Accounts, Medicare would receive about $23 billion of the potential savings per year, and private payers would receive $31 billion per year.[48] Computerized Physician Order Entry (CPOE)—one component of EHR—increases patient safety by listing instructions for physicians to follow when they prescribe drugs to patients. Naturally, CPOE can tremendously decrease medical errors: CPOE could eliminate 200,000 adverse drug events and save about $1 billion per year if installed in all hospitals.[49] Furthermore, If patients are aware of their opportunities, they are more likely to comply with their doctors’ recommendations; thus, reducing future hospital visits and saving money.

The steep price of EHR and provider uncertainty regarding the value they will derive from adoption in the form of return on investment has a significant influence on EHR adoption.[50] In a project initiated by the Office of the National Coordinator for Health Information (ONC), surveyors found that hospital administrators and physicians who had adopted EHR noted that any gains in efficiency were offset by reduced productivity as the technology was implemented, as well as the need to increase information technology staff to maintain the system.[50]

The U.S. Congressional Budget Office concluded that the cost savings may only occur only in large integrated institutions like Kaiser Permanente, and not in small physician offices. They challenged the Rand Corp. estimates of savings. "Office-based physicians in particular may see no benefit if they purchase such a product – and may even suffer financial harm. Even though the use of health IT could generate cost savings for the health system at large that might offset the EHR's cost, many physicians might not be able to reduce their office expenses or increase their revenue sufficiently to pay for it. For example. the use of health IT could reduce the number of duplicated diagnostic tests. However, that improvement in efficiency would be unlikely to increase the income of many physicians." If a physician performs tests in the office, it might reduce his or her income. "Given the ease at which information can be exchanged between health IT systems, patients whose physicians use them may feel that their privacy is more at risk than if paper records were used."[51]

[edit] Start-up costs and software maintenance costs

In a 2006 survey, lack of adequate funding was cited by 729 health care providers as the most significant barrier to adopting electronic records.[52] At the American Health Information Management Association conference in October 2006, panelists estimated that purchasing and installing EHR will cost over $32,000 per physician, and maintenance about $1,200 per month (including the amortization of startup investment).[53][54][55] Vendor costs account for 60-80% of these costs.[56]

There are exceptions. A November 2006 survey of a widely available open source EHR reported startup costs of only $1083 – $7500/provider and $67 – $750/month per provider.[57]

Some proponents of EHR systems suggest that startup costs will be recouped within 3 years.[58] A study of the effects of EHRs in primary care settings published in the American Journal of Medicine estimated net benefits from EHR use of over $86,000 per provider over a five-year period.[59]

Some physicians are skeptical of such published cost-savings claims, however. They believe the data is skewed by vendors and by others who have a stake in the success of EHR implementation. Many are resistant to invest in a system which they are not confident will provide them with a return on their investment.[60][61]

Brigham and Women’s Hospital in Boston, Massachusetts, estimated it achieved net savings of $5 million to $10 million per year following installation of a computerized physician order entry system that reduced serious medication errors by 55 percent. Another large hospital generated about $8.6 million in annual savings by replacing paper medical charts with EHRs for outpatients and about $2.8 million annually by establishing electronic access to laboratory results and reports.[62]

Furthermore, software technology advances at a rapid pace. Most software systems require frequent updates, often at a significant ongoing cost. Some types of software and operating systems require full-scale re-implementation periodically, which disrupts not only the budget but also workflow. Costs for upgrades and associated regression testing can be particularly high where the applications are governed by FDA regulations (e.g. Clinical Laboratory systems). Physicians desire modular upgrades and ability to continually customize, without large-scale reimplementation.

Training of employees to use an EHR system is costly, just as for training in the use of any other hospital system. New employees, permanent or temporary, will also require training as they are hired.[63]

In the United States, a substantial majority of healthcare providers train at a VA facility sometime during their career. With the widespread adoption of the Veterans Health Information Systems and Technology Architecture (VistA) electronic health record system at all VA facilities, few recently-trained medical professionals will be inexperienced in electronic health record systems. Elderly practitioners who have never used computer-based systems eventually retire.

[edit] Customization

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Each healthcare environment functions differently, often in significant ways. It is difficult to create a "one-size-fits-all" EHR system.

