THE PEN IS MIGHTIER THAN THE SCALPEL: THE CASE FOR ELECTRONIC MEDICAL RECORDS # D. Hartmann 1* & S. Sooklal 2

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1 THE PEN IS MIGHTIER THAN THE SCALPEL: THE CASE FOR ELECTRONIC MEDICAL RECORDS # D. Hrtmnn 1* & S. Sookll 2 1 School of Mechnicl, Industril nd Aeronuticl Engineering University of the Witwtersrnd, South Afric 1 Dieter.Hrtmnn@wits.c.z ABSTRACT A cse study evluted how physicl medicl records re mnged nd curted t lrge tertiry hospitl. It ws found tht the current microfiching technology ws outdted, ineffective, nd in mny cses n impediment to pproprite cre. Alterntive recordkeeping techniques were evluted. A proposl for loclised electronic medicl record (EMR) system, disseminted by tblet computer, is presented in this pper. Issues bout ethics nd ccess to informtion re explored, nd some of the issues tht hve ffected globl implementtion re highlighted. OPSOMMING n Gevllestudie wt hndel oor die bestuur vn mediese rekords vn n tersiêre hospitl word voorgehou n Voorstel word gemk om die bestnde dtstelsel te vervng met n elektroniese rekordstelsel. Etiese- en toegngsngeleenthede word behndel. 1 The uthor ws enrolled for n MSc. Eng (Industril) degree in the School of Mechnicl, Industril nd Aeronuticl Engineering t the University of the Witwtersrnd. 2 The uthor ws enrolled for BSc. Eng (Industril) degree in the School of Mechnicl, Industril nd Aeronuticl Engineering t the University of the Witwtersrnd. # This rticle is n extended version of pper presented t the 2011 ISEM conference. * Corresponding uthor. South Africn Journl of Industril Engineering, July 2012, Vol 23 (2): pp

2 1. INTRODUCTION The methods of dt storge nd ptient record mngement t South Africn tertiry hospitl were investigted. This pper explores the fesibility of using electronic medicl records t this site [1], nd further investigtes wht would be necessry for their implementtion, both on single-site bsis nd for wider network. Impediments to implementing centrlised systems re highlighted, nd issues concerning ethics nd ccess to informtion re explored. Excessive witing in hospitls cn be cused by wsteful processes before or during tretment. This includes time spent witing for medicl records. Medicl records llow for continuity in tretment, nd enble smooth ptient hnd-over between medicl professionls. Records mitigte risks tht might otherwise rise when medicl professionls re not personlly fmilir with the medicl histories nd needs of their ptients [2]. It is vitl to hve robust, ccurte, relible, inviolble, nd ccessible medicl record system tht is esily shred nd understood. Medicl records must not degrde or become otherwise inccurte over time. 1.1 Objectives This reserch is intended to: criticlly evlute the current stte of hospitl s helth record system; estblish globl best prctice in record storge nd mngement; determine the desirbility of introducing more technologicl record storge mechnisms; nd quntify the benefits of lterntive systems. 2. METHODOLOGY A single cse study [3] ws conducted t South Africn public hospitl. The current stte of dt storge ws investigted using qulittive nd quntittive methods [4]. Direct observtion [3], dt bse extrction, nd work studies were employed. The deficiencies were evluted, nd recommendtions for systemtic improvements were mde, bsed on interntionl best prctice from the literture. From this, smple fesibility nd implementtion pln ws constructed. This concentrted on cost implictions (especilly on brek-even nlysis), ethicl issues, nd infrstructurl fesibility. This ws then extrpolted to more generlised level for the South Africn context, nd identified the lessons lerned tht might require further reserch. 3. CURRENT SITUATION The medicl records deprtment is the curtor of ll medicl records creted in the hospitl under study. It occupies more thn 400 squre metres, nd employs 46 people, of whom 39 fulfil clericl role; the rest re messengers. The totl wge bill is R3,000,000 p.., nd the overll budget mounts to R4.5 million p.. [5], excluding the cost of the pper used for record-keeping. The deprtment hs two roles: storing medicl records, nd issuing them when requested. These functions differ in terms of criticlity. Storing is less time-criticl thn issuing; tretment without records my be dngerous or compromise ptient s helth, while delyed storge should not. Documents re stored on microfiche in system introduced in 1980 [5]. Creting microfiche requires severl steps. A document is photogrphed nd chemiclly developed to be In re. Typiclly DIN A4 sheet of pper will be reduced to less thn 10 mm x 10 mm. 192

