EXPERIMENTAL AND THERAPEUTIC MEDICINE 11: 2083-2085, 2016
Recent perspectives of electronic medical record systems (Review) XIAO‑YING ZHANG1 and PEIYING ZHANG2 1
Nanjing University of Chinese Medicine, Information Institute, Nanjing; 2Department of Cardiology, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China Received February 2, 2016; Accepted April 6, 2016 DOI: 10.3892/etm.2016.3233 Abstract. Implementation of electronic medical record (EMR) systems within developing contexts as part of efforts to monitor and facilitate the attainment of health‑related aims has been on the increase. However, these efforts have been concentrated on urban hospitals. Recent findings showed that development processes of EMR systems are associated with various discrepancies between protocols and work practices. These discrepancies were mainly caused by factors including high workload, lack of medical resources, misunderstanding of the protocols by health workers, and client/patient practices. The present review focused on the effects of EMRs on patient care work, and on appropriate EMR designs principles and strategies to ameliorate these systems. Contents 1. Introduction 2. Benefits/effects of EMRs 3. Functionality of EMR systems 4. EMR design issues and principles 5. Conlusions 1. Introduction Information and communication technologies are currently being implemented in healthcare settings with the belief that they can contribute to improved efficiency, access and quality of healthcare services (1,2). Among these technologies, electronic medical record (EMR) systems are recognized as one of the prime transformers of healthcare and a central element in Health Information Systems (2). From a care perspective,
Correspondence to: Dr Peiying Zhang, Department of Cardiology, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, 199 South Jiefang Road, Xuzhou, Jiangsu 221009, P.R. China E‑mail: [email protected]
Key words: electronic medical record, patient care, health information system
EMR systems are expected to improve the accuracy of patient care information recorded in health records, support clinical decision‑making, and improve accessibility of patients' healthcare information for continuity of care over space and time (3). From a managerial perspective, EMR systems can generate health care statistics, which are crucial in the management and planning of health services, thereby, improving the quality of routine health data in health systems (3). The implementation and use of EMR systems in develo ping countries has been examined for over a decade and reported benefits of using this technology have included reduced waiting time for patients, reduced medication order errors, guiding healthcare protocols and simplified generation of mandatory reports to higher authorities (4). Due to low healthcare budgets in developing countries, the use of free and open source software is particularly advocated as a strategy to eliminate licensing costs for sustaining the system. This has resulted in the development of various free and open source EMR systems (5). EMR, electronic patient record (EPR), computer‑based patient record (CPR), and electronic health record (EHR) are all terms that have been used interchangeably to refer to a collection of electronically maintained information regarding an individual's health status and health care (6). However, EMR, EPR and CPR often refer to records implemented at a single or several related healthcare institutions, while EHR is often associated with a record containing all the personal health information of an individual during their lifetime, entered (or accepted) and accessible by healthcare providers distributed on multiple sites, including all ambulatory care settings at which the patient receives care (6,7). In this sense, the EHR is an integrated, centralised record, and constitutes the ultimate goal that national health systems aime of achieve (8). Another related term that has emerged is that of ‘personal health records’, which is similar to EHRs, but is managed by the individual instead of health institutions (9). Medical records, whether in paper or electronic form, serve multiple purposes within healthcare. Their function is to create a basis for the historical record, support communication among providers, anticipate future health problems, record standard preventive measures, identify deviations from expected trends, provide a legal record, and support clinical research (10). However, paper‑based medical records have limitations in that they may be inaccessible when in use by someone else or if misplaced, there may be missing data in the records due to oversight of the health provider, the data may be difficult to read, the records increase in size over time, there
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ZHANG and ZHANG: RECENT PERSPECTIVES OF ELECTRONIC MEDICAL RECORD SYSTEMS
