Improving the Adoption of Electronic Health Record in the US Lessons from the UK, Denmark, and Canada

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1 Improving the Adoption of Electronic Health Record in the US Lessons from the UK, Denmark, and Canada HM893 Public Health Capstone Angela Lee 12/14/2011 Abstract: Among the OECD countries, less than 30% of healthcare providers in the US reported to use electronic health record (EHR), which places the US among the bottom. With passing of the HITECH Act, healthcare providers in the US are given financial incentives to adopt the EHR which encourages EHR use in the healthcare. However, when looking at the successful EHR adoptions in other countries, financial incentive alone is not sufficient for the healthcare providers to fully adopt the EHR. Instead, a multifaceted approach that includes a firm commitment from government and medical association is necessary. Improvement in the EHR technology, clear statement of healthcare policy & standards, and supportive environment created by the management are also necessary to achieve a nation wide EHR adoption.

2 Introduction It is apparent when you look at the development of new gadgets, we have insatiable appetite for technology. Despite American s tendency to consume technology, the healthcare industry has been defying the trend. Only in 2009, the HITECH act has given a comprehensive framework for updating the current healthcare infrastructure by encouraging adoption of health information systems (e.g. electronic health record, and Health Information Exchanges). With the recent changes to the federal law, there is finally an incentive for the healthcare providers to adopt the technology, and thereby potentially changing how the healthcare is delivered in the US. With estimated $27 billion available over 10 years from the HITECH Act (Blumenthal & Tavenner, 2010), healthcare organizations have financial incentives to adopt and utilize electronic health records (EHR). The healthcare providers are awarded not only for adopting the EHR by Centers for Medicare & Medicaid Services (CMS), but they must also use the system meaningfully in their practices. What is now known as Meaningful Use outlines the metrics which the healthcare providers would be measured against 1. Although the HITECH Act may be one of the comprehensive push from the US federal government, the effort for the national adoption of the EHR is not new. In 2004, Bush administration attempted to promote the EHR, with projected end date of 2014 (CMS, 2011). Despite the efforts by the Bush administration, in 2008, only 13% of survey respondents had a basic EHR that did not include advance functions such as clinical decision support system (CDSS) or e prescription (DesRoches, et al., 2008). Furthermore, the projected EHR adoption by 2014 (planed completion date by the Bush administration) was not favorable. One model only projected only 47% of small practices would adopt the EHR even 1 Summary of CMS s Meaningful Use guideline is found at https://www.cms.gov/ehrincentiveprograms/30_meaningful_use.asp 1

3 assuming that the EHR would eventually be adopted by the healthcare providers (Ford, Menachemi, Peterson, & Huerta, 2009). Interestingly, the Bush administration intervention did not facilitate the EHR adoption at all. In fact, according to the model, the intervention was a hindrance to the EHR adoption; by 2014, the model s predicted adoption rate would drop to 47% from the previously projected 62% (Ford, Menachemi, Peterson, & Huerta, 2009). The federal government s efforts to promote EHR were also noted in 2007; CMS announced a 5 year EHR demonstration study under HHS s initiative for EHR and HIE adoption. Although the project was terminated early due to enactment of the HITECT Act, the strategy was similar to Meaningful Use in that the participants were awarded based on the degree of EHR adoption and use (CMS, 2011). Despite these past efforts, the rate of the EHR adoption in the US is low compared to other countries. Studies estimate that less than 30% of healthcare providers are using the EHR, while other countries boasts more than 90% adoption rate (Davis & Stremikis, 2009). To understand why the differences may exit, healthcare system in other countries will be compared, and discuss the potential barriers for the EHR adoption in the US. Theoretical Advantages of EHR Theoretically, the EHR has potentials to help stakeholders, who are comprised of healthcare administrators, patients, healthcare providers, and the community (i.e. the public). For the hospitals and the private practices, the EHR could streamline the administrative process which could allow more efficient patient care and reduce the cost of healthcare. Such potential savings could be valued as much as $81 billion annually (Wilson, 2007). Moreover, the EHR would allow a greater control over the patient records than the traditional paper records (Wager, Lee, & Glaser, 2009) and thereby improving 2