3 times smller thn the originl document. The negtive is mounted on crd, nd the originl is destroyed by shredding. Crds re stored in numericlly-indexed librry system. Retrievl requires tht positive of the microfiche be generted nd printed to pper. Microfiche technology represented compct nd simple storge nd mngement solution before the dvent of ffordble computeristion. Now, however, it is out-dted. Despite the technologicl deficiencies inherent in this system, it remins functionlly dequte. There re, however, concerns relted to ccess to informtion, prticulrly speed of ccess, dt integrity, nd the ultimte qulity nd legibility of records. The deprtment stores bout 50,000 records per dy, nd issues bout 2,000. The significnt difference between the number of stored nd issued documents is curious, nd points to the fct tht doctors were disinclined to request medicl records for every ptient. Retrieving documents took too long, nd thus they were of little vlue by the time tht they hd rrived. Due to their limited contct with ech ptient, doctors generlly didn t hve the time to red records. For rnge of resons, doctors often ssume the content of the record, or rely on medicl informtion - including precise condition nd tretment history - from the ptient, who is in mny cses uneducted. 3.1 Problems experienced Severl issues relting to document qulity, relibility of the technology, nd speed of service were identified. The process is slow. The verge retrievl time for booked records ws 52 minutes per delivery, while emergency retrievls took 13 minutes on verge. Both of these times re further compounded by runners 4 who deliver documents in the hospitl. This dds further 27 minutes to the process, nd prticulrly in emergency cses, it cn dely or compromise the sfety of the tretment. Becuse of these delys, the file-opening sttion preferred to open new files rther thn cll up n existing record for the ptient. The file-opening process, however, is lso slow: it tkes n verge totl time of 57 minutes per ptient [6]. Severl qulity issues were identified, relting to both technologicl nd procedurl mtters. Figure 1 shows n exmple of the type of qulity defect tht is possible. This kind of issue is common, nd renders the ptient record worthless. This is n exmple of problem with exposure, which my hve been cused t either the photogrphy or the development stge. Other issues include documents tht re out of focus, microfilm tht hs been cut cross record, or instnces where the film is otherwise dmged for exmple, scrtched or kinked. In ll these cses, the document is irreprble nd therefore deemed lost. Filing microfiche is problemtic. It cn be plced in the incorrect envelope, or envelopes cn be filed in the wrong shelf-position, or individul microfiche sheets cn be lost or misplced. Such records re deemed to be irretrievble, nd so re lso considered lost. The records deprtment uses lrge mounts of pper. The records rrive on pper, which is microfiched, nd the originl is destroyed. On retrievl, the ptient record is reprinted on pper, the record is ugmented by doctors, nd gin microfiched. The current crbon footprint of the pper opertions of the hospitl ws clculted to be t lest 300,000 kg of CO 2 e p.. This ws clculted only on the vlue of the pper consumed, nd excluded pper trnsporttion cost from the mill, the inefficiency of the mill, nd the ctul crbon footprint contribution of the printing process. Our conservtive estimte is tht the ctul crbon footprint of pper opertions is t lest double this vlue. 4 In most cses the term is very inpproprite. 193

4 Figure 1: Exmple of qulity defect Most documents scnned rrive s DIN A4. However, in the bsence of stndrdised document sizes, up to 10% of them rrive in other sizes, thicknesses, or colours, mking stndrdistion difficult nd cusing pper jms. The 35-yer-old mchines hve frequent brekdowns. Most spre prts re no longer vilble, nd therefore need costly rebuilds or hybridistion. Service technicins re scrce. Vlue-strem mpping the unit showed tht non-vlue-dding (NVA) steps ccount for bout 40% (see Figure 2). Wste is lrgely due to movement. As cn be seen for emergency dmissions, the NVA component is overwhelmingly lrger (98%). This is due to the time tht the runner tkes more thn n hour to deliver the document. Booked dmissions Emergency dmissions 0:01:31 2% 5:06:05 37% 8:51:00 63% 1:05:10 98% Vlue Added Non Vlue Added Vlue Added Non Vlue Added 194 Figure 2: Vlue-Added vs. Non-Vlue-Added nlysis for record retrievl dmissions The lck of trust in the centrl system hs cused some specilist deprtments to keep their own records. This excerbtes the problem, s there re multiple versions of ptient records. Tretment continuity is consequently prejudiced. 4. SOLUTIONS FOR PATIENT RECORD STORAGE This pper explores three ctegories: the input method nd storge formt; the dissemintion medium; nd storge loctions.

