Electronic medical record
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An electronic medical record (EMR) is a medical record in digital format.
In health informatics, an EMR is considered by some to be one of several types of EHRs (electronic health records), but in several contexts EMR and EHR are used as synonymous.[1] The term has sometimes included other systems which keep track of medical information, such as the practice management system which supports the electronic medical record.
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[edit] Issues & Concerns
As of 2006[update], adoption of EMRs and other health information technology, such as computer physician order entry (CPOE), has been minimal in the United States, in spite of studies showing revenue gains after implementation.[2] Fewer than 10% of American hospitals have implemented health information technology,[3] while a mere 16% of primary care physicians use EHRs.[4] The vast majority of healthcare transactions in the United States still take place on paper, a system that has remained unchanged since the 1950s. If all medical payment transactions in the U.S. were handled electronically, America could save $11 billion annually[5]. The healthcare industry spends only 2% of gross revenues on information technology, which is meager compared to other information intensive industries such as finance, which spend upwards of 10%.[6] The following issues are behind the slow rate of adoption:
[edit] Interoperability
In healthcare, interoperability is the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged. [7]
In the United States, the development of standards for EMR interoperability is at the forefront of the national health care agenda.[4] EMRs, while an important factor in interoperability, are not a critical first step to sharing data between practicing physicians, pharmacies and hospitals. Many physicians currently have computerized practice management systems that can be used in conjunction with health information exchange (HIE), allowing for first steps in sharing patient information (lab results, public health reporting) which are necessary for timely, patient-centered and portable care. There are currently multiple competing vendors of EHR systems, each selling a software suite that in many cases is not compatible with those of their competitors. Only counting the outpatient vendors, there are more than 25 major brands currently on the market. In 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONC), originally headed by David Brailer, in order to address interoperability issues and to establish a National Health Information Network (NHIN). Under the ONC, Regional Health Information Organizations (RHIOs) have been established in many states in order to promote the sharing of health information. Congress is currently working on legislation to increase funding to these and similar programs.
The Center for Information Technology Leadership described four different categories (“levels”) of data structuring at which health care data exchange can take place. [8] While it can be achieved at any level, each has different technical requirements and offers different potential for benefits realization.
The four levels are[9]:
| Level | Data Type | Example |
|---|---|---|
| 1 | Non-electronic data | Paper, mail, and phone call. |
| 2 | Machine transportable data | Fax, email, and unindexed documents. |
| 3 | Machine organizable data (structured messages, unstructured content) | HL7 messages and indexed (labeled) documents, images, and objects. |
| 4 | Machine interpretable data (structured messages, standardized content) | Automated transfer from an external lab of coded results into a provider’s EHR. Data can be transmitted (or accessed without transmission) by HIT systems without need for further semantic interpretation or translation. |
[edit] Privacy
A major concern is adequate confidentiality of the individual records being managed electronically. According to the LA 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.[10] Multiple access points over an open network like the Internet increases possible patient data interception. In the United States, this class of information is referred to as Protected Health Information (PHI) and its management is addressed under the Health Insurance Portability and Accountability Act (HIPAA) as well as many local laws.[11] 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.[12] The organizations and individuals charged with the management of this information are required to ensure adequate protection is provided and that access to the information is only by authorized parties. The growth of EHR creates new issues, since electronic data may be physically much more difficult to secure, as lapses in data security are increasingly being reported.[13] Information security practices have been established for computer networks, but technologies like wireless computer networks offer new challenges as well.
