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Implementation

Physicians And Ambulatory Electronic Health Records

Abstract

 
Few U.S. physicians use outpatient electronic health records (EHRs), although it appears that most would like to begin. The main barriers are not technical, because adoption rates in other countries are high. The biggest barrier is reimbursement, because physicians must pay for EHRs, but most of the benefits accrue to payers and purchasers. The lack of interoperability is also pivotal. Others include capital and risk tolerance; physicians’ resistance related to time concerns, fears about privacy, system maintenance, the number of vendors in the marketplace, and the transience of vendors. The key initial policy changes will be those addressing financial incentives and interoperability.

A key issue is the degree to which physicians are ready to make the transition to EHRs. National data for the United States across physician specialties do not appear to be available. Nonetheless, the surveys that have been done suggest that this is not because U.S. physicians do not believe that EHRs improve care or do not want to begin using them. For example, in a 2003 survey of Massachusetts physicians, more than 80 percent reported that they believed that EHRs improve quality and that doctors should computerize writing prescriptions, recording patient summaries, and keeping treatment records.⁴ Nonetheless, about half did not intend to do so. Similarly, in a national survey by the American Academy of Family Physicians (AAFP) of its members, 81 percent reported that they were interested in EHR software.⁵

The EHR adoption gap is especially profound between large and small practices. In the Commonwealth study noted earlier, 57 percent of physicians in practices with more than fifty physicians used an EHR, compared with only 13 percent of solo practitioners, and there was a strong relationship between practice size and adoption rate.⁶

Physicians in small practices face special challenges in adopting EHRs.⁷ The costs per full-time physician are much higher for these practices, and some vendors will not even sell to them because they think that the economics do not justify it. Costs such as hiring a system administrator are much easier to justify in a large practice than in a small one.

Another important issue is whether to target the first initiatives promoting EHRs to primary care physicians only or to all physicians. For a wide variety of reasons, including the integrative role of primary care, the fact that most office visits are to primary care providers, and because EHRs need some tailoring to work in specialty care, it makes the most sense to begin in primary care.⁸ That has been the approach taken in every other nation that has proceeded down this path. Specialists should also begin using EHRs soon, and their participation is essential, but their use of EHRs tends to be less intensive than that of primary care providers, at least at first.

This paper begins with a discussion of the barriers to EHR introduction, including financing, the lack of interoperability, and physician resistance related to a variety of factors. Some of these are extremely important, while others may be more perception than reality; the available evidence is discussed for each. This is followed by a discussion of key policy issues and debates relating to the barriers, then the potential roles of specific stakeholders including specific policy recommendations, and conclusions.

Barriers To The Introduction Of EHRs

Top Barriers To The Introduction... Addressing The Barriers: Key... Roles Of Specific Groups NOTES

 
Financial issues. The single most important barrier to physicians’ use of EHRs is financial. Although physicians must make the investment in EHR systems, they accrued only 11 percent of the benefit in one study of the economic benefits of computerized ordering, which results in much of the savings.⁹ Most of the benefit goes instead to payers and purchasers. The reason for this is that many of the savings occur because of efficiencies, such as lower drug costs, and physicians are not rewarded for prescribing more efficiently or using fewer tests under current reimbursement mechanisms. For practices that have little or no capitation, the most important financial benefits early after adoption will come from reductions in chart pulls and transcriptions, and probably also better capture of charges.¹⁰ However, the savings in drug spending and in improved laboratory and radiology test use dwarf these savings.¹¹ Although some data suggest that the return to providers will be good over a five-year period, the timing of benefit is less certain, and few data are available comparing the benefit among different vendor products.

Another key financial issue relates to capital and risk. Most U.S. primary care is delivered in small practices, and many of these are doing poorly financially. Increases in expenses outpaced the increase in physician compensation in primary care for three straight years, according to the Medical Group Management Association.¹² As a result, primary care providers appear to be finding it particularly hard to justify the risk in making any investment, especially in a new technology that they perceive as risky with uncertain returns for them, such as an EHR.

Interoperability. Interoperability represents another major problem, since most EHRs do not interoperate well with other applications. The result is that for many physicians, even if they start using an EHR, much of the data in it will be data they have provided. Clinicians’ first needs are for information such as laboratory and radiology results and medication lists, although moving clinical information to and from hospitals is also extremely important. A recent national analysis of the value of interoperability suggested that fully standardized interoperability could save the nation $77.8 billion annually.¹³ Thus, implementing approaches that ensure that EHRs will be able to interoperate is a high priority.