5 4.1 Input nd formt The modern equivlent to microfiching is document imging: document is scnned nd sved in picture formt. Retrievl nd reproduction in document imging is mterilly fster, reducing led time. The humn resources required to operte the system re lower, s serching nd mintining the librry re eliminted. The qulity nd integrity of the document my be better, while the number of lost nd misfiled documents will be negligible. Being n evolved form of microfiching, however, mens tht imges remin uneditble nd unserchble, nd the technology relies on the use of pper. An lterntive is full text record, which sves records where possible in n editble formt. The dvntges of this vry. Digitised content results in smller files nd llows physicins to serch for content. A mjor drwbck is tht the burden of creting text records will fll either to the doctors [7] who re usully unwilling to tke on the role of typing (s opposed to hnd-scribbling) records or dt cpturers, who would be responsible for trnscribing doctors hndwritten notes bout ptient. Becuse of the volume of round 50,000 documents per dy in the current system, this would require significnt humn resources. Unfortuntely opticl chrcter recognition (OCR) is not n option, s the records re hnd-written, thus perpetuting the relince on pper. 4.2 Storge Three options exist for storge loction: ntionl, locl, nd ptient-borne dtbses. The ntionl option is centrlised ntionl helth record dtbse, such s hs been estblished in Denmrk [8]. Ech individul s medicl history is stored centrlly, nd is ccessible to ny medicl professionl, from those in lrge hospitls to privte prctitioners. The benefit of such system is tht ccurte nd comprehensive medicl informtion is vilble to ll clinicins, thus reducing the dnger of missing something during dignosis. The gretest difficulty of implementing such system is the complex rchitecture: this system requires significnt investment in hrdwre, softwre, nd ICT professionls to crete, dminister, run, nd mintin it. A second, less intensive method of storge is to hve locl server t ech hospitl. This is less complex system thn ntionl one. However, significnt dupliction occurs, nd it my potentilly led to site-specific document customistion occurring, rther thn stndrdised medicl records. As there is no wy to prevent ptients from hving records t more thn one fcility, there my be discontinuous medicl informtion on the ptient. A third option is to store ptient informtion on medium tht is crried by the ptient. The South Africn Deprtment of Home Affirs hs discussed the introduction of smrt identifiction crd for South Africns [9], which will be ble to store personl, biometric, licence, nd other informtion [10]. This informtion my include medicl informtion. This storge system is useful, s it plces the ptients records under their personl curtorship; nd whenever ptients hve their crd with them, their full medicl records re vilble. Severl precutions would need to be tken, prticulrly in sfegurding medicl records on these crds from unuthorised ccess, nd lso ensuring tht complete record loss does not occur if ptients lose their ID. Any such system would therefore need dequte ccess control nd bck-up solutions. None of the three options is sufficient by itself. All hve deficiencies: these include the skills required, the ICT infrstructure needed, or issues of document sfety nd recoverbility. The risk inherent to electronic ptient records is highlighted by Vlli [11], who wrns of the dngers of such records being hcked or otherwise compromised. He points out tht encryption nd suitble protection systems re vilble, but these should nevertheless be ugmented by mking sure tht only physicins who hve legitimte reson to ccess ptient s records re ble to do so. 195