is redundant recording of data in different locations, and it is tedious to extract data for clinical research. EMRs are therefore considered a solution for these shortfalls in paper‑based records. 2. Benefits/effects of EMRs EMRs are perceived to have direct and indirect benefits for healthcare in several areas. EMRs are expected to have positive effects on access to data and the quality of the data since they can be accessed whenever needed and the documentation is more legible (10). A computer can also improve completeness and accuracy through validation checks on data entered, and prompts on missing data. In addition, EMRs are expected to improve the efficiency of the care process in terms of time efficiency, as well as improving the quality of care rendered through, for instance, increased adherence to protocols and reduced medical errors (11). Furthermore, ultimately, EMRs are expected to improve the clinical outcomes in terms of the health status. However, its acceptance clinically is controversial as there are factors that affect clinical outcomes (12). Apart from these benefits on patient care, secondary uses of EMR data in administration, disease surveillance, management and monitoring of the services are also expected to improve health services (13). Other expected benefits are reduced financial costs over time through savings on, for instance, billings, transcription costs, patient cycle time, utilisation of services and support staff salary (14). Nevertheless, the negative effects of EMRs have also been reported. For instance, despite EMRs improvement of access to records, it may be difficult to conduct a search and efficiently review the information in the record (11). Furthermore, EMRs may impose additional administrative work tasks on already heavily burdened health providers (15). EMRs may also foster errors in the processes of entering and retrieving information, and in communication and coordination (16). In addition, Car et al (13) have indicated that the quality of data in EMRs varies due to sociotechnical factors surrounding individual users. Other concerns with EMRs have included issues regarding privacy and confidentiality, hardware problems, system failures, time required to learn how to operate it, and decreased patient‑physician interaction. Thus, the abovementioned studies revealed mixed effects of EMRs on care processes and outcomes. The benefits of EMRs are, therefore, considered to be dependent on the quality of the implementation process and the extent to which decision support is integrated (17). Tang and McDonald (15) identified four specific factors on which benefits depend. These factors are: comprehensiveness of information, duration of use and retention of data, degree of structure of data, and ubiquity of access. Intrinsically, these issues are associated with the system's functionality and design, and the development process. These issues are examined in the subsequent subsections. 3. Functionality of EMR systems EMRs are not simply an electronic version of the paper record, but constitute a part of a comprehensive system, which has additional information management tools (18). The scope of functionality in EMR systems varies in different contexts.
However, recent findings indicated that a comprehensive EMR system should comprise the following functional components: an integrated view of patient data, clinical decision support, clinician/provider order entry, access to knowledge resources, integrated communication support and analysis of aggregated data (19). An integrated view of patient data stems from the provider's need for a historical overview of the patient's health status. This creates a need for the exchange of health information between different systems for the continuity of patient care among different healthcare service providers (20). However, achieving such integration is not a simple task as it requires implementing different types of standards, i.e., system, vocabulary, messaging and security standards. Hammond and Cimino (21) also indicated a need for standardized identifiers for individuals, healthcare providers, health plans, and employers, that could be recognized across systems. Decision support functionality is considered crucial when dealing with decisions associated with diagnosis and therapy. Computers may assist in the diagnosing of a disease based on the individual patient data, and in determining the best treatment based on evidence. The evidence may be based on, for instance, clinical guidelines and care protocols (22). Decision support functionality is considered most effective when provided at the point of care where the provider formulates their assessment of a patient's condition and makes relevant decisions. It is, however, recommended that the applications allow the provider to override a system‑provided recommendation and select an alternative action. Reminders and alerts are some of the forms of decision support. The provider order entry functions relate to the ordering of laboratory tests, prescription of drugs or creating referrals to other allied health services (22). The use of decision support functions in these activities is considered essential, as previously mentioned. Furthermore, access to sources of knowledge is another functionality that is considered important for supporting the decision‑making process for a particular patient (15). The functionality of supporting communication among different healthcare providers is considered important with the distribution of the care process. Thus, communication tools that enable the sharing of information (e.g., lab results) within the EMR are advocated. Communication with a patient, for instance, through email, is another aspect that is considered important. In developing the required functionality, a number of design issues should be considered, as indicated below. 