For years, healthcare institutions have relied on outdated and traditional approaches to information management. These approaches mainly involved the use of paper-based systems to record patient information. While they allowed the institutions to have useful records of patient details, these approaches were ineffective and unreliable. The disadvantages of these approaches inspired the development of more modern information management systems. Unlike the traditional approaches which are based on outdated systems, the modern information management systems that are being adopted leverage modern technology. As a result of the adoption of advanced information management, hospitals and other healthcare providers have witnessed vast improvements in staff satisfaction and patient outcomes. If they wish to record similar improvements, healthcare providers should be prompt in their adoption of advanced information management. The discussion below examines various aspects of health information systems. While the discussion is rather general, it is based mostly on the adoption of the EPIC system in a health facility.
A1. Advantages and Disadvantages of Information System
The numerous advantages that health information systems (HIS) present should incentivize healthcare providers to abandon traditional approaches and embrace advanced information management. Improved clinical outcomes are among the main benefits of HIS. It has been shown that upon the adoption of HIS, medical service providers witness significant improvements in the quality of care and patient safety (Hessels et al., 2015). HIS provides practitioners with the insights that they need to correct errors and integrate the latest evidence into their work. Other benefits of HIS include increase in the revenues that providers earn, cost minimization and compliance with regulatory guidelines (Kwon & Johnson, 2013). Since HIS enables providers to minimize errors, they are also able to reduce the cost of delivering care thereby maximizing revenue. Moreover, HIS eliminates the need for healthcare providers to spend huge amounts on purchasing paper and other stationery. HIS also facilitates efficiency by challenging providers to minimize costs and deliver quality care. Physician satisfaction is yet another advantage of HIS (Rittenhouse et al., 2017). HIS reduces the workload of physicians while enabling them to deliver quality and safe care, thereby enhancing their satisfaction levels.
Delegate your assignment to our experts and they will do the rest.
While it is true that HIS presents various benefits, it has also been blamed for a number of negative outcomes. High initial cost of implementation is one of the drawbacks of HIS (Wanderer & Ehrenfeld, 2014). When adopting HIS, a facility incurs costs when purchasing such tools as computers. That HIS requires highly trained specialists is another drawback. When these specialists are lacking, providers are forced to spend huge amounts on training. The revenue that facilities lose when the operation of the HIS is interrupted, privacy concerns, fears of security breaches and over-reliance on technology are other drawbacks that providers should be wary of when adopting HIS. Issues with usability and compatibility are other disadvantages that HIS presents (Sittig, Belmont & Singh, 2018). If the HIS is too complex, the practitioners at a particular facility may lack the skills and competence needed to use it. It may also be that the HIS cannot be adopted across various platforms. For example, it could be that a HIS has been designed for the computers yet a facility wishes to use the system on mobile devices. Compatibility is another issue which causes concern. It is possible that the system that a facility has in place is not aligned with the HIS it wishes to adopt. The facility is forced to either abandon its plans of adopting HIS or incur huge costs to overhaul its current system so as to accommodate the HIS. Overall, the benefits of HIS outweigh the risks and drawbacks.
The discussion above has addressed some of the common benefits and drawbacks of HIS. For the discussion to become more relevant to the facility being examined, it is important to scrutinize how such issues as scalability, interoperability, usability and compatibility. Essentially, scalability refers to the capacity of a system to be adapted to levels that match the needs of an organization. For example, small health facility may opt for a customizable HIS which comes with lower storage capacity as opposed to a larger facility which would prefer more storage. The key advantage of HIS as regards scalability is that it allows firms to customize HIS to suit their needs (Zhang & Zhang, 2013). While a scalable system provides advantages, one of its drawbacks is that it is difficult to safeguard the security of data while promoting practitioner performance (Zhang & Zhang, 2013).The examples provided above illustrate this point. Interoperability refers to the ability of HIS to be used by different practitioners across different units and departments (Hammami, Bellaaj & Kacem, 2013). For example, a well-designed system should allow practitioners in the pharmacy department to access the same information as those in the oncology unit. One of the advantages of HIS in relation to interoperability is that it enhances collaboration by allowing for seamless interaction of data (Hammami, Bellaaj & Kacem, 2013). For example, since they are able to access information, practitioners can work together on the same cases. Exposing data to the threat of theft or hacking is among the cons of HIS. As more practitioners engage with the HIS, the risk of an attack occurring is elevated. For example, practitioners may ignore security safeguards, thereby creating opportunities for hackers.