Practical issues. Beyond financial and interoperability issues, physicians’ reluctance to make the switch to EHRs relates to factors such as the time it will take to practice with an EHR, fears about privacy issues, worry about maintenance of systems, difficulty choosing among the many vendors, and concern that the vendor they select may go out of business and leave them without access to their data.

Application speed is a critical determinant of physicians’ acceptance of health care applications in general.¹⁴ One of the key reasons for physicians’ fixation on speed undoubtedly relates to the current reimbursement model. However, although there is clearly a productivity drop in the transition period, it may or may not take longer to use EHRs in ambulatory care in the long run. Two formal time-motion studies now suggest that after an initial period, using an EHR may actually be modestly faster than practicing on paper.¹⁵ The first of these studies addressed only ordering, but the second compared use of paper with use of an EHR. It is important to note that both of these studies were done with physician-designed, homegrown EHRs, and comparable data are not available for vendor applications, so that these results may not be generalizable to all EHRs.

The activity that takes the longest is writing notes, and a key branch point is whether to capture these via dictation or coded entry. This is complicated by the need to adhere to the evaluation and management (E&M) guidelines, which are unnecessarily complex. The marginal value of notes—compared with other types of information such as the medication list and problem list—is probably fairly low, at least in the short run. In the longer term, getting information about certain key variables (such as New York classification in a patient with congestive heart failure) will likely be important in particular in caring for patients with chronic diseases and in delivering decision support for acute conditions. However, several recent trials on the impact of HIT for improving chronic disease management have been negative.¹⁶

Privacy and security. Privacy and security are clearly important issues, and physicians rate these areas highly when asked about their concerns about EHRs. Although few empirical data are available, security may actually be better with electronic records than with paper, although breaches of security can be more catastrophic with electronic records.¹⁷ Security and privacy are also very important to the public, to an extent that could slow or derail the movement toward electronic records. In a recent Harris Poll, 48 percent of adults said that EHRs’ benefits to patients and society outweighed the risks, while 47 percent said the opposite.¹⁸ Both physicians and the public will need to learn more about and become more comfortable with measures to protect electronic security and privacy in the coming years, and additional legislation will likely be needed, although there appears to be little appetite for this at the federal level, given the recent experiences with the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

System maintenance. Worries about system maintenance are a real concern for providers. Providers lack the skills and expertise to do their own maintenance, and especially those in small practices want a turnkey solution. However, many vendors provide relatively little in terms of maintenance, or they charge high fees. In fact, active maintenance of anything as dynamic as the EHR is pivotal to success, and managing this successfully will be one of the most important success factors for providers making the switch.

Other issues. Other important issues that physicians may not widely recognize as barriers, but that will be critical in achieving the desired gains, are lack of physician knowledge about quality techniques in small practices, and variability in the decision support included in vendor systems. EHRs represent tools that may be used to improve practices, but achieving the desired gains in quality requires using them effectively—for example, by reviewing registries regularly, standardizing among providers, using case managers, and changing workflow. These will not happen as a natural consequence of using records; providers will need to learn about the techniques of quality improvement.¹⁹ Furthermore, decision support in ambulatory care is generally immature and highly variable among systems. The benefits of EHRs, however, are highly dependent on the level of decision support included, and EHRs only become cost-effective with high levels of decision support.²⁰ Publicly accessible clearinghouses for knowledge and tools are not available, so many practices must rely on vendors or user groups for decision support.

Addressing The Barriers: Key Policy Issues

Top Barriers To The Introduction... Addressing The Barriers: Key... Roles Of Specific Groups NOTES

 
Financial incentives. Financial incentives will almost certainly represent a key lever for accelerating adoption, and these must come from payers, both public and private. A key area of debate, however, relates to how best to do this. Options include paying providers more if they use EHRs, paying them more if they use specific functionality within the records, providing rewards for submitting data, and providing rewards only for reaching specific benchmarks. Because the first step in adoption is actually using a record, this represents an attractive option.