A related concern is the potential privacy risk posed by interoperability. 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."[14]
[edit] Older record incorporation
To attain the wide accessibility, efficiency, patient safety and cost savings promised by EMR, older paper medical records ideally should be incorporated into the patient's record. The digital scanning process involved in conversion of these physical records to EMR is an expensive, time-consuming process, which must be done to exacting standards to ensure exact capture of the content. Because many of these records involve extensive handwritten content, some of which may have been generated by different healthcare professionals over the life span of the patient, some of the content is illegible following conversion. The material may exist in any number of formats, sizes, media types and qualities, which further complicates accurate conversion. In addition, the destruction of original healthcare records must be done in a way that ensures that they are completely and confidentially destroyed. Results of scanned records are not always usable; medical surveys found that 22-25% of physicians are much less satisfied with the use of scanned document images than that of regular electronic data.[15]
[edit] Social and organizational barriers
According to the Agency for Healthcare Research and Quality's National Resource Center for Health Information Technology, EMR implementations follow the 80/20 rule; that is, 80% of the work of implementation must be spent on issues of change management, while only 20% is spent on technical issues related to the technology itself. Such organizational and social issues include restructuring workflows, dealing with physicians' resistance to change (or, alternatively, software engineers' evolving research in deep modeling of the physician's knowledge and workflow domains), as well as IT personnels' resistance to design and implementation flexibility needed in the complex healthcare environment, and creating a collaborative environment that fosters communication between physicians and information technology project managers. Exemplifying this need are several highly publicized HIT implementation failures, such as one at Cedars Sinai Medical Center in Los Angeles, in which physicians revolted and forced the administration to scrap a $34 million CPOE system [16] as well as others compiled at a collection of cases of health IT difficulties by medical informatics specialists.[17] There are, however, several successful examples of EMR implementations in large hospitals, usually hospital systems that have had years of experience developing custom EMRs, for example the Veterans Administration hospital system, Kaiser Permanente's HealthConnect and the VistA EMR.
[edit] Technology limitations
Limitations in software, hardware and networking technologies has made EMR difficult to affordably implement in small, budget conscious, multiple location healthcare organizations. Until recently most EMR systems were developed using older programming languages such as Visual Basic and C++; however with many systems now being developed using Microsoft .NET Framework and Java technology EMRs can be securely implemented across multiple locations with greater performance and interoperability.[18] Prior to the recent introduction of IEEE 802.11g/n wireless technology, access to large files such as MRI and X-Ray images was slow. With these new wireless technologies data can be securely transferred at speeds of up to 108 Mbit/s, across extended distances and in older buildings built with brick or concrete walls. In the ASP model, where the EMR data is stored at an off-site data center, the bandwidth limitation of the last mile Internet access still remains as the bottleneck and as a technological limitation for large scanned file transfers.Tablet PC technology has significantly improved over the recent years, Li-Ion/polymer batteries for battery life of up to 8 hours, biometric security, low-voltage processors and lighter weight solutions. For the new generation of Tablet PC, there are now EMRs that are fully handwriting capable[19]
[edit] Preservation
Under data protection legislation and the law generally responsibility for patient records (irrespective of the form they are kept in) is always on the creator and custodian of the record, usually a health care practice or facility. The physical medical records are the property of the medical provider (or facility) that prepares them. This includes films and tracings from diagnostic imaging procedures such as X-ray, CT, PET, MRI, ultrasound, etc. The patient, however, according to HIPAA, owns the information contained within the record and has a right to view the originals, and to obtain copies under law.[20] Additionally, those responsible for the management of the EMR are responsible to see the hardware, software and media used to manage the information remain usable and not degraded. This requires backup of the data and protection being provided to copies. It will also require the planned periodic migration of information to address concerns of media degradation from use.[21]
[edit] Legal status
Medical records, such as physician orders, exam and test reports are legal documents, which must be kept in unaltered form and authenticated by the creator.
- Digital signatures Most national and international standards accept electronic signatures.[22] According to the American Bar Association, "A signature authenticates a writing by identifying the signer with the signed document. When the signer makes a mark in a distinctive manner, the writing becomes attributable to the signer."[23] With proper security software, electronic authentication is more difficult to falsify than the handwritten doctor's signature. However, as the recent rise in identity theft demonstrates, no security method can totally prevent fraud, so auditing information security will continue to be prudent when using EMR.
- Digital records such as EHR create difficulties ensuring that the content, context and structure are preserved when the records do not have a physical existence. As of 2006[update], national and state archives authorities are still developing open, non-proprietary technical standards for electronic records management (ERM).[24]
[edit] Standards
Though there are few standards for modern day EMR systems as a whole, there are many standards relating to specific aspects of EHRs and EMRs. These include:
- ASTM International Continuity of Care Record - a patient health summary standard based upon XML, the CCR can be created, read and interpreted by various EHR or EMR systems, allowing easy interoperability between otherwise disparate enities.[25]
- ANSI X12 (EDI) - A set of transaction protocols used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information, because several of the transactions became required by the Health Insurance Portability and Accountability Act (HIPAA) for transmitting data to Medicare.