Usability and compatibility are two concepts that relate to HIS. On the one hand, usability refers to the ease with which an average professional is able to meaningfully adopt HIS. When a HIS is designed properly, with particular focus given to a friendly user interface, practitioners are able to witness nearly all of the benefits discussed above. For instance, a friendly user interface enhances practitioner satisfaction and performance. However, a poorly designed HIS could be the source of errors (Minshall, 2013). For example, suppose that a practitioner is unable to make sense of the instructions on a complicated HIS. It can be expected that this practitioner will commit errors which compromise patient safety and data security. On the other hand, compatibility concerns the alignment between a facility’s existing structures, processes and operations with the HIS that it wishes to adopt. Enabling facilities to minimize the cost of adoption is the main advantage of HIS as regards compatibility. To make this point clearer, an example is needed. The case of a hospital which plans to adopt a modern HIS but its existing infrastructure is outdated, may be considered. If the adoption of the HIS at this facility is to be successful, the facility will be forced to overhaul its infrastructure. This will undoubtedly be a cost-intensive undertaking. Therefore, before adopting HIS, facilities need to confirm that the system is compatible with their existing systems and processes. It has been shown that incompatible systems have an adverse impact on the performance of healthcare professionals (Salleh, Zakaria & Abdullah, 2016). For example, if a system is incompatible, it could spark frustration and cause stress among practitioners. This is among the drawbacks of HIS with regard to compatibility.
A2. Patient Care and Documentation
In the discussion above, some of the benefits of HIS have been identified. The main impact of these benefits is improved patient care. It has been established that HIS provides practitioners with information in a timely and accurate fashion (El-Kareh, Hasan & Schiff, 2013). Thus information is then used to understand and respond to the needs of patients. HIS also enhances practitioner satisfaction. When they are pleased and satisfied with their jobs and working environment, practitioners are better placed to deliver quality care. HIS provides decision support (Bowles, Dykes, & Demiris, 2015). The implication of this is that providers are able to make better decisions that are based on accurate information. Consequently, an encouraging improvement in patient care is witnessed. Documentation is another area of healthcare delivery that benefits from HIS. HIS allows facilities to document and store patient information (Jardim, 2013). With appropriate security safeguards in place, the information is insulated against security breaches and privacy violations. HIS also facilitates interoperability as different medical units are able to access and share information. Today, it is possible for practitioners to access patient information remotely. Thanks to the remote access, the practitioners are able to take all necessary steps to safeguard patient outcomes.
A3. Quality and Delivery of Nursing Care and Patient Outcomes
Promoting the quality of care is one of the primary goals of HIS. As they access information held in HIS, practitioners are able to enhance quality. The information provides the practitioners with insights into the medical histories of patients. Consequently, it is possible to deliver quality care that accounts for the medical histories. As noted earlier, HIS offers decision support. The information stored in the HIS enables nurses and other medical practitioners to make quick and information-based decisions (Mutale et al., 2013). These decisions translate into improved quality of care. Quality improvement is another impact that HIS has on nursing care and patient outcomes. Thanks to the adoption of HIS, practitioners are able to understand issues that require improvement. For example, by accessing patient records, nurses may recognize that there is need to minimize the length of patient hospital stays. HIS also facilitates the delivery of safe care (Lavin, Harper & Barr, 2015). It does this by helping practitioners to eliminate costly errors. A HIS can be designed such to include details on the medication and treatment that patients require. Using these details, practitioners ensure that the patients receive all the care that they require. Overall, through the adoption of HIS, healthcare institutions are able to deliver quality care which enhances patient outcomes.