A difficulty here is defining what constitutes the minimum to qualify as an EHR; it is hoped that the Certification Commission for Healthcare Information Technology (CCHIT)—which has been commissioned by the Office of the National Coordinator of Healthcare Information Technology—will be helpful in this regard. In particular, the decision will need to be made regarding whether something less than an EHR, such as a handheld device for electronic prescribing, should be included. The benefits of handheld prescribing tools are so much less and the availability of EHRs widespread enough that this is probably not a desirable strategy. Providing rewards for submitting data may be a useful approach and should be required eventually, but it will be tricky to operationalize this in the near term, especially if a number of vendors are involved. Providing rewards based on achieving beneficial outcomes represents a desirable goal eventually, but it is probably impractical to take this approach at the beginning, especially because of problems with small sample sizes and case-mix. In particular, this might cause providers to avoid patients whose illnesses are severe.²¹ Nonetheless, there is strong support for this approach from payers, but it will likely be opposed by physician groups.

Pay-for-performance programs are springing up widely and are especially prominent in certain regions, such as California and eastern Massachusetts; the key debate, again, is how to structure them and what to reward. In such programs, EHRs could obtain—in a way that does not require additional provider work—a much broader and deeper array of measures, which rely on claims data. One model was just implemented in the United Kingdom, where 30 percent of GPs’ salaries is at risk based on their performance of a complex set of parameters, measured through the EHR.²² In the United States, probably the best set of clinical measures that begin to go beyond claims is the Doctors Office Quality Information Technology (DOQ-IT) set, which has just been developed.²³ One example of legislation that would authorize support for additional Medicare payment for providers who use IT is House Resolution 747, introduced in the 2005 Congress by Rep. John M. McHugh (R-NY) and Rep. Charles A. Gonzalez (D-TX). This bill targets small providers and would reward those who use EHRs, but it does not link these incentives to performance.²⁴ Overall, initially, it will probably be better from the policy perspective to reward providers for adopting EHRs, with a gradual move over several years to payment based on reports of process and outcomes measures and performance on these measures, although pilots of pay-for-performance would be desirable even in the near term.

Access to capital. Another key issue is making low-risk capital available. As noted earlier, a large proportion of U.S. small practices are in poor financial health, which has made them highly risk-averse. Thus, development of programs such as zero-interest or revolving loans that make capital available to provider groups at low interest rates is essential. The bill sponsored by McHugh and Gonzalez includes a provision that would enable this.

Interoperability. Achieving interoperability of clinical information will be a key to making EHR use a cornerstone of practice. With clinical interchange, the record will become the place to go when a clinician needs information. Although physicians are desperate to be able to access test results in particular, in many areas it is probably not realistic to expect that these results will be integrated with the record at the time that physicians begin using EHRs, because of an array of logistical issues such as patient identification and managing privacy. From the EHR perspective, perhaps the key stepping-stone will be to require vendors to represent key clinical data using standard formats. This will require "building out" and additional refinement of existing standards. Clinical data exchange is likely to occur beginning in a variety of regions and will be galvanized by the development of regional health information organizations (RHIOs).²⁵

Selection of a vendor. Although certification of the vendor applications represents an important first step, physicians will need additional information to be able to make good decisions in selecting a vendor. Issues such as how long it takes to do certain tasks and usability must be addressed and scored; this information will likely be developed in the private sector.

Another problem is that the current number of vendors is untenable. In particular, having a very large number of vendors (there are several hundred nationally, most with very low penetration) makes it difficult for providers to select an EHR system, but, more importantly, this makes clinical data exchange difficult to achieve. Many would prefer to wait for the market to mature. Although natural selection would eventually occur, this would be slow. Instead, regions may want to make specific vendors "preferred" in their regions. In other countries that have achieved high levels of adoption, this approach has been used; typically, they identify two to four vendors for a region and require them to adhere to certain standards to facilitate clinical data exchange, meaning transfer of clinical information between disparate health care entities.²⁶

Massachusetts recently identified seven vendors as "preferred," although communities will be required to pick only two to three apiece.²⁷ Another problem is that in some areas of the country (such as Idaho), nearly all of the providers are in small practices. It might be helpful for such regions to set up "virtual groups," which would lack the financial links that a group practice would have but would allow physicians to band to together to interact with vendors.

Vendor transience has also been a major concern for providers. Keys here will be requiring vendors to adhere to data standards and developing contracts that allow providers to take their data and make the transition to a different vendor should that vendor fail or underperform. Many current vendor contracts include clauses that specifically preclude extraction of clinical data, and this practice should not be allowed.