4 security and privacy of patient data as mandated in HIPAA (Centers for Medicare & Medicaid Services, 2007). Most direct benefit of the EHR would be realized by the individual patients. Utilizing the EHR with other informatics systems such as CDSS, has immense potentials to improve the quality of patient care (Health Canada, 2001). The clinical systems such as the EHR have shown to improve public health surveillances; improve compliance to guideline based care; and reduce medical errors (Chaudhry, et al., 2006). Since computers has little variances in performance under different conditions, potential difference in human judgment causing medical error could be reduced by utilizing computers in the healthcare (i.e. the systems will respond the same way, which creates consistency even if the human users do not). Reduction in human error would also benefit the healthcare provider. If a CDSS is used in conjunction with the EHR, potential for human error could be minimized. For instance, CDSS could check for a drug interaction as the doctors prescribe medicine (Hunt, Haynes, Hanna, & Smith, 1998). Moreover, the healthcare providers could benefit from adopting the EHR by improved access to patient records. For example, the healthcare providers will be able to view and search patient records with ease with the EHR. The healthcare providers will benefit even more if the EHR was interoperable with other health informatics systems (e.g. radiology, lab results, etc.). For example, if the EHR communicates with radiology and aggregate the information in one location, the physicians would be able to view and access patient information in a timely fashion, and reduce unnecessary diagnostic tests. Last but not least, the adoption of the EHR would benefit the public. For example, public health surveillance data from physicians and laboratories could be submitted electronically in a timely fashion, which could lead to a faster intervention by the county and state health departments. With the fast interventions, potential outbreak could be contained and reduce impact on the public. Quality of data will also remove as the EHR could require some data which will provide more complete picture about 3

5 the community s status. Moreover, the EHR could allow researchers to access quality data (Health Canada, 2001). Considering the healthcare is shifting more towards evidence based practices, the ability to research medical conditions will be greatly augmented by adopting the EHR in a community. Global Trends in EHR Adoption Although the US federal government started the major promotion of the EHR recently, the changes have been occurring in other nations already. Among the OECD countries, UK, Netherlands, Australia, and New Zeeland have greater than 90% adoption rate, whereas only estimated 10 30% of physicians in both Canada and the US have adopted the EHR (Figure 1) (Jha, Doolan, Grandt, Scott, & Bates, 2008). Figure 1: EHR adoption rates in countries as of From (Davis & Stremikis, 2009). SMA Interview showed slightly different numbers than Jha et al (2008); however, it too reported a low EHR adoption rate in the US. The survey also showed that the regional models had the highest adoption rate and that the highest adoption was shown in Nordic countries (Figure 2) (Neumann, 2011). A regional EHR model gives more decision making power to each region (Accenture, 2010), which could increase more customization and increase the EHR adoption. To understand factors driving the EHR adoption, healthcare systems of UK, Canada, Denmark, and US will be compared. 4

6 Figure 2: EMR adoption rates for countries as of From SMA Interviews in (Neumann, 2011) The United Kingdom The UK boasts a universal health system that pays for all medical services through the National Health Services (NHS). The NHS is funded primarily through taxes and the UK residents have small co pays (Boyle, 2008). Supplementary private insurances are available to receive faster elective surgeries and to see specialists of choice. Approximately 10% of population has the supplementary insurance. Primary care physicians practice at private clinics with annual contracts from the NHS. They are paid salary, capitation, and reimbursed based on fee for service. Unlike the primary care physicians, specialists are mostly employed by hospitals (The Commonwealth Fund, 2010). Although estimates of the adoption rate vary, most surveys indicate 90% or more healthcare providers use the EHR to record clinical findings and transmit laboratory results. The UK s successful EHR adoption included major commitment from the government; the NHS s push for EHR adoption has cost the nation estimated $2.5 billion over a 7 year period (Health Canada, 2001). The high rate of adoption has also been attributed to promotions of free computers, inexpensive software, and direct government funding for recurrent costs of the EHR (Jha, Doolan, Grandt, Scott, & Bates, 2008). The NHS s increasing emphasis on evidence based medicine also helped the EHR adoption since the metrics can be easily tracked through the EHR (Wilson, 2007). 5