4. EMR design issues and principles Primarily, for the benefits of EMRs to be achieved, it is required that the data be structured and coded to a certain degree (23). However, entering structured data requires increased effort from providers, who are more accustomed to recording narrative textual data on paper‑based records. The effort required in entering data is one of the reasons for the limited use of EMRs by providers during patient consultations. There are three data entry methods that can be used: transcription of dictated or written notes, data entry from structured encounter forms, or direct entry at the point of care (23). The most commonly used approach is data entry, which is carried out by support personnel using structured encounter forms that are completed by the care provider. For all methods, it is important for the user
EXPERIMENTAL AND THERAPEUTIC MEDICINE 11: 2083-2085, 2016
interface design and the physical input/output devices to be appropriate for the user's requirements and work context (24). Concerning the user interface, a basic design principle in relation to navigation, layout, and color requires it be kept simple (25). Difficulty in navigation may lead to use of paper documents instead of the EMR. The use of symbols in EMRs is considered important for enabling quick access and enhancing usability. In addition, incorporating different types of validity checks is recommended for error prevention during data entry. These checks included range, pattern, consistency and spelling checks. Guest and Conrick (25) further indicated that incorporating the following elements could assist in reducing or preventing errors: menu selection (as opposed to form completion), no alphabetical characters where numbers are expected, checks prior to proceeding with major actions, and feedback on errors. In relation to layout, a design that appropriately groups information by function and reduces the overall information density on a screen is recommended. Consistency in the layout and highlighting important information is also recommended (23). Furthermore, confidentiality and privacy are central concerns in the use of EMRs, and therefore authentication and access control are important in the design of such systems. 5. Conclusions It can be concluded that health information technology in the form of electronic medical systems is evolving and is benefitting the medical community in numerous ways. However, a number of efforts are required to make this technology accessible. References 1. World Health Organization: Management of patient information: trends and challenges in Member States: based on the findings of the second global survey on eHealth. Vol 6. Global Observatory for eHealth series, Geneva, 2012. 2. Dzenowagis J and Kernen G: Connecting for health: global vision, local insight. Report for the World Summit on the Information Society. World Health Organization, Geneva, 2005. 3. Fitzpatrick G and Ellingsen G: A review of 25 years of CSCW research in healthcare: contributions, challenges and future agendas. Comput Support Coop Work 22: 609‑665, 2013. 4. Douglas GP: Engineering an EMR System in the Developing WorldNecessity is the Mother of Invention (unpublished PhD thesis). University of Pittsburgh, School of Medicine, etd‑04302009‑101747, 2009. 5. Fraser HS, Biondich P, Moodley D, Choi S, Mamlin BW and Szolovits P: Implementing electronic medical record systems in developing countries. Inform Prim Care 13: 83‑95, 2005. 6. Heard S: Electronic Health Records. In: Health Informatics: Transforming Healthcare with Technology. Conrick M (ed). Thomson Social Science Press, Victoria, 2006. 7. WHO Western Pacific Region: Electronic Health Records: Manual for Developing Countries. World Health Organization, Regional Office for the Western Pacific, Manila, 2006. 8. Fagan LM and Shortliffe EH: The Future of Computer Applications in Health Care. In: Medical Informatics: Computer Applications in Health Care and Biomedicine. Shortliffe Eh and Perreault LE (eds). Springer, New York, NY, 2001.
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9. Sood SP, Nwabueze SN, Mbarika VWA, Prakash N, Chatterjee S, Ray P and Mishra S: Electronic Medical Records: A Review Comparing the Challenges in Developed and Developing Countries, HICSS 2008. In: Proceedings of the 41st Hawaii International Conference on Systems Sciences, Big Island, Hawaii, p248, 2008. 10. Shortliffe EH and Barnett GO: Medical Data: Their Acquisition, Storage, and Use. In: Medical Informatics. Computer Applications in Health Care and Biomedicine. Shortliffe EH and Perreault LE (eds). Springer, New York, NY, 2001. 11. Holroyd‑Leduc JM, Lorenzetti D, Straus SE, Sykes L and Quan H: The impact of the electronic medical record on structure, process, and outcomes within primary care: A systematic review of the evidence. J Am Med Inform Assoc 18: 732‑737, 2011. 12. Blaya JA, Fraser HSF and Holt B: E‑health technologies show promise in developing countries. Health Aff (Millwood) 29: 244‑251, 2010. 