6 4.3 Dissemintion medi The finl mjor issue in setting up new ptient record system is the choice of the dissemintion medium tht is, how doctors will ccess these records. Here we cn distinguish between two options: trditionl pper formt, or n electronic dissemintion formt. The use of pper is the most common wy of disseminting ptient records. The difficulty of moving wy from pper is one of the gretest impediments to implementing electronic medicl records [12] [13]. The dvntges of pper records re tht they re physiclly tngible, esily editble by writing on them, nd esily understood nd circulted mong people who work closely together. If pper records re fvoured, then the decision needs to be mde whether to print centrlly or loclly. If printing records remins centrlised with the record deprtment, the losses implicit in mnully running pper within hospitl will remin, but the lrge printing infrstructure will benefit from economies of scle. If printing were done t wrd level, documents would be ccessible more quickly. However, the ssocited cost of dditionl stff nd ICT infrstructure in ech wrd would need to be considered. This would include loclised brekdowns nd the mintennce strtegy necessry to del with this. The institution tht ws investigted for this study uses t lest twenty boxes of pper per dy. This mens tht the hospitl spends bout R10 million nnully on pper, the bulk of which is destroyed. This excludes the dditionl cost of custom-printed sttionery. Pper, though trditionlly ppeling, is fr from idel, s it cn only be in one plce t time, nd poses the risk of there being different versions of ptient records. Pper furthermore requires intensive rchivl effort to ensure tht records remin legible nd recoverble. Erly implementers of fully electronic ptient records used conventionl lptop computer tht could be wheeled round. This solution ws found to be dequte, nd ws successfully dopted in t lest one hospitl in the USA [12], s cn be seen in Figure 3. Figure 3: Pole-mounted wireless lptop, Indin University Medicl Center [12] Some hospitls in the USA nd Europe hve equipped doctors with tblet computers or smrt phones so tht they cn ccess medicl records t the bedside [14]. The speed nd convenience of ccessing records in this wy mkes doctors more likely to use them. Such records would be editble nd updted in rel time, nd with the wireless infrstructure they would be vilble to ny other medicl professionl lso involved in the tretment of tht ptient. This system is updted by the medicl professionls. Mintennce, however, becomes crucil function. The hospitl would hve to invest in skills to ensure tht this system remined functioning, nd did not go down which could be literlly mtter of 196

7 life or deth. Mngement would hve to ensure the buy in of doctors nd nurses, s their prticiption would be fundmentl to the success of such system. 5. ETHICAL CONSIDERATIONS AND ACCESS TO INFORMATION Keeping helth records nd mintining confidentility nd ptient privcy is required by lw, both globlly nd in South Afric [2] [15]. Systems need to mintin ptient confidentility so tht, within reson, medicl informtion my even be withheld from other treting physicins if this is deemed pproprite [16]. Ese of ccess to electronic medicl records is possibly the single gretest benefit of such system, though it is lso one of its gretest inherent risks. Mny fer tht security nd confidentility will be wek in electronic helth records [17]. In lrge network, such s the internet, records re potentilly vulnerble to being ccessed illegitimtely or inppropritely [18] by unuthorised people. The prllels between electronic nd physicl records seem tenuous, but they re similr, becuse both forms of record need to be generted, preserved, stored, kept sfe, shred ppropritely, nd destroyed in controlled mnner when necessry. Physicl records re not ccessible worldwide, nd re physiclly nd geogrphiclly constrined. This mens tht document cn only be violted if the violtor is in the spce where the record is. Nevertheless, the sfegurd for physicl records remins fllibly humn. This mens tht lock pick, corrupt filing clerk, or someone crelessly leving files lying round cn undermine document security 5. To secure electronic ptient dt, ccess to informtion must be rigorously mnged by setting up rights, nd by retining the medicl professionl s the person who decides on the extent of record shring, s it is the doctor s duty to mintin ptient confidentility. With these mesures in pkce, the confidentility of electronic records would be t lest s secure s physicl records. To drw prllel: electronic sfegurds protect worldwide bnking dt, nd it is generlly greed tht breches of bnking security re usully trceble to irresponsible client behviour [19]. Unscrupulous individuls who hve legitimte ccess to documents nd who re thus ble to disseminte records remin the biggest thret to dt integrity [17]. However, rndom, ccidentl, or incidentl ccess my occur less often thn with the hrd copy system. 5.1 The role of the Stte Informtion Technology Agency (SITA) The Stte Informtion Technology Agency ws creted in 1998 by n Act of the South Africn Prliment [20], nd lter mended [21]. The gency is responsible for providing ICT support, systems, nd relted systems to government deprtments s needed [20]. The requirements of ntionl dt system would fll within the mbit of section 7 of the Act [20]. However, the SITA my be excluded from the development of loclised systems, s these would be dministrtive site functions rther thn systemtic government support functions. Future development would require the involvement of the SITA s dt integrtor, nd would centrlise security nd control of medicl informtion in line with the SITA s mndte [20]. 6. INTERNATIONAL PERSPECTIVE ON CENTRALISATION Developed ntions, primrily those in North Americ nd in Europe, re estblishing universl nd comprehensive medicl informtion systems. Mny hve ttempted to implement ntionl helth record systems. Very few hve succeeded in full. Attempts in developed economies hve been costly [22], slow, nd not yet universlly successful [23]. 5 A good exmple of this ws the sle nd subsequent publiction in the medi of the medicl records of the South Africn Minister of Helth, Dr Mnto Tshbll Msimng [3]. 197