An ideal EHR system will have record standardization but interfaces that can be customized to each provider environment. Modularity in an EHR system facilitates this. Many EHR companies employ vendors to provide customization.

This customization can often be done so that a physician's input interface closely mimics previously utilized paper forms.[64]

At the same time they reported negative effects in communication, increased overtime, and missing records when a non-customized EMR system was utilized.[65] Customizing the software when it is released yields the highest benefits because it is adapted for the users and tailored to workflows specific to the institution.[66]

Customization can have its disadvantages. There is, of course, higher costs involved to implementation of a customized system initially. More time must be spent by both the implementation team and the healthcare provider to understand the workflow needs.

Development and maintenance of these interfaces and customizations can also lead to higher software implementation and maintenance costs.[67][68]

These hurdles make customizations that can be made publicly available through an open source model more desirable.

[edit] Successful implementations of EHR systems

In the United States, the Department of Veterans Affairs (VA) has the largest enterprise-wide health information system that includes an electronic medical record, known as the Veterans Health Information Systems and Technology Architecture (VistA). A key component in VistA is their VistA imaging System which provides a comprehensive multimedia data from many specialties, including cardiology, radiology and orthopedics. A graphical user interface known as the Computerized Patient Record System (CPRS) allows health care providers to review and update a patient’s electronic medical record at any of the VA's over 1,000 healthcare facilities. CPRS includes the ability to place orders, including medications, special procedures, X-rays, patient care nursing orders, diets, and laboratory tests.

The US Indian Health Service uses an EHR similar to VistA called RPMS. VistA Imaging is also being used to integrate images and co-ordinate PACS into the EHR system.

As of 2005, the National Health Service (NHS) in the United Kingdom also began an EHR system. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practitioners in England access to the National Programme for IT (NPfIT).[69]

Australia is dedicated to the development of a lifetime electronic health record for all its citizens. HealthConnect is the major national EHR initiative in Australia, and is made up of territory, state, and federal governments. MediConnect is a related program that provides an electronic medication record to keep track of patient prescriptions and provide stakeholders with drug alerts to avoid errors in prescribing.[70]

The Canadian province of Alberta started a large-scale operational EHR system project in 2005 called Alberta Netcare, which is expected to encompass all of Alberta by 2008.

[edit] See also

 The length of this "see also" section may adversely affect readability. Please ensure that the "see also" links are not mentioned elsewhere in the article, are not red links, are as few in number and as relevant as possible.