Maintenance issues. Handling maintenance and trouble-shooting with EHRs—in particular, the resources to address the problem when the application slows or goes down—in an ongoing way represents one of the most important and nettlesome issues that must be addressed. For physicians in networks, this is a functionality that will typically be addressed by the network. However, the bulk of U.S. physicians are still not in networks. Although vendors do provide such services, they are often expensive, and many practices will likely elect to do without them, which sometimes has negative results. This represents a particularly vulnerable spot for the entire effort, and many practices will underperform and EHRs will fail because this issue has not been adequately addressed.

Acceptance of technology. There has also been a general perception that physicians are resistant to adopting EHRs. It is not accurate, however, to suggest that physicians as a group are resistant to using computers or technology. Although there will be some laggards with this technology as with any other, if the financial incentives are aligned and the other barriers such as concern about vendor selection and longevity are addressed, physicians will be willing to make the transition.²⁸

Roles Of Specific Groups

Top Barriers To The Introduction... Addressing The Barriers: Key... Roles Of Specific Groups NOTES

 
Private sector. The private sector will clearly play a key role in accelerating the adoption of EHRs. Payers and ideally purchasers must come together and begin to provide incentives for providers across regions to begin adopting EHRs. This has already occurred in some areas; for example, a number of payers in Massachusetts have all agreed to pay physicians approximately 4 percent more per year if they use an EHR than if they do not. In other markets in which payers are more fragmented, this has not occurred as frequently, although David Brailer, the national coordinator for health information technology (HIT), is trying to bring together groups in a number of regions to catalyze this type of approach. The exact price point for physicians is unclear, but reimbursement strategies that provide a greater margin to providers who use EHRs compared with those who do not will likely be effective and should be implemented and assessed. Financial incentives that reward providers based on outcomes are especially likely to promote dumping of problematic patients. The best way to mitigate this risk is probably to reward a complex mix of process and outcomes measures and to severity-adjust for the outcome measures when possible, as is being done in the United Kingdom.²⁹

Vendors. Vendors must recognize that the road ahead lies with greater standardization and clinical data exchange, and they should support efforts such as the CCHIT. To their credit, the vendor community has participated enthusiastically in such activities to date. Achieving full benefit from EHRs will also require the ability to bring in new knowledge rapidly, so this is an essential area for vendors to focus on closely.

Coalitions. Coalitions will also play a key role. Groups such as Connecting for Health and the eHealth Initiative have already been extremely effective at bringing together key stakeholders to address issues such as addressing issues around privacy and security and clinical data exchange. Other groups such as the National Alliance for Primary Care Informatics (NAPCI), a coalition of primary care provider organizations, and the Physicians’ Electronic Health Record Coalition (PEHRC), a coalition of medical specialty and professional societies, are trying to promote EHR adoption in practices around the country.³⁰ Although many of the particularly knotty problems remain unresolved and will require societal input, these groups are well positioned to promote public dialogue around issues such as how to uniquely identify patients and how to operationalize clinical data exchange at the national level with an acceptable level of security.

Specialty groups. Specialty societies can help in a variety of ways. Many groups, including the AAFP, the American College of Physicians, and the American Academy of Pediatrics, have active programs to help providers understand the benefits of EHRs and to help them select a vendor. These groups should also develop modules covering quality improvement that will help practices learn the skills they need to fundamentally transform their practices.

Public sector. The public sector also has a number of key roles. The U.S. government appears determined to take a different course from its U.K. counterpart, which has paid for implementation of EHRs. The U.S. approach may eventually be effective, but the level of federal investment to date has been grossly inadequate, and financial incentives for adoption are not yet in place. The Centers for Medicare and Medicaid Services (CMS) covers the largest group of Americans (the elderly), and by virtue of size and programming, its policies have extraordinary influence with public and private insurers. Thus, it is pivotal for the CMS to provide financial incentives to providers, for either using EHRs, measuring quality data, or achieving certain quality benchmarks. For the initial transition, access to capital will be pivotal, and the federal and state governments could help by providing access to capital. States could make it easier for small providers to form virtual groups, which might help them gain access vendors at prices that would not be available to individual groups. The federal government has greatly accelerated the adoption of standards for clinical data, but not all of the key domains have sufficiently developed standards, and the government could play a key catalytic role to accelerate development of additional standards for domains such as medications and clinical knowledge. Furthermore, a national repository of rules and knowledge would represent a valuable resource, and providing support for such a repository, which would receive federal support but not be federally operated, would represent a hugely important step forward.