- CEN - CONTSYS (EN 13940), a system of concepts to support continuity of care.
- CEN - EHRcom (EN 13606), the European standard for the communication of information from EHR systems.
- CEN - HISA (EN 12967), a services standard for inter-system communication in a clinical information environment.
- DICOM - a heavily used standard for representing and communicating radiology images and reporting
- HL7 - HL7 messages are used for interchange between hospital and physician record systems and between EMR systems and practice management systems; HL7 Clinical Document Architecture (CDA) documents are used to communicate documents such as physician notes and other material.
- ISO - ISO TC 215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures.
- openEHR - next generation public specifications and implementations for EHR systems and communication, based on a complete separation of software and clinical models.
Various factors involving the timing, the right players, market history, utility, and governance play a key role in the overall enrichment of the standard and certification development. The standardization and certification even though seem to bring uniformity in the EMR development, do not guarantee their acceptability and sustainability in the long run. [26] In 2005 the US Federal Government awarded a contract to CCHIT - Certification Commission for Healthcare Information Technology to develop certification criteria for EMR. Starting in early 2007 vendors began to utilize these certification criteria for their EMR systems.
[edit] Customization
Pricing for EMR systems is highly dependent on each practice's unique needs. Because every medical practice has distinct requirements, systems usually need to be custom tailored. This is due to the majority of EMR systems being based on templates that are initially general in scope. In many cases, these templates can then be customized in co-operation with the vendor/developer to better fit data entry based on a medical specialty, environment or other specified needs. There are also EMR systems available that do not use templates for data entry and therefore can be easily personalized by each individual user. Alternative data entry methods include concept processing, voice recognition, and transcription.
[edit] Public implementations
As of 2005, one of the largest projects for a national EMR is by the National Health Service (NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic medical record by 2010.
The Canadian province of Alberta's Alberta Netcare project is a large-scale operational Electronic Health Record (EHR) system.[citation needed]
Adoption of electronic medical records by US doctors is increasing slowly. The latest data from the National Ambulatory Medical Care Survey (NAMCS) indicate that one-quarter of office-based physicians report using fully or partially electronic medical record systems (EMR) in 2005, a 31% increase from the 18.2 percent reported in the 2001 survey.[27] However, the survey also states that just 9.3% of these physicians actually have a "complete EMR system", with all four basic functions deemed minimally necessary for a full EMR: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes.[28] Barriers to adopting an EMR system include training, costs and complexity, as well as the lack of a national standard for interoperability among competing software options.[29] Advocates of electronic health records hope that product certification will provide US physicians and hospitals with the assurance they need to justify significant investments in new systems. The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards and certify vendors who meet them. On July 18 2006, CCHIT released its first list of 20 certified ambulatory EMR and EHR products.[30] and then on July 31 2006, additionally announced that two further EMR and EHR products had achieved certification.[31]
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 or VistA. 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.
[edit] Comparison of EMR software solutions