7 The UK s payment structure could also attribute to high EHR adoption rate. Because this model can be influenced greatly by the government s policy, the government could easily exert control and push the industry to benefit the public. However, as the Danish healthcare system demonstrated, once decentralized (or becomes regional healthcare model), incentives from the federal government (i.e. centralized incentive) could be met with resistance especially if regional autonomy is strong (CIVITAS, 2002). Canada Unfortunately, having a universal healthcare alone does not guarantee a successful EHR adoption. Like the UK, Canada too has a universal system; however, Canada s EHR adoption rate is not as impressive as the UK. Canadian healthcare is a universal system that is mainly run by provincial governments (the healthcare system is broadly referred as Medicare) unlike the UK where the NHS in charge. Although each provincial government is responsible for running Medicare, they must follow guidelines set by Canada Health Act, which prohibits private practices or insurances that provide same services as the provincial government s Medicare (Health Canada, 2011). However, private supplemental insurances are permitted for services that are not covered under Medicare (e.g. dental) and approximately 60% of Canadians carry such insurance. Most Canadian physicians practice medicine in private clinics and are paid on fee for service basis (The Commonwealth Fund, 2010). In Canada, healthcare is funded through taxation, which is distributed by the federal government to the provinces (Health Canada, 2011). Although the EHR adoption rate in Canada was approximately 23% in 2006 (Jha, Doolan, Grandt, Scott, & Bates, 2008), provinces have varying degree of the EHR adoption; in Alberta, 61% of the healthcare providers have reportedly use the EHR (Protti, Edworthy, & Johansen, 2007). This was possible due to a joint effort by Alberta Medical Association, Alberta Health, and regional health associations. This coalition formed a program that dramatically improved the EHR adoption in Alberta. This program 6

8 provides funding for health information technology services (e.g. data management, privacy issue, etc.) so that the practices can implement the EHR (Physician Office System Program, 2011). Aside from Alberta s effort, Canadian federal government has also committed to creating a nation wide information exchange. To facilitate this goal, Canada Health Infoway was established in 2001 by the federal government, which is a nonprofit cooperation (Canada Health Infoway, 2011). Along with creating the national information exchange, Canada Health Infoway strives to achieve a 100% EHR adoption in Canada (The Commonwealth Fund, 2010). Although Canada has been promoting the EHR since 2001 (Canada Health Infoway, 2011), the EHR adoption rate is still low. As shown in Figure 3, most survey participants were below Stage 3 of HIMSS adoption model, where Stage 7 indicates complete EHR adoption (HIMSS Analytic, 2011). Figure 3: Progress on EMR adoption as of rd quarter for the US and Canada (HIMSS Analytic, 2011) Denmark As one of Nordic countries, Denmark boasts impressive EHR adoption rate. Denmark s healthcare is similar to the UK s and Canada s in that it is publically funded system. Danish healthcare, which is 7