13. Car J, Black A, Anandan C, Cresswell K, Pagliari C, Mckinstry B, Procter R, Majeed A and Sheikh A: The Impact of e‑health on the quality and safety of healthcare: a Systematic overview and synthesis of the literature. Imperial College London, London, 2008. 14. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC and Shekelle PG: Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 144: 742‑752, 2006. 15. Tang PC and McDonald CJ: Computer‑Based Patient Record Systems. In: Medical Informatics. Computer Applications in Health Ca re and Biomedicine. Shor tliffe Eh and Perreault LE (eds). Springer, New York, NY, 2001. 16. Ash JS, Berg M and Coiera E: Some unintended consequences of information technology in health care: The nature of patient care information system‑related errors. J Am Med Inform Assoc 11: 104‑112, 2004. 17. Root J, Oster NV, L Jackson S, Mejilla R, Walker J and Elmore JG: Characteristics of Patients Who Report Confusion After Reading Their Primary Care Clinic Notes Online. Health Commun: Nov 3, 2015 (Epub ahead of print). 18. Price M, Weber JH, Davies I and Bellwood P: Lead User Design: Medication Management in Electronic Medical Records. Stud Health Technol Inform 216: 237‑241, 2015. 19. Khurshid S, Keaney J, Ellinor PT and Lubitz SA: A Simple and Portable Algorithm for Identifying Atrial Fibrillation in the Electronic Medical Record. Am J Cardiol 117: 221‑225, 2016. 20. Conrick M, Walker S, Scott P and Frean I: Health Information Interchange. In: Health Informatics: Transforming Healthcare with Technology. Conrick M (ed). Thomson/Social Science Press, Victoria, 2006. 21. Hammond WE and Cimino JJ: Standards in Medical Informatics. In: Medical Informatics: Computer Applications in Health Care and Biomedicine. Shortliffe EH and Perreault LE (eds). Springer, New York, NY, 2001. 22. Ribbons RM: Clinical information systems. In: Health Informatics: Transforming Healthcare with Technology. Conrick M (ed). Thomson/Social Science Press, Victoria, 2006. 23. Ginneken AM, Lei JVD and Bemmel JHV: Structuring the Computer‑based Patient Record. In: Handbook of Medical Informatics. Bemmel JHV and Musen MA (eds). Bohn Stafleu Van Loghum, Houten, 1997. 24. Patel VL and Kushniruk AW: Human‑Computer Interaction in Health Care. In: Handbook of Medical Informatics. Bemmel JHV and Musen MA (eds). Bohn Stafleu Van Loghum, Houten, Netherlands, 1997. 25. Guest K and Conrick M: Human technology interfaces and ergonomics. In: Health Informatics: Transforming Healthcare with Technology. Conrick M (ed). Thomson Social Science Press, Victoria, 2006.
Recent perspectives of electronic medical record systems (Review) XIAO‑YING ZHANG1 and PEIYING ZHANG2 1
Nanjing University of Chinese Medicine, Information Institute, Nanjing; 2Department of Cardiology, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu 221009, P.R. China Received February 2, 2016; Accepted April 6, 2016 DOI: 10.3892/etm.2016.3233 Abstract. Implementation of electronic medical record (EMR) systems within developing contexts as part of efforts to monitor and facilitate the attainment of health‑related aims has been on the increase. However, these efforts have been concentrated on urban hospitals. Recent findings showed that development processes of EMR systems are associated with various discrepancies between protocols and work practices. These discrepancies were mainly caused by factors including high workload, lack of medical resources, misunderstanding of the protocols by health workers, and client/patient practices. The present review focused on the effects of EMRs on patient care work, and on appropriate EMR designs principles and strategies to ameliorate these systems. Contents 1. Introduction 2. Benefits/effects of EMRs 3. Functionality of EMR systems 4. EMR design issues and principles 5. Conlusions 1. Introduction Information and communication technologies are currently being implemented in healthcare settings with the belief that they can contribute to improved efficiency, access and quality of healthcare services (1,2). Among these technologies, electronic medical record (EMR) systems are recognized as one of the prime transformers of healthcare and a central element in Health Information Systems (2). From a care perspective,
Correspondence to: Dr Peiying Zhang, Department of Cardiology, Xuzhou Central Hospital, The Affiliated Xuzhou Hospital of Medical College of Southeast University, 199 South Jiefang Road, Xuzhou, Jiangsu 221009, P.R. China E‑mail: [email protected]
Key words: electronic medical record, patient care, health information system
EMR systems are expected to improve the accuracy of patient care information recorded in health records, support clinical decision‑making, and improve accessibility of patients' healthcare information for continuity of care over space and time (3). From a managerial perspective, EMR systems can generate health care statistics, which are crucial in the management and planning of health services, thereby, improving the quality of routine health data in health systems (3). The implementation and use of EMR systems in develo ping countries has been examined for over a decade and reported benefits of using this technology have included reduced waiting time for patients, reduced medication order errors, guiding healthcare protocols and simplified generation of mandatory reports to higher authorities (4). Due to low healthcare