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Basic general information about major software solutions: creator/company, license/price etc., focusing on small-scale practice systems.
| Creator | Preferred Vendor | Latest stable version | Cost (USD) | Software license | |
|---|---|---|---|---|---|
| MedEZ | MedEZ/ISS | www.MedEz.com - MedEZ - 954-332-4700 | 6.0.4 | Module Based with Electronic Document Management and Clinical Notes-Customizable | Proprietary |
| Medisoft Clinical | McKesson Corp | http://www.JBMMS.com, JB Medical, 877-787-8686 |
9.3 | CCHIT Certified - $5480 First Doc, $3400 Subsequent | Proprietary |
| PrognoCIS | BizMatics, Inc. | http://www.bizmaticsinc.com, PrognoCIS, 1-877-693-6748 or 619-677-5972 |
36 | CCHIT Certified / EMR and PM / ASP and Client Server | Proprietary |
| SequelMed | Sequel Systems, Inc. | http://www.sequelmed.com, SequelMed, 631-694-3600 |
7.0 | CCHIT Certified / EMR and PMS / ASP | Proprietary |
| EMR | BizSecure, Inc. | www.lushtech.com | 4.0 | CCHIT Certified / EMR and PM / ASP and Client Server | Proprietary |
| Iasis Free EMR-EHR Practice Management | www.IasisNet.org | www.IasisNet.org Online Doctors Community Forums,Medical News |
V1.0.0.315 | $0.0 Freeware -Registration Required-Multi User, Customizable,All Specialties Supported | Proprietary |
| Document Busters | Document Busters, Inc. | www.documentbusters.net | CCHIT Certified / EMR and PM / ASP and Client Server | Proprietary | |
| EDrawer | LSSP Corporation | www.edrawer.com | 4.3.209 | CCHIT Certified / EMR and PM / ASP and Client Server | Proprietary |
| ICS | National Medical Imaging | www.nmics.com | 2.5 | EMR Scheduling/ Billing / PM / PACS / ASP and Client Server Initial Setup plus a Monthly Fee | GNU GPL V2 and Proprietary |
| ClearHealth | ClearHealth Inc. | Clearhealth | 2.2 | EMR Scheduling/ Billing / PM | GNU GPL V2 |
| Therapy Office EMR | Asmakta Ltd | www.therapyoffice.net | 1.1 | EHR only $1500, Practice Management $3600, MD w/Rx $5000 | Proprietary |
| Amazing Charts EHR | Jonathan Bertman | 4.0 | from $995 | Proprietary | |
| MicroMD EMR | Henry Schein Medical Systems | Henry Schein Medical Systems | 6.0 | ? | Proprietary |
| eClinicalWorks | eClinicalWorks | http://www.easemd.com, EaseMD Systems, 866-321-2828 |
8.0 | CCHIT Certified - Monthly fee; Direct Purchase: $10,000 for first doc, $5,000 for subsequent | Proprietary |
| Sevocity | Conceptual MindWorks, Inc. | 5.1 | from $460 per month | Proprietary | |
| e-MDs Razor EMR | e-MDs | 6.3 | from $2,995 | Proprietary | |
| Praxis EMR | Infor-Med | From Co. or Implementation/Project Managers i.e. PKLEnterprises 509-965-4050 | 4 | From 9,900 with training/implementation | |
| CureMD EMR | CureMD Corporation | 10 | (custom pricing) | Proprietary | |
| Medscribbler | Scriptnetics Inc. | 5 | from $2,899.99 (custom pricing) | Proprietary | |
| MedicWare EMR | MedicWare | ? | ? | ? | Proprietary |
| MedInformatix EMR | MedInformatix | MedInformatix, Inc. 5777 W. Century Blvd., Suite 1700 Los Angeles, California 90045 | 7.0 | ? | Proprietary |
| SOAPware | SOAPware EMR Systems | 5.x | from $1,999.99 (custom pricing) | Proprietary | |
| NextGen EMR | NextGen | MMIC Technology Solutions, 1-800-328-5532, mmicgroup.com | ? | $50,000+ First Doc | Proprietary |
| PeakPractice | Eclipsys | JB Medical - 877-787-8686 | Current | ASP Model, Purchase: $10000 First Doctor, $5000 Subsequent | Proprietary |
| MediNotes e EHR | MediNotes | AutoMED Software 516.369.7091, Medisys 304-204-3400 | 5.2 | from 5,000.00 | Proprietary |
| JonokeMed | Jonoke Software Development Inc. | 4.05.01 | ? | Proprietary | |
| HealthHighway EMR | HealthHighway Inc. | ? | 3.1 | ? | Proprietary |
| HARMONY | MedTec | 5.21 | ? | Proprietary | |
| OmniMD EMR | OmniMD EMR | OmniMD CCHIT Certified EMR and PM, Hitender Soni, 914-332-5590 ext 307, Soni@OmniMD.com | 7.0 | from $325/month (custom pricing available) | Proprietary |
| simplifyMD | Matt Ethington | Internal - 866-551-0346 | 3.0 | Custom per Practice | Proprietary |
| ICChart | InteGreat Concepts, Inc. | 6.1 | See vendor | web-based system | |
| Greenway PrimeSuite | Greenway Medical Technologies | Mds medical - www.mdsmedicalsoftware.com | 14.2.13.1 | Custom Pricing | Proprietary |