8 Electronic medicl records in developing countries, by contrst, re usully chrcterised by very smll networks or contining limited informtion. AMRS in Keny [24] nd Crewre in Ugnd [24] both hve two sites, nd EMR in Mlwi [24] hs only one. Dispersed networks were found only in Brzil, where ntionwide drug-control system (SICLOM) monitors prescriptions [24]. A literture serch found no geogrphiclly wide informtion-rich EMR systems in the developing world. Introducing centrlised medicl records in South Afric my be n overly mbitious venture, prticulrly in light of the fct tht this country hs lrge nd widely dispersed popultion, with vstly diverging levels of development. Countries tht hve been successful to n extent tend to be either physiclly smll (like Denmrk) or hve smll popultions (such s Norwy or Sudi Arbi), or both (such s Estoni). Common to ll these ntions is tht they hve very high humn development index (HDI) [25]. By comprison, South Afric s HDI is medium, which is mid-rnge (rnked 110 th of 169 countries). The uthors view implementing ntionwide system s unwise, s it lcks competently implemented interntionl role models. Cution should nevertheless be pplied before summrily rejecting the notion of future universl helth record system. Insted, configurtion mngement should be introduced, including stndrds for future integrtion. 7. THE NEW SYSTEM Switching over to nd implementing the new system will need to be phsed. This pper proposes, in the light of the rchivl rigorousness of modern computing power, tht n electronic storge nd indexing system would be more suitble method to dminister medicl records in this prticulr hospitl. It would be text-bsed, loclly-stored system; medicl prctitioners would enter the dt using suitble wireless devices. These records would be centrlly stored on server mintined by locl ICT specilist. Records would be regulrly bcked up off-site. Introducing the system would cost roughly R35 million to instll the necessry infrstructure. The system would use the existing LAN bckbone. A brekeven nlysis (Figure 4) shows the implementtion nd running costs of the new system compred with the existing one, nd indictes tht brekeven for the new system would be fter bout three-nd--hlf yers. Cost escltion in both cses ws estimted t 10% p.., which is consistent with recent medicl record deprtment budget increses. The stff required to implement the new system would be drsticlly reduced: the deprtment could now be serviced by three ICT specilists, rther thn the current stff of 46. Stff could be redeployed elsewhere in the hospitl. This would reduce the slry budget from bout R3 million p.. to bout R800,000 p.. The pper cost to the institution would reduce by roughly R10 million p.. 8. DISCUSSION A costly, out-dted, mintennce-intensive infrstructure needs high levels of skill, yet it only produces sub-stndrd documents slowly, with rndom dt loss, misfiling, nd high pper usge. A lck of stndrdised reporting formts mkes efficient dt cpture problemtic. An unwillingness to engge the inefficiency of the medicl record deprtment explins why there is huge difference between the number of records requested nd the number of records stored dily. The cost of introducing the system is estimted t R35 million, which includes the instlltion of wireless equipment tht would piggybck on the hospitl s existing LAN 6. The principl cost would be for the purchse, instlltion, nd mintennce of the servers nd 6 The LAN is old nd my need to be upgrded in future. This cost is excluded. 198