budgets in developing countries, the use of free and open source software is particularly advocated as a strategy to eliminate licensing costs for sustaining the system. This has resulted in the development of various free and open source EMR systems (5). EMR, electronic patient record (EPR), computer‑based patient record (CPR), and electronic health record (EHR) are all terms that have been used interchangeably to refer to a collection of electronically maintained information regarding an individual's health status and health care (6). However, EMR, EPR and CPR often refer to records implemented at a single or several related healthcare institutions, while EHR is often associated with a record containing all the personal health information of an individual during their lifetime, entered (or accepted) and accessible by healthcare providers distributed on multiple sites, including all ambulatory care settings at which the patient receives care (6,7). In this sense, the EHR is an integrated, centralised record, and constitutes the ultimate goal that national health systems aime of achieve (8). Another related term that has emerged is that of ‘personal health records’, which is similar to EHRs, but is managed by the individual instead of health institutions (9). Medical records, whether in paper or electronic form, serve multiple purposes within healthcare. Their function is to create a basis for the historical record, support communication among providers, anticipate future health problems, record standard preventive measures, identify deviations from expected trends, provide a legal record, and support clinical research (10). However, paper‑based medical records have limitations in that they may be inaccessible when in use by someone else or if misplaced, there may be missing data in the records due to oversight of the health provider, the data may be difficult to read, the records increase in size over time, there
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ZHANG and ZHANG: RECENT PERSPECTIVES OF ELECTRONIC MEDICAL RECORD SYSTEMS
is redundant recording of data in different locations, and it is tedious to extract data for clinical research. EMRs are therefore considered a solution for these shortfalls in paper‑based records. 2. Benefits/effects of EMRs EMRs are perceived to have direct and indirect benefits for healthcare in several areas. EMRs are expected to have positive effects on access to data and the quality of the data since they can be accessed whenever needed and the documentation is more legible (10). A computer can also improve completeness and accuracy through validation checks on data entered, and prompts on missing data. In addition, EMRs are expected to improve the efficiency of the care process in terms of time efficiency, as well as improving the quality of care rendered through, for instance, increased adherence to protocols and reduced medical errors (11). Furthermore, ultimately, EMRs are expected to improve the clinical outcomes in terms of the health status. However, its acceptance clinically is controversial as there are factors that affect clinical outcomes (12). Apart from these benefits on patient care, secondary uses of EMR data in administration, disease surveillance, management and monitoring of the services are also expected to improve health services (13). Other expected benefits are reduced financial costs over time through savings on, for instance, billings, transcription costs, patient cycle time, utilisation of services and support staff salary (14). Nevertheless, the negative effects of EMRs have also been reported. For instance, despite EMRs improvement of access to records, it may be difficult to conduct a search and efficiently review the information in the record (11). Furthermore, EMRs may impose additional administrative work tasks on already heavily burdened health providers (15). EMRs may also foster errors in the processes of entering and retrieving information, and in communication and coordination (16). In addition, Car et al (13) have indicated that the quality of data in EMRs varies due to sociotechnical factors surrounding individual users. Other concerns with EMRs have included issues regarding privacy and confidentiality, hardware problems, system failures, time required to learn how to operate it, and decreased patient‑physician interaction. Thus, the abovementioned studies revealed mixed effects of EMRs on care processes and outcomes. The benefits of EMRs are, therefore, considered to be dependent on the quality of the implementation process and the extent to which decision support is integrated (17). Tang and McDonald (15) identified four specific factors on which benefits depend. These factors are: comprehensiveness of information, duration of use and retention of data, degree of structure of data, and ubiquity of access. Intrinsically, these issues are associated with the system's functionality and design, and the development process. These issues are examined in the subsequent subsections. 3. Functionality of EMR systems EMRs are not simply an electronic version of the paper record, but constitute a part of a comprehensive system, which has additional information management tools (18). The scope of functionality in EMR systems varies in different contexts.