[edit] References

  1. ^ Gunter, T.D. and Terry, N.P. 2005 The Emergence of National Electronic Health Record Architectures in the United States and Australia: Models, Costs, and Questions in J Med Internet Res 7(1)
  2. ^ [Electronic Health Records Overview]
  3. ^ HIMSS - Electronic Health Record (EHR)
  4. ^ Smaltz, Detlev and Eta Berner. The Executive's Guide to Electronic Health Records. (2007, Health Administration Press) p.03
  5. ^ "Medicare Part B Imaging Services" (PDF). United States government Accountability Office Report to Congressional Requesters. http://www.gao.gov/new.items/d08452.pdf. 
  6. ^ Hoffman S, Podgurski, A (Fall 2008). "Finding a Cure; The Case for Regulation and Oversight of Electronic Health Record Systems" (PDF). Harvard Journal of Law & Technology 22 (1): 107. http://jolt.law.harvard.edu/articles/pdf/v22/22HarvJLTech103.pdf. 
  7. ^ Evans DC, Nichol WP, Perlin JB (April 2006). "Effect of the implementation of an enterprise-wide Electronic Health Record on productivity in the Veterans Health Administration". Health Econ Policy Law 1 (Pt 2): 163–9. doi:10.1017/S1744133105001210. PMID 18634688. http://journals.cambridge.org/action/displayAbstract;jsessionid=7C274D08947B0625B3B540BEF2E70367.tomcat1?fromPage=online&aid=416400. 
  8. ^ "VistA:Winner of the 2006 Innovations in American Government Award" (PDF). The Ash Institute for Democratic Governance and Innovation at Harvard University's John F. Kennedy School of Government. http://www.innovations.va.gov/innovations/docs/InnovationsVistAInfoPackage.pdf. 
  9. ^ Institute of Medicine (1999). "To Err Is Human: Building a Safer Health System (1999)". The National Academies Press. http://fermat.nap.edu/catalog/9728.html#toc. Retrieved 2006-06-20. 
  10. ^ Adapted from the IEEE definition of interoperability, and legal definitions used by the FCC (47 CFR 51.3), in statutes regarding copyright protection (17 USC 1201), and e-government services (44 USC 3601)
  11. ^ "EHR Definition, Attributes and Essential Requirements" (PDF). Healthcare Information and Management Systems Society. 2003. http://www.himss.org/content/files/EHRAttributes.pdf. Retrieved 2006-07-28. 
  12. ^ Moore, Pamela (2008). "Navigating The Tech Maze". Physicians Practice. http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1214/page/1.htm. Retrieved 2009-08-23. 
  13. ^ Gabriel, Barbara (2008). "Do EMRs Make You a Better Doctor?". Physicians Practice. http://www.physicianspractice.com/index/fuseaction/articles.details/articleID/1203/page/1.htm. Retrieved 2009-08-23. 
  14. ^ DJ Ringold, JP Santell, and PJ Schneider (01 Oct 2000). "ASHP national survey of pharmacy practice in acute care settings: dispensing and administration—1999". American Journal of Health-System Pharmacy 57 (19): 1759–75. PMID 11030028. http://www.ajhp.org/cgi/content/abstract/57/19/1759. 
  15. ^ Johnston, Doughlas, et al. "The Value of Computerize Provider Order Entry in Ambulatory Settings: Executive Preview." Wellesley, MA: Center for Information Technology Leadership, 2003
  16. ^ Linder JA, Ma J, Bates DW, Middleton B, Stafford RS (July 2007). "Electronic health record use and the quality of ambulatory care in the United States". Arch. Intern. Med. 167 (13): 1400–5. doi:10.1001/archinte.167.13.1400. PMID 17620534. http://archinte.ama-assn.org/cgi/content/short/167/13/1400. 
  17. ^ a b National Center for Health Statistics: Electronic Medical Record Use by Office-Based Physicians:, United States, 2005 Retrieved July 24, 2006
  18. ^ CDC's National Center for Health Statistics: More Physicians Using Electrical Medical Records Retrieved July 27, 2006
  19. ^ Raymond, B. and C. Dold (2002). "Clinical Information Systems: Achieving the Vision". Kaiser Permanente Institute for Health Policy. http://www.informatics-review.com/thoughts/vision.html. 
  20. ^ Simon SR, Kaushal R, Cleary PD, et al. (2007). "Correlates of electronic health record adoption in office practices: a statewide survey". J Am Med Inform Assoc 14 (1): 110–7. doi:10.1197/jamia.M2187. PMID 17068351. 
  21. ^ Menachemi N, Perkins RM, van Durme DJ, Brooks RG (2006). "Examining the adoption of electronic health records and personal digital assistants by family physicians in Florida". Inform Prim Care 14 (1): 1–9. PMID 16848961. http://openurl.ingenta.com/content/nlm?genre=article&issn=1476-0320&volume=14&issue=1&spage=1&aulast=Menachemi. 
  22. ^ "EHR Meaningful Use and Certified EHR Requirements of HITECH Act (ARRA)". http://www.emrandhipaa.com/emr-and-hipaa/2009/02/17/economic-stimulus-bill-simplified/. 
  23. ^ Mandl KD, Szolovits P, Kohane IS (February 2001). "Public standards and patients' control: how to keep electronic medical records accessible but private". BMJ 322 (7281): 283–7. doi:10.1136/bmj.322.7281.283. PMID 11157533. PMC 1119527. http://bmj.com/cgi/pmidlookup?view=long&pmid=11157533. 
  24. ^ Ruotsalainen P, Manning B (2007). "A notary archive model for secure preservation and distribution of electrically signed patient documents". Int J Med Inform 76 (5-6): 449–53. doi:10.1016/j.ijmedinf.2006.09.011. PMID 17118701. 
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[edit] External links

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