More research is also needed on how to provide decision support, especially for chronic diseases. A series of controlled trials has recently demonstrated no effect for the care of these conditions. The Agency for Healthcare Research and Quality (AHRQ) and the National Library of Medicine should support this work. In addition, the current quality measures—as noted above—were developed largely with the contingency that they could be measured using claims data. With the availability of more clinical information, it is essential to develop the next generation of quality measures, but this will require research to build and refine them. When these measures are implemented in clinical systems, it will be possible to drive improvement through point-of-care decision support, and this will dramatically facilitate iterative improvement.

The limited data avail able suggest that U.S. physicians are ready to make the transition to EHRs. This is clearly overdue, especially given the rest of the world’s experience. This transition will have the greatest effect if it begins in primary care. The current EHRs are already much better than paper, although a tremendous amount remains to be learned, and a great deal of consolidation can be expected in this marketplace. The single most important issue to be addressed is financial incentives for providers, and the CMS has the most important role in making this transition occur; even a small signal on its part could be transformative. Issues relating to interoperability also represent a high priority. The key here is further development of standards; the government’s role should be catalytic and also to endorse standards when they are ready. Government should also implement policies to make capital accessible to provider groups and to facilitate virtual linkage of small providers so that they can access EHR systems at a reasonable price.

Editor's Notes

 
David Bates (dbates{at}partners.org) is chief of the Division of General Internal Medicine at Brigham and Women’s Hospital (Boston, Massachusetts); medical director of clinical and quality analysis for Partners HealthCare System; a professor of medicine at Harvard Medical School; and a professor of health policy and management at the Harvard School of Public Health, where he is also codirector of the Program in Clinical Effectiveness. He also chairs the National Alliance for Primary Care Informatics.

The author thanks Maria Staroselsky for assistance with preparation of the manuscript.

NOTES

Top Barriers To The Introduction... Addressing The Barriers: Key... Roles Of Specific Groups NOTES

 