However, recent findings indicated that a comprehensive EMR system should comprise the following functional components: an integrated view of patient data, clinical decision support, clinician/provider order entry, access to knowledge resources, integrated communication support and analysis of aggregated data (19). An integrated view of patient data stems from the provider's need for a historical overview of the patient's health status. This creates a need for the exchange of health information between different systems for the continuity of patient care among different healthcare service providers (20). However, achieving such integration is not a simple task as it requires implementing different types of standards, i.e., system, vocabulary, messaging and security standards. Hammond and Cimino (21) also indicated a need for standardized identifiers for individuals, healthcare providers, health plans, and employers, that could be recognized across systems. Decision support functionality is considered crucial when dealing with decisions associated with diagnosis and therapy. Computers may assist in the diagnosing of a disease based on the individual patient data, and in determining the best treatment based on evidence. The evidence may be based on, for instance, clinical guidelines and care protocols (22). Decision support functionality is considered most effective when provided at the point of care where the provider formulates their assessment of a patient's condition and makes relevant decisions. It is, however, recommended that the applications allow the provider to override a system‑provided recommendation and select an alternative action. Reminders and alerts are some of the forms of decision support. The provider order entry functions relate to the ordering of laboratory tests, prescription of drugs or creating referrals to other allied health services (22). The use of decision support functions in these activities is considered essential, as previously mentioned. Furthermore, access to sources of knowledge is another functionality that is considered important for supporting the decision‑making process for a particular patient (15). The functionality of supporting communication among different healthcare providers is considered important with the distribution of the care process. Thus, communication tools that enable the sharing of information (e.g., lab results) within the EMR are advocated. Communication with a patient, for instance, through email, is another aspect that is considered important. In developing the required functionality, a number of design issues should be considered, as indicated below. 4. EMR design issues and principles Primarily, for the benefits of EMRs to be achieved, it is required that the data be structured and coded to a certain degree (23). However, entering structured data requires increased effort from providers, who are more accustomed to recording narrative textual data on paper‑based records. The effort required in entering data is one of the reasons for the limited use of EMRs by providers during patient consultations. There are three data entry methods that can be used: transcription of dictated or written notes, data entry from structured encounter forms, or direct entry at the point of care (23). The most commonly used approach is data entry, which is carried out by support personnel using structured encounter forms that are completed by the care provider. For all methods, it is important for the user
EXPERIMENTAL AND THERAPEUTIC MEDICINE 11: 2083-2085, 2016
interface design and the physical input/output devices to be appropriate for the user's requirements and work context (24). Concerning the user interface, a basic design principle in relation to navigation, layout, and color requires it be kept simple (25). Difficulty in navigation may lead to use of paper documents instead of the EMR. The use of symbols in EMRs is considered important for enabling quick access and enhancing usability. In addition, incorporating different types of validity checks is recommended for error prevention during data entry. These checks included range, pattern, consistency and spelling checks. Guest and Conrick (25) further indicated that incorporating the following elements could assist in reducing or preventing errors: menu selection (as opposed to form completion), no alphabetical characters where numbers are expected, checks prior to proceeding with major actions, and feedback on errors. In relation to layout, a design that appropriately groups information by function and reduces the overall information density on a screen is recommended. Consistency in the layout and highlighting important information is also recommended (23). Furthermore, confidentiality and privacy are central concerns in the use of EMRs, and therefore authentication and access control are important in the design of such systems. 5. Conclusions It can be concluded that health information technology in the form of electronic medical systems is evolving and is benefitting the medical community in numerous ways. However, a number of efforts are required to make this technology accessible. References 1. World Health Organization: Management of patient information: trends and challenges in Member States: based on the findings of the second global survey on eHealth. Vol 6. Global Observatory for eHealth series, Geneva, 2012. 2. Dzenowagis J and Kernen G: Connecting for health: global vision, local insight. Report for the World Summit on the Information Society. World Health Organization, Geneva, 2005. 3. Fitzpatrick G and Ellingsen G: A review of 25 years of CSCW research in healthcare: contributions, challenges and future agendas. Comput Support Coop Work 22: 609‑665, 2013. 4. Douglas GP: Engineering an EMR System in the Developing WorldNecessity is the Mother of Invention (unpublished PhD thesis). University of Pittsburgh, School of Medicine, etd‑04302009‑101747, 2009. 5. Fraser HS, Biondich P, Moodley D, Choi S, Mamlin BW and Szolovits P: Implementing electronic medical record systems in developing countries. Inform Prim Care 13: 83‑95, 2005. 6. Heard S: Electronic Health Records. In: Health Informatics: Transforming Healthcare with Technology. Conrick M (ed). Thomson Social Science Press, Victoria, 2006. 7. WHO Western Pacific Region: Electronic Health Records: Manual for Developing Countries. World Health Organization, Regional Office for the Western Pacific, Manila, 2006. 8. Fagan LM and Shortliffe EH: The Future of Computer Applications in Health Care. In: Medical Informatics: Computer Applications in Health Care and Biomedicine. Shortliffe Eh and Perreault LE (eds). Springer, New York, NY, 2001.