9 primarily funded through taxes, is delivered through collaboration between 5 health regions, municipals, and doctors in private practices (Protti, Edworthy, & Johansen, 2007). Similar to the Canadian healthcare system, primary healthcare is funded by the government and patients have co pays for some services such as dental and optometry. These additional fees can be covered through private insurances, which approximately 40% of the population carries. The primary care physicians are paid based on both capitation and fee for service (The Commonwealth Fund, 2010). Interestingly, the fee for service includes doctor s communication with their patients through e mail (Protti, Edworthy, & Johansen, 2007), which would further encourage technology adoption. The history of the EHR adoption in Denmark dates as far back as 1990; initial efforts started as connecting two hospital systems together. As the national healthcare strategy was formed in 2000, more focus was placed on creating interoperable systems that allowed communication between different healthcare providers (Protti, Edworthy, & Johansen, 2007). This strategy ultimately helped to shape the successful EHR adoption in Denmark. The structure of Danish healthcare itself lends nicely to the EHR adoption. Because the system is a single payer that universally covers the entire population, any cost saving measures is beneficial to all stakeholders. This direct finical benefit is more difficult to realize in the private, multilevel healthcare systems such as the US, since the savings may not be direct or apparent to some stakeholders. Moreover, having a strong national strategy for the EHR adoption in Denmark, which was non existent in the US until the HITECH Act, drove and coordinated the nationwide EHR adoption. These national strategies include financial incentives to the healthcare providers, as well as addressing privacy issues. For example, patients in Denmark could access their information through a single portal which allows them to monitor who accessed their records (Castro, 2009). 8

10 EHR Adoption in the US As both Figure 1 & Figure 2 show, the EHR adoption in the US is limited compared to the other OECD countries. Even as recent as 2011, only 1% of survey participants had fully adopted EHR and achieved Stage 7 in HIMSS s EMR Adoption Model (HIMSS Analytic, 2011). Barriers for the slow adoption in the US can be broadly divided into 3 categories: human, machine, and environmental barriers. Human Barrier As the healthcare providers adopt the EHR, learning the system would slow their productivity initially as the physicians get used to the new system. However, this potential for productivity loss is one of many barriers to the EHR adoption (Menachemi, 2006). Familiarity of using a standardized system also seems to affect how the EHR is received by the healthcare providers; one study noted that nurses were more efficient with using computer systems than the physicians. The authors argued that because the nurses were often using standardized forms prior to using the EHR, they became more efficient at using the standardized EHR system over time than the physicians (Poissant, Pereira, Tamblyn, & Kawasumi, 2005). The healthcare provider s lack of computer skill is another barrier (Jha, et al., 2009). Because the healthcare provider is not familiar with computers in general, it could deter them from using the EHR altogether. Machine Barrier The slow EHR adoption can also be attributed to the design of the EHR. Since the healthcare providers must interact with the machine (i.e. EHR), it should be designed with usability in mind and be intuitive for the users. For instance, if the EHR format is not intuitive or familiar to the users, using the standardized EHR would slow the workflow (Russ, et al., 2010). Moreover, the workflow could be slowed even more because the standardization leaves no room for customization (Russ, et al., 2010). 9

11 Poorly displayed data is another machine barrier. When physician s satisfactions with the EHR were evaluated, screen design and layout had highest correlation, not the speed of retrieval (Siittig, Kuperman, & Fiskio, 1999). Therefore, how the EHR presents data to the users is just as important as how the data are collected in the EHR. Another barrier arises from the EHR's inability to replicate the advantages of paper records. Although EHR provides benefits that paper records can t match (e.g. limiting access to records), distinctive benefits of having paper records may hinder physicians from fully adopting EHR. For example, paper records are faster to read than reading same information on a computer screen (Walsh, 2004). If the advantages of paper records are considered, it is not surprising that 75% of clinical records are still in the paper format (Gans, Kralewski, Hammons, & Dowd, 2005). The persistent use of paper records even after implementing the EHR (Russ, et al., 2010) indicates that advantages of paper system still are not replicated well in the EHR. Lastly, format of the data also affects the EHR adoption. When storing medical data, the second most prevalent format is dictation, first being the paper medical records (Gans, Kralewski, Hammons, & Dowd, 2005). Because dictation data is unstructured, it is difficult to search for data within the EHR. Moreover, the dictation, which is in natural language format, makes difficult to extract meaning since a simple word search (i.e. taking a word out of context) could distort the meaning. These format issues (unstructured and natural language) could negate the EHR's ability to query and search data. To remedy this problem, one could process the dictation data into a structured data which is searchable. However, any natural language processing of the data need careful consideration since deciphering human speech is not an easy task. 10