B1. Ways QI Data can Lead to Measurable Improvement
This far, the discussion has examined various benefits of HIS. One of the most important advantages of HIS is that it facilitates quality improvement. The insights that practitioners gain through the HIS enable them to adopt approaches which lead to improved quality and better patient outcomes (AlHazme et al., 2016). HIS handles data on a wide range of healthcare issues. The cost of delivering care is among these issues. For example, a facility could adopt a HIS which allows it to track the costs that patients incur as they seek treatment. The data on the costs can be used to achieve measurable improvement. It is possible for a provider to rely on cost data to adopt measures aimed at minimizing costs (AlHazme et al., 2016). For example, consider the case of a facility whose cost of healthcare delivery is unjustifiably high. In an effort to reduce this cost, the facility sets out to eliminate errors and redundancies using its HIS. The example of this facility shows that the data provided by the HIS can be used to achieve measurable improvement. Therefore, providers which wish to minimize the cost of healthcare delivery should adopt HIS.
Cost minimization is not the only measurable quality improvement issue that HIS enhances. Well-designed information systems also enable healthcare providers to improve response to patient needs (Higgins et al., 2015). To understand how quality improvement data can be used to enhance response, it is helpful to consider an example. Suppose that a facility has been tracking the length of time between a patient’s first contact with a practitioner and the delivery of care. The data gained from the tracking can be used to determine if the response time is in line with the objectives of the facility. For example, it could be that the hospital wishes to reduce the response time from 45 minutes to 20 minutes. By tracking how long it takes before practitioners attend to patients, the facility is able to achieve this goal. Therefore, quality improvement data can be used to challenge practitioners to be more prompt in their response to the needs of patients. Patients become the greatest beneficiaries. They do not have to wait for too long as they await care. Given the critical role that HIS plays in improving quality, facilities should be quick in integrating the latest information technology into healthcare delivery.
B2. HITECH and HIPAA Security Standards and Regulations
The US government is among the stakeholders who are committed to improving the quality of care. Through Congress, the government has enacted laws and adopted policies whose primary purpose is to enhance the quality of services that the American people receive. The Health Information Technology for Economic and Clinical Health (HITECH) Act (2009) and the Health Insurance Portability and Accountability Act (HIPAA) (1996) are some of the laws which challenge healthcare institutions to adopt health information technology for quality improvement. Among the provisions of these acts is that institutions need to ensure that patient records are retrievable and backed up safely. Furthermore, the acts stipulate that the facilities which fail to comply with their provisions could face harsh penalties. In the discussion below, the steps that can be taken to ensure full compliance with the HITECH and HIPAA acts are examined.
The HITECH and HIPAA acts require that practitioners should ensure the safety and integrity of data. When storing data, it is important for medical institutions to prevent corruption of the data. To achieve data storage integrity, institutions need to carefully monitor changes to the data. Furthermore, the institutions should limit access to the data. Only practitioners who are authorized should be permitted to access the data. Access by unauthorized individuals could lead to corruption and loss of the data. The adoption of stringent encryption protocols is another measure that safeguards the integrity of data (“Encryption: Protect”, 2013). When storing data, institutions should use encryption technologies which make it difficult for hackers and other unscrupulous individuals to access and steal the data. The integrity of storage data can also be ensured through the adoption of standard procedures which are applied in both emergency and normal situations. In general, when they adhere to these guidelines, institutions are able to prevent the corruption of data, thereby ensuring integrity.
The requirements of the HITECH and HIPAA acts go beyond the need for institutions to ensure data integrity. These acts also stipulate that institutions should take all necessary steps to backup data and ensure its recovery. A system that is well-designed should allow an institution to comply with this requirement. To facilitate backup and recovery, the system should be accompanied with protocols and procedures for backup (Kruse et al., 2017). These procedures allow the practitioners to understand the steps that they should take as they attempt to backup data. Among the advantages of the procedures is that it makes it possible for practitioners who lack technical competence to backup and restore data by following simple instructions. It is also important for the HIS to allow for tests. Data recovery is usually conducted when such an event as an attack which has wiped out data has occurred. Before such an event occurs, an institution should be able to test if the system allows for data recovery to be conducted.