1. A.M. Audet et al., "Information Technologies: When Will They Make It into Physicians’ Black Bags?" Medscape General Medicine 6, no. 4 (2004), www.medscape.com/viewarticle/493210 (14 February 2005; registration required).
2. Michael Bainbridge, chair, Primary Health Care Specialist Group, British Computer Society, personal communication, 16 February 2004.
3. D. Bomba, "A Comparative Study of Computerised Medical Records Usage among General Practitioners in Australia and Sweden," Med info 9, part 1 (1998): 55–59.
4. Massachusetts Medical Society, "MMS Survey: Most Doctors Are Slow to Incorporate Technology into Practices," 4 December 2003, www.massmed.org/AM/Template.cfm?Section=Search&template=/CM/HTMLDisplay.cfm&ContentID=10048 (11 July 2005).
5. I. Valdes et al., "Barriers to Proliferation of Electronic Medical Records," Informatics in Primary Care 12, no. 1 (2005): 3–9.
6. Audet et al., "Information Technologies."
7. R.H. Miller and I. Sim, "Physicians’ Use of Electronic Medical Records: Barriers and Solutions," Health Affairs 23, no. 2 (2004): 116–126.[Abstract/Free Full Text]
8. D.W. Bates et al., "A Proposal for Electronic Medical Records in U.S. Primary Care," Journal of the American Medical Informatics Association 10, no. 1 (2003): 1–10.[Abstract/Free Full Text]
9. J. Walker et al., "The Value of Health Care Information Exchange and Interoperability," Health Affairs, 19 January 2005, content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.10 (17 May 2005).
10. S.J. Wang et al., "A Cost-Benefit Analysis of Electronic Medical Records in Primary Care," American Journal of Medicine 114, no. 5 (2003): 397–403.[CrossRef][Web of Science][Medline]
11. Ibid.
12. Medical Group Management Association, "MGMA Reports Nominal Increases in Physician Compensation in 2003, Medical Group Practice Managers’ Compensation Keeping Pace," Press Release, 11 August 2004, www.mgma.com/press/phymgmtcomp.cfm (28 May 2005).
13. Walker et al., "The Value of Health Care Information."
14. Bates et al., "A Proposal."
15. J.M. Overhage et al., "Controlled Trial of Direct Physician Order Entry: Effects on Physicians’ Time Utilization in Ambulatory Primary Care Internal Medicine Practices," Journal of the American Medical Informatics Association 8, no. 4 (2001): 361–371[Abstract/Free Full Text]; and L. Pizziferri et al., "Primary Care Physician Time Utilization Before and After Implementation of an Electronic Health Record: A Time-Motion Study," Journal of Biomedical Informatics 38, no. 3 (2005): 176–188.[CrossRef][Web of Science][Medline]
16. M. Eccles et al., "Effect of Computerised Evidence Based Guidelines on Management of Asthma and Angina in Adults in Primary Care: Cluster Randomised Controlled Trial," British Medical Journal 325, no. 7370 (2002): 941[Abstract/Free Full Text]; M.D. Murray et al., "Failure of Computerized Treatment Suggestions to Improve Health Outcomes of Outpatients with Uncomplicated Hypertension: Results of a Randomized Controlled Trial," Pharmacotherapy 24, no. 3 (2004): 324–337[CrossRef][Web of Science][Medline]; and W.M. Tierney et al., "Effects of Computerized Guidelines for Managing Heart Disease in Primary Care," Journal of General Internal Medicine 18, no. 12 (2003): 967–976.[CrossRef][Web of Science][Medline]
17. D.W. Bates, "Quality, Costs, Privacy, and Electronic Medical Data," Journal of Law, Medicine, and Ethics 25, no. 2–3 (1997): 111–112, 182.[Web of Science][Medline]
18. B. Bright, "Most Americans Are Unwilling to Pay for E-Mail with Doctors," Wall Street Journal, 1 March 2005.
19. A.M. Audet et al., "Measure, Learn, and Improve: Physicians’ Involvement in Quality Improvement," Health Affairs 24, no. 3 (2005): 843–853.[Abstract/Free Full Text]
20. Wang et al., "A Cost-Benefit Analysis."
21. T.P. Hofer et al., "The Unreliability of Individual Physician ‘Report Cards’ for Assessing the Costs and Quality of Care of a Chronic Disease," Journal of the American Medical Association 281, no. 22 (1999): 2098–2105.[Abstract/Free Full Text]
22. NHS Connecting for Health, "What Is QMAS?" www.connectingforhealth.nhs.uk/programmes/qmas (9 June 2005).
23. See the Doctors’ Office Quality Information Technology Program home page, www.doqit.org/doqit/jsp/index.jsp.
24. C.A. Gonzalez et al., National Health Information Incentive Act of 2005, HR 747i (introduced in the U.S. House of Representatives), 109th Cong., 1st sess. (2005).
25. U.S. Department of Health and Human Services, "Office of the National Coordinator for Health Information Technology (ONCHIT)," 9 November 2004, www.hhs.gov/healthit/executivesummary.html (14 February 2005).
26. E.M. Rogers, Diffusion of Innovations (New York: Free Press, 1983).
27. Bates et al., "A Proposal."
28. See the Massachusetts E-Health Collaborative home page, www.maehc.org/index.htm.
29. U.K. Department of Health, The NHS Plan: A Plan for Investment, a Plan for Reform, 7 January 2000, www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4002960&chk=07GL5R (9 June 2005).
30. See the National Alliance for Primary Care Informatics home page, www.napci.org; and the Physicians’ Electronic Health Record Coalition (PHERC) home page, www.centerforhit.org/x199.xml.

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				A. Milstein Health Information Technology Is A Vehicle, Not A Destination: A Conversation With David J. Brailer Health Aff., March 1, 2007; 26(2): w236 - w241. [Abstract] [Full Text] [PDF]

				D. C. Classen, A. J. Avery, and D. W. Bates Evaluation and Certification of Computerized Provider Order Entry Systems J. Am. Med. Inform. Assoc., January 1, 2007; 14(1): 48 - 55. [Abstract] [Full Text] [PDF]

				S. R. Simon, R. Kaushal, P. D. Cleary, C. A. Jenter, L. A. Volk, E. G. Poon, E. J. Orav, H. G. Lo, D. H. Williams, and D. W. Bates Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey J. Am. Med. Inform. Assoc., January 1, 2007; 14(1): 110 - 117. [Abstract] [Full Text] [PDF]

				K. M. McConnochie Potential of Telemedicine in Pediatric Primary Care. Pediatr. Rev., September 1, 2006; 27(9): e58 - e65. [Full Text] [PDF]

				P. C. Tang, J. S. Ash, D. W. Bates, J. M. Overhage, and D. Z. Sands Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption J. Am. Med. Inform. Assoc., March 1, 2006; 13(2): 121 - 126. [Abstract] [Full Text] [PDF]

				R. Kaushal, D. W. Bates, and D. Blumenthal National Health Information Network Cost and Structure Ann Intern Med, January 17, 2006; 144(2): 147 - 147. [Full Text] [PDF]