12 Environmental Barrier Healthcare in the US is mostly provided by physicians in private practices (The Commonwealth Fund, 2010) so the providers must be mindful of their finances to stay viable in the industry. Although various stakeholders would benefit from physicians adopting the EHR, initial cost of adoption is placed mostly on the healthcare providers. Because the healthcare providers must bear the cost upfront, it s not surprising that financial consideration plays role in the EHR adoption (Rainu, et al., 2009), especially in small practices (DesRoches, et al., 2008). Moreover, current payment structure in the US does not reward the doctors for tracking patient outcome which is one advantage of the EHR over paper records. Instead, the payment structure of the US is fee for service where there are no financial incentives for the healthcare providers to track and report the outcome (Wilson, 2007). Hence, it is difficult to take advantage of the EHR fully and promote its use in the US. Social environment around the healthcare providers could also affect the EHR adoption. For instance, physicians often practice in groups; if one member of the group complains about the EHR, it could affect the opinions of the partners. Social influence of management also impacts the adoption negatively if the management is not committed to the changes (Boonstra & Broekhuis, 2010). Potential Solutions Success in the UK and Denmark suggest that having a strong centralized influence is important. Moreover, having a strong strategy and to have a strong commitment from the government also seem to attribute to the success. Although larger countries have difficult time encouraging the EHR adoption (Castro, 2009), it could still be possible to achieve the similar adoption rate by implementing multifaceted approach. To encourage the EHR adoption in the US, one paper suggests adoption these strategies: give financial incentive; create standards for the EHR and related informatics tool; create 11

13 policies on the EHR adoption; and making efforts in education, marketing and supporting of the EHR (Cooper, 2005). With the HITECH Act, three of these suggestions are being addressed. Currently the HITECH Act is designed to provide financial incentives to the healthcare providers through the Meaningful Use criteria; financial incentive in the Meaningful Use awards the healthcare for using the EHR and measuring patient outcome. To further encourage the EHR adoption, financial incentives could also include a grant to purchase EHR systems. Because the healthcare providers also factor in the ongoing financial cost of the EHR (e.g. cost of system administration) (Boonstra & Broekhuis, 2010), continuous promotion about the value of EHR may be necessary to fully adopting the EHR. The financial incentive could also help create a social environment that encourages the EHR adoption. For example, it is in the best interest of a hospital to encourage the EHR use by the doctors in order to receive the incentives. This would address environmental barriers to the EHR adoption since commitment from management is important for a successful adoption. Although the financial incentive can be a strong reason for adopting the EHR, incentives may not be received well for the areas where physician autonomy is strong (CIVITAS, 2002; Castro, 2009). In areas with strong physician autonomy, the healthcare providers could view the financial incentive as method to exercise control by the government or insurance companies. Moreover, the financial incentive may encourage adoption initially; however, incentive alone can t push adopting the EHR fully (e.g. achieving Stage 7 in HIMSS model 2 ) may not be achieved by only having the financial incentives (Ford, Menachemi, Peterson, & Huerta, 2009). Setting the standard and creating a policy are also addressed with the HITECH Act. National communication standards, which will help with interoperability of systems, are listed as HL7 V2 and HL7 2 According to HIMSS s model, criteria for higher stage include clinical decision support, clinical charts with structured field, and exchange of medical record electronically (HIMSS Analytic, 2011). 12