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9. Sood SP, Nwabueze SN, Mbarika VWA, Prakash N, Chatterjee S, Ray P and Mishra S: Electronic Medical Records: A Review Comparing the Challenges in Developed and Developing Countries, HICSS 2008. In: Proceedings of the 41st Hawaii International Conference on Systems Sciences, Big Island, Hawaii, p248, 2008. 10. Shortliffe EH and Barnett GO: Medical Data: Their Acquisition, Storage, and Use. In: Medical Informatics. Computer Applications in Health Care and Biomedicine. Shortliffe EH and Perreault LE (eds). Springer, New York, NY, 2001. 11. Holroyd‑Leduc JM, Lorenzetti D, Straus SE, Sykes L and Quan H: The impact of the electronic medical record on structure, process, and outcomes within primary care: A systematic review of the evidence. J Am Med Inform Assoc 18: 732‑737, 2011. 12. Blaya JA, Fraser HSF and Holt B: E‑health technologies show promise in developing countries. Health Aff (Millwood) 29: 244‑251, 2010. 13. Car J, Black A, Anandan C, Cresswell K, Pagliari C, Mckinstry B, Procter R, Majeed A and Sheikh A: The Impact of e‑health on the quality and safety of healthcare: a Systematic overview and synthesis of the literature. Imperial College London, London, 2008. 14. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC and Shekelle PG: Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 144: 742‑752, 2006. 15. Tang PC and McDonald CJ: Computer‑Based Patient Record Systems. In: Medical Informatics. Computer Applications in Health Ca re and Biomedicine. Shor tliffe Eh and Perreault LE (eds). Springer, New York, NY, 2001. 16. Ash JS, Berg M and Coiera E: Some unintended consequences of information technology in health care: The nature of patient care information system‑related errors. J Am Med Inform Assoc 11: 104‑112, 2004. 17. Root J, Oster NV, L Jackson S, Mejilla R, Walker J and Elmore JG: Characteristics of Patients Who Report Confusion After Reading Their Primary Care Clinic Notes Online. Health Commun: Nov 3, 2015 (Epub ahead of print). 18. Price M, Weber JH, Davies I and Bellwood P: Lead User Design: Medication Management in Electronic Medical Records. Stud Health Technol Inform 216: 237‑241, 2015. 19. Khurshid S, Keaney J, Ellinor PT and Lubitz SA: A Simple and Portable Algorithm for Identifying Atrial Fibrillation in the Electronic Medical Record. Am J Cardiol 117: 221‑225, 2016. 20. Conrick M, Walker S, Scott P and Frean I: Health Information Interchange. In: Health Informatics: Transforming Healthcare with Technology. Conrick M (ed). Thomson/Social Science Press, Victoria, 2006. 21. Hammond WE and Cimino JJ: Standards in Medical Informatics. In: Medical Informatics: Computer Applications in Health Care and Biomedicine. Shortliffe EH and Perreault LE (eds). Springer, New York, NY, 2001. 22. Ribbons RM: Clinical information systems. In: Health Informatics: Transforming Healthcare with Technology. Conrick M (ed). Thomson/Social Science Press, Victoria, 2006. 23. Ginneken AM, Lei JVD and Bemmel JHV: Structuring the Computer‑based Patient Record. In: Handbook of Medical Informatics. Bemmel JHV and Musen MA (eds). Bohn Stafleu Van Loghum, Houten, 1997. 24. Patel VL and Kushniruk AW: Human‑Computer Interaction in Health Care. In: Handbook of Medical Informatics. Bemmel JHV and Musen MA (eds). Bohn Stafleu Van Loghum, Houten, Netherlands, 1997. 25. Guest K and Conrick M: Human technology interfaces and ergonomics. In: Health Informatics: Transforming Healthcare with Technology. Conrick M (ed). Thomson Social Science Press, Victoria, 2006.