| gGastro / gCardio / gUro | gMed | gMed- http://www.gmed.com ] | 4.7.1.3 | See vendor | Proprietary |
| Powerchart | Cerner | www.cerner.com | ? | ? | Proprietary |
| Turbo-Doc | Turbo-Doc Electronic Medical Records | www.turbodoc.com | 11x | $4000/doctor(associated staff included), Optional $600/yr maintenance/upgrade agreement. | Proprietary |
| MedTrak | MedTrak Systems, Inc. | MedTrak Systems | Continuously updated (web based system) | Transaction based pricing based on type of visit | Proprietary |
| Medical and Practice Management Suite | LSS Data Systems | LSS Data Systems | 5.6 | See Vendor | |
| Creator | Preferred Reseller | Latest stable version | Cost (USD) | Software license |
Operating system compatibility:
| Client | Windows | Mac OS X | Linux | BSD | Unix | AmigaOS |
|---|---|---|---|---|---|---|
| MedEZ | Yes | No | No | No | No | No |
| Iasis Free EMR-EHR Practice Management | Yes | No | No | No | No | No |
| Medisoft Clinical | Yes | No | No | No | No | No |
| PrognoCIS | Yes | No | Yes | No | No | No |
| SequelMed | Yes | No | No | No | No | No |
| EMR Experts | Yes | No | Yes | No | No | No |
| NMICS.com | Yes | Yes | Yes | Yes | Yes | Yes |
| Therapy Office EMR | Yes | No | No | No | No | No |
| Amazing Charts | Yes | Yes | Yes | No | No | No |
| MicroMD EMR | Yes | No | No | No | No | No |
| eClinicalWorks EMR | Yes | No | Yes | No | ? | No |
| Sevocity | Yes | Yes | Yes | No | Yes | No |
| e-MDs 'Razor' EMR | Yes | Yes | Yes | Yes | Yes | Yes |
| Praxis EMR | Yes | No | No | No | No | No |
| CureMD EMR | Yes | No | No | No | No | No |
| Medscribbler | Yes | No | No | No | No | No |
| MedicWare EMR | Yes | No | No | No | No | No |
| SOAPware | Yes | No | No | No | No | No |
| NextGen EMR | Yes | No | No | No | No | No |
| PeakPractice | Yes | No | No | No | No | No |
| MediNotes e EMR | Yes | No | No | No | No | No |
| JonokeMed | Yes | Yes | No | No | No | No |
| HealthHighway EMR | Yes | Yes | Yes | No | Yes | No |
| HARMONY | Yes | No | Yes | No | Yes | No |
| OmniMD EMR | Yes | Yes | Yes | No | No | No |
| simplifyMD | Yes | Yes | Yes | Yes | Yes | Yes |
| ICChart | Yes | No | No | No | No | No |
| Greenway PrimeSuite | Yes | No | No | No | No | No |
| MedTrak | Yes | Yes | No | No | No | No |
| gGastro / gCardio / gUro | Yes | No | No | No | No | No |
| Turbo-Doc | Yes | No | No | No | No | No |
| Client | Windows | Mac OS X | Linux | BSD | Unix | AmigaOS |
[edit] See also
- Continuity of Care Record
- Electronic health record
- European Institute for Health Records (EuroRec)
- MUMPS
- Veterans Health Information Systems and Technology Architecture (VistA)
- List of open-source Electronic Health Record systems
- Composite Health Care System
- Canadian EMR
- Office suites including online office suites
- List of open source EMR vendors
[edit] References
- ^ "A State Policy Approach: Promoting Health Information Technology in California". California Legislative Analyst Office. February 2007. http://www.lao.ca.gov/2007/health_info_tech/health_info_tech_021307.aspx.
- ^ Development of a Module for Point-of-care Charge Capture and Submission Using an Anesthesia Information Management System by David L. Reich, Ronald A. Kahn and David Wax, et al PMID 16810010)
- ^ 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?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&sortspec=relevance&volume=57&firstpage=1759&resourcetype=HWCIT. Retrieved on 2006-08-04.
- ^ Johnston, Doughlas, et al. "The Value of Computerize Provider Order Entry in Ambulatory Settings: Executive Preview." Wellesley, MA: Center for Information Technology Leadership, 2003
- ^ IT's Role in Efficient Practice[1]
- ^ Raymond, B. and C. Dold. "Clinical Information Systems: Achieving the Vision. Prepared for the Meeting "The Benefits of Clinical Information Systems" Sponsored by the Kaiser Permanent Institute for Health Policy, 2001.
- ^ 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)
- ^ Walker J, Pan E, Johnston D, Adler-Milstein J, Bates D, Middleton B. The Value Of Health Care Information Exchange And Interoperability. Health Affairs. Web Exclusive, January 19, 2005.