9 Millions Cumultive Cost (R M) Old p.. New p.. Old Cum. New Cum Yer Figure 4: Brekeven nlysis for the introduction of the new system the wireless infrstructure, nd the purchse of reding nd editing devices. Electronic medicl record storge reduces the overll cost of producing medicl records, s the technology is pperless. There is concern tht the new system would slow doctors down. The old system mostly sw doctors using no records for their consulttions, nd then scribbling notes when necessry. The new system might induce doctors to mke use of medicl records fr more regulrly, nd then hve to type up notes relted to the cse. Typing might slow down the cre process somewht, perhps leding to incresed queues. However, this is likely to be offset by the improved qulity of cre tht EMR cn bring [26]. This improved cre my reduce the incidence of filure demnd i.e. where incorrect tretment requires ptient to return with the sme condition. We suspect tht this would reduce the number of cses where tretment hs cused hrm. We believe tht the incresed ese with which records could be ccessed would result in their being used more. We hve no bsis for predicting significnt increse in requested volumes, but this is resonbly likely scenrio. Our expecttion is tht there would be demnd on the new system for 20,000 documents per dy. Introducing centrlised medicl records in South Afric would be highly mbitious venture, prticulrly in light of the fct tht we hve lrge, widely dispersed popultion, with vstly diverging levels of development. It is our opinion tht the optimum would be to crete loclised system in hospitls tht took over the role of the current physicl record deprtment. Such record system would need common medicl record (CMR) stndrd nd stndrdised vocbulry for future integrtion [18]. 9. CONCLUSION Use of document imging, whether computer-bsed or on microfiche, is out-dted nd ineffective becuse such imges cnnot be serched or edited. Introducing loclly-stored, full-text-plus-picture, tblet-computer-disseminted EMR system to the hospitl in question would be wise nd cost-effective. 199

10 Such system significntly reduces the spce nd infrstructure dedicted to medicl record storge. The risk of lost, misplced, illegible, dmged, or otherwise useless documents is virtully eliminted. The reduced relince on pper records should sve t lest R10 million p.., nd reduce the hospitl s crbon footprint by t lest 300,000kg of CO 2 e p.. Such system should brek even fter period of less thn four yers, nd significntly reduce mintennce nd ssocited costs. Simplifying ccess to medicl records would encourge their use, which in turn should improve the qulity of tretment nd cre. Rel-time ccess to, nd editing of, records improves the bility of medicl professionls to collborte on ptient tretment. South Afric s level of development is insufficient to dopt ntionl centrlised electronic medicl record system. In nticiption of future integrtion, the record system must conform to stndrds of dignostic lnguge nd formt. The Stte Informtion Technology Agency would become involved t the point of integrtion, nd consulttion t this level of development would be wise. 10. FUTURE WORK To implement this work fully, the IT infrstructure nd the officil policy need to be ddressed. The ICT infrstructure hs been described superficilly; however, it is in need of detiled design, nd should prticulrly focus on three res. First, the dtbse needs to be designed, being guided by medicl professionls in respect of structure nd desired fields. Second, network security must be designed to give esy ccess to uthorised medics nd to block ll other ttempts to ccess dt. Third, the interfce with which medics will interct must be designed to llow user-friendly nd intuitive ccess to the informtion contined in the dtbse. On policy level, three importnt spects present themselves. First, legisltive chnges need to be mde to the Ntionl Helth Act explicitly to permit web-bsed electronic medicl records. Second, it is importnt tht long-term policy decision is tken to develop n electronic helth record stndrd, ccompnied by rodmp to relise eventul universl coverge for South Africns. Third, it is necessry to implement ventures tht improve efficiency in helthcre generlly nd in ptient record mngement specificlly. REFERENCES [1] Hrtmnn, D. & Sookll, S The pen is mightier thn the sclpel. Interntionl Conference on Industril Engineering, Systems Engineering, nd Engineering Mngement, Stellenbosch. [2] Helth Professions Council of South Afric Guidelines for good prctice in the helthcre professions. HPCSA, Pretori. [3] Yin, R.K Cse study reserch: design nd methods, 6th ed. Beverley Hills: Sge Publictions, Inc. [4] Fuller, S.S. & Wtt, R Using qulittive nd quntittive reserch to promote orl helth, 1st ed. London: Eden Binchi Press. [5] Sookll, S As-is nlysis of the dt systems in public hospitl. University of the Witwtersrnd, Johnnesburg, finl yer project. [6] Jgjiwn, S Improving the file opening procedure t public hospitl. University of the Witwtersrnd, Johnnesburg, finl yer thesis. [7] Shortliffe, E.H The evolution of electronic medicl records. Acdemic Medicine, 74(4), [8] Timmins, N System upgrde. Finncil Times: Helth, 2, [9] SA Press Assocition Smrt crd ID to be lunched soon. The Str, Februry [10] Behrie, S SA to get smrt with new ID system, The Str, Februry [11] Vlli, C The insider thret to medicl records: Hs the network ge chnged nything? Edith Cown University, Mount Lwley. [12] McDonld, C.J The brriers to electronic medicl record systems, nd how to overcome them. Journl of the Americn Medicl Informtics Assocition, 4,

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