14 CDA (Jaffe, 2011). Because uncertainty is one of deterring factors (DesRoches, et al., 2008), by clearly stating the standards, it would reduce uncertainty about the EHR (i.e. reduce machine barrier) and could increase the EHR adoption. One important solution that the HITECH Act doesn t address is training. By educating placing efforts in education, marketing and supporting of the EHR, it would address human barriers such as familiarity and learning associated with the new system, and ultimately increase productivity. However, the training itself is not enough; without further intervention, decrease in productivity was noted as little as 3 month after the initial training (Poissant, Pereira, Tamblyn, & Kawasumi, 2005). Therefore, it is critical to have on going support from management or their partners (i.e. having an environment that encourages the EHR uses) and training about the EHR. The training shouldn t be limited to the healthcare providers in the clinic. By introducing the EHR to medical students during their medical school (Ford, Menachemi, Peterson, & Huerta, 2009), they would be more likely to use the EHR continuously as they practice medicine. This would address both human and environmental barriers: it would increase familiarity of the system (human barrier) and create a social norm of using EHR (environmental barrier). For physicians already in a practice, they may benefit from CME credits and in depth one on one training sessions (Ford, Menachemi, Peterson, & Huerta, 2009). As the success in Alberta Canada showed, involving medical associations would also encourage the EHR adoption and create a social environment that is conducive to the EHR use. As a byproduct of the federal law, machine barriers could also be addressed. Because the demand for EHR has increased, more EHR products will be created. The increased competition in the market could stimulate the venders to address some of usability and technological barriers of the EHR adoption, which would encourage EHR adoption. 13

15 Summary Despite the past attempt from the federal government, the adoption rate in the US ranks lower than other OECD countries. Barriers to EHR adoption can be divided into human, machine, and environmental barriers. Although some issues are unique to the US (e.g. physician s practice setting and payment structure), other issues seem to be universal among the countries with low EHR adoption (e.g. lack of support from the peers). To achieve a higher EHR adoption rate in the US and thereby changing how the healthcare industry, a multifaceted approach should be considered to address different barriers to the EHR adoption. 14

16 Reference Physician Office System Program. (2011). Retrieved November 13, 2011, from posp.aspx Accenture. (2010, August). Overview of International EMR/EHR Markets: Results from a Survey of Leading Health. Retrieved from er_vfinal.pdf Blumenthal, D., & Tavenner, M. (2010, August 5). The Meaningful Use Regulation for Electronic Health Records. n engl j med, 363(6), doi: /nejmp Boonstra, A. & Broekhuis, M. (2010). Barriers to the acceptance of electronic medical records by physicians from systematic review to taxonomy and interventions. BMC Health Services Research, 10, 231. Boyle, S. (2008, February). The UK Health Care System. Retrieved from Canada Health Infoway. (2011). About Canada Health Infoway. Retrieved from Canada Health Infoway: https://www.infoway inforoute.ca/lang en/about infoway Castro, D. (2009, September). Explaining International IT Application Leadership: Health IT. Retrieved from leadership healthit.pdf Centers for Medicare & Medicaid Services. (2007, March). Security Standards: Technical Safeguards. HIPAA Security Series, 2(4), pp Retrieved September 30, 2011, from Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E.,... Shekelle, P. G. (2006). Systematic Review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern MEd, CIVITAS. (2002). Background Briefing Health Care Lessons from Denmark. Retrieved from CMS. (2011, August 2). Electronic Health Records Demonstration. Retrieved October 18, 2011, from https://www.cms.gov/demoprojectsevalrpts/md/itemdetail.asp?itemid=cms Cooper, G. J. (2005). Defining a Workable Strategy to Stimulate Widespread Adoption of Electronic Health Records in the United States. J Am Med Inform Assoc, 12(1), 1 2. doi:doi /jamia.M1706 Davis, K., & Stremikis, K. (2009, January 26). Health Information Technology: Key Lever in Health System Transformation Annual Report, pp DesRoches, C. M., Campbell, E. G., Rao, S. R., Donelan, K., Ferris, T. G., Jha, A.,... Blumenthal, D. (2008). Electronic Health Records in Ambulatory Care A National Survey of Physicians. N Engl J Med, 359, doi: /nejmsa