- ^ NAHIT Levels of EHR Interoperbility [2] Retrieved April 4, 2007
- ^ Health & Medicine (2006-06-26). "At risk of exposure: In the push for electronic medical records, concern is growing about how well privacy can be safeguarded.". Los Angeles Times. http://www.latimes.com/features/health/medicine/la-he-privacy26jun26,1,3180537.column?ctrack=1&cset=true. Retrieved on 2006-08-08.
- ^ US Code of Federal Regulations, Title45, Volume 1 (Revised October 1, 2005): of Individually Identifiable Health Information (45CFR164.501) Retrieved July 30, 2006
- ^ European Parliament and Council (24 October 1995): EU Directive 95/46/EC - The Data Protection Directive Retrieved July 30, 2006
- ^ CNN.com (May 23, 2006): FBI seeks stolen personal data on 26 million vets Retrieved July 30, 2006
- ^ JM Appel. Why shared medical database is wrong prescription. Orlando Sentinel, December 30, 2008. http://www.orlandosentinel.com/news/opinion/views/orl-opappel3008dec30,0,4065787.story
- ^ Hallvard Lærum, MD, Tom H. Karlsen, MD, and Arild Faxvaag, MD, PhD (2003). "Effects of Scanning and Eliminating Paper-based Medical Records on Hospital Physicians' Clinical Work Practice". Journal of the American Medical Informatics Association 10: 588–595. doi:. PMID 12925550. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=264437. Retrieved on 2006-07-30.
- ^ Connolly, Ceci (2005-03-21). "Cedars-Sinai Doctors Cling to Pen and Paper". The Washington Post. http://www.washingtonpost.com/wp-dyn/articles/A52384-2005Mar20.html. Retrieved on 2006-08-03.
- ^ Sliverstein, Scot. "Sociotechnologic Issues in Clinical Computing: Common Examples of Healthcare IT Difficulties". Drexel University. http://www.ischool.drexel.edu/faculty/ssilverstein/medinfo.htm. Retrieved on 2007-11-15.
- ^ EMR Experts: State of the Industry - Electronic Medical Records eBook Retrieved January 14, 2007
- ^ Handwriting and mobile computing experts: [3] Retrieved August 20, 2008
- ^ Medical Board of California: Medical Records - Frequently Asked Questions Retrieved July 30, 2006
- ^ National Archives and Records Administration (NARA): Long-Term Usability of Optical Media Retrieved July 30, 2006
- ^ American Bar [[Association, Section of Science and Technology, Information Security Committee: Jurisdictions with legislation regarding electronic signatures Retrieved July 31, 2006
- ^ American Bar Association, Section of Science and Technology, Information Security Committee: Digital Signature Guidelines] Retrieved July 31, 2006
- ^ The National Archives: Electronic Records Management Initiative retrieved July 31, 2006
- ^ Nainil C. Chheda, MS (November 2005). "Electronic Medical Records and Continuity of Care Records - The Utility Theory" (PDF). Application of Information Technology and Economics. http://www.emrworld.net/emr-research/articles/emr-ccr.pdf. Retrieved on 2006-07-25.
- ^ Nainil C. Chheda, MS (January 2007). "Standardization & Certification: The truth just sounds different" (PDF). Application of Healthcare Governance. http://www.nainil.com/research/whitepapers/Standardization_and_Certification.pdf. Retrieved on 2007-01-16.
- ^ National Center for Health Statistics: Electronic Medical Record Use by Office-Based Physicians:, United States, 2005 Retrieved July 24, 2006
- ^ CDC's National Center for Health Statistics: More Physicians Using Electrical Medical Records Retrieved July 27, 2006
- ^ Gans D, Kralewski J, Hammons T, Dowd B (2005). "Medical groups' adoption of electronic health records and information systems". Health affairs (Project Hope) 24 (5): 1323–1333. doi:. PMID 16162580.
- ^ Certification Commission for Healthcare Information Technology (July 18, 2006): CCHIT Announces First Certified Electronic Health Record Products Retrieved July 26, 2006
- ^ Certification Commission for Healthcare Information Technology (July 31, 2006):CCHIT Announces Additional Certified Electronic Health Record Products Retrieved July 31, 2006