17 Ford, E. W., Menachemi, N., Peterson, L. T., & Huerta, T. R. (2009). Resistance Is Futile: But It Is Slowing the Pace of. J Am Med Inform Assoc., 16, doi: /jamia.m3042 Gans, D., Kralewski, J., Hammons, T., & Dowd, B. (2005). Medical groups adoption of electronic health records and information systems. Health Affairs, 24(5), doi: /hlthaff Health Canada. (2001, January). Toward Electronic Health Records. Retrieved from sss/pubs/ehealth esante/2001 towards vers ehr dse/index eng.php Health Canada. (2011, June 9). Canada's Health Care System. Retrieved November 4, 2011, from sc.gc.ca/hcs sss/pubs/system regime/2011 hcs sss/index eng.php HIMSS Analytic. (2011). EMR Adoption Model. Retrieved from Hunt, D. L., Haynes, B., Hanna, S. E., & Smith, K. (1998). Effects of COmputer Based Clinical Decision Support systems on Physician Performance and Patient Outcomes. JAMA, 280(15), Jaffe, C. (2011, February 23). HL7 & Meaningful Use. HIMSS 11. Retrieved November 22, 2011, from 1C23 BA17 0CB03CD0103A52EB/calendarofevents/himss/2011/HL7%20and%20Meaningful%20Use.pdf Jha, A. K., Doolan, D., Grandt, D., Scott, T., & Bates, D. W. (2008). The use of health information technology in seven nations. International Journal of Medical Informatics, 77(12), doi: /j.ijmedinf Jha, A. K., Bates, D. W., Jenter, C., Orav, E.J., Zheng, J., Cleary, P., & Simon, R. (2009). Electronic Health Records: Use, Barriers and Satisfaction Among Physicians Who Care For Black and Hispanic Patients. Journal of Evaluation in Clinical Practice, 15(1), Menachemi, N. (2006). Barriers to ambulatory EHR: who are imminent adopters and how do they differ from other physicians? Informatics in Primary Care, 14, Neumann, L. (2011, October 4). Comparative Domestic and International EHR Adoption. Retrieved from Poissant, L., Pereira, J., Tamblyn, R., & Kawasumi, Y. (2005). The impact of electronic health record on time efficiency of physicians and nurses: a systematic review. J Am Med Inform Assoc, 12(5), doi: /jamia.m1700 Protti, D., Edworthy, S., & Johansen, I. (2007). Adoption of Information technology in Primary Care Physician Offices in Alberta and Denmark, Part1: Historical, Technical and Cultural Forces. Healthcare Quarterly, 10(3), Retrieved from Rainu, K., Batess, D. W., Jenter, C. A., Mills, S. A., Vol, L. A., Burdick, E.,... Simon, S. R. (2009). Imminent adopters of electroic health records in ambulatory care. Informatics in Primary Care, 17(1), Russ, A. L., Saleem, J. J., Justice, C. F., Woodward Hagg, H., Woodbridge, P. A., & Doebbeling, B. N. (2010). Electronic health information in use: characteristics that support employee workflow and patient care. Health Informatics Journal, 16(4), doi: /

18 Siittig, D. F., Kuperman, G. J., & Fiskio, J. (1999). Evaluating physician satisfaction regarding user interactions with an electronic medical record system. Proc AMIA Symp, The Commonwealth Fund. (2010, June). International Profiles of Health Care Systems. Retrieved October 17, 2011, from 17_Squires_Intl_Profiles_622.pdf Wager, K. A., Lee, F. W., & Glaser, J. P. (2009). Health Care Information Systems: A Practical Approach for Health Care Management (2nd ed.). San Francisco, CA: Jossey Bass. Walsh, S. H. (2004). The clinician s perspective on electronic health records and how they can affect patient care. BMJ, 328, Wilson, J. F. (2007, March 20). Lessons for Health Care Could Be Found Abroad. Annals of Internal Medicine,

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