B3. Protection of Patient Privacy
One of the key provisions of the HIPAA act concerns patient privacy. The act mandates healthcare institutions to accord patient information ultimate security. For patient privacy to be guaranteed, a health information system needs to be equipped with a number of important features. The requirement that users should provide passwords as part of authentication is among these features (Taitsman, Grimm, & Agrawal, 2013). Passwords and PIN numbers are security safeguards which seal loopholes that can be exploited to invade patient privacy. In addition to requiring users to enter passwords and PIN numbers, the system should also come with a firewall (Taitsman, Grimm, & Agrawal, 2013). The main purpose of the firewall is to prevent malicious programs and individuals from gaining access. Antivirus programs can also be used to ensure privacy and security. The first line of defense in safeguarding system security and patient privacy is imbuing the system with features which help to prevent security breaches. It is important to note that personnel can also play a vital role in ensuring patient privacy. Some of the actions that practitioners can take include updating software and deleting the information stored on mobile devices (Taitsman, Grimm, & Agrawal, 2013). Undergoing training on the techniques that hackers use to violate patient privacy is another measure that practitioners can institute.
B4. Organizational Efficiency and Productivity
It is the desire of nearly all medical institutions to achieve efficiency and to enhance the productivity of their employees. Health information systems hold the key to the attainment of this desire. Among the numerous benefits of HIS is that it promotes organizational efficiency and productivity. One of the ways through which HIS promotes productivity and efficiency is standardized documentation. Organizations waste time and resources as they use different documentation styles to record patient information. HIS eliminates the need to maintain documents in different formats and styles. As they adopt HIS, facilities are able to adopt a standard approach to documentation. The standardization enhances seamless operations while preventing confusion, thereby promoting efficiency and productivity. Reduction in waste is another way through which HIS enhances efficiency and productivity. Fraud is one of the factors blamed for the high cost of care in the US. Since it minimizes human involvement, HIS helps to eradicate fraud, thereby helping organizations to reduce waste (Konnikova, 2016). Allowing practitioners to access patient information easily is another impact that HIS has on the operations of healthcare providers. Since they can access patient data easily, the practitioners do not waste time. This helps medical institutions to become more efficient while boosting the productivity of practitioners.
Increased productivity and enhanced management of human and capital resources are other benefits that HIS present. It has been established that HIS reduces the workload of practitioners thereby enhancing their satisfaction and engagement levels (Lee, McCullough & Town, 2013). When they are satisfied, the practitioners commit all their effort to serving the needs of patients. In an effort to encourage practitioners to welcome the adoption of HIS, an institution may offer financial incentives. These incentives have the effect of enhancing productivity (Lee, McCullough & Town, 2013). Organizations which have adopted HIS witness increased levels of collaboration among their practitioners. The enhanced collaboration is among the ways though which HIS increases productivity. In addition to boosting practitioner productivity, HIS also facilitates the management of human capital. It is common for healthcare providers to train their employees on how to use HIS. The training equips the practitioners with skills and knowledge which allow them to become more effective providers of quality care. As part of the adoption of HIS, healthcare providers also define the roles that each practitioner will be required to perform. The clear definition of the roles allows the organizations to effectively manage their personnel.
C. Interdisciplinary Team Identification
For an organization to find success in its implementation of a HIS, a team of employees drawn from different disciplines is needed. The Chief Executive Officer (CEO), the Chief Information Officer (CIO), the Human Resource Manager and the Accounts Manager are the key personnel who will constitute the interdisciplinary team. The main mandate of the CEO is overseeing the general operations of the organization. As regards the adoption of the HIS, the CEO will be expected to coordinate the efforts of the other members to the team. He will need to ensure that all the members work together to ensure the successful adoption of the HIS. The CEO possesses expertise that will allow him to oversee the successful adoption of the HIS. His years of experience managing the overall operations of the organization are the main source of his expertise. On his part, the CIO will be in charge of the particular details of the implementation of the HIS. Working with information technology experts, the CIO will consolidate resources and monitor progress. His technical qualifications, educational background and work experience are the key sources of the CIO’s expertise.
The Human Resource Manager and the Accounts Manager are other members of the HIS implementation team. In general, the HR manager’s main role is to coordinate personnel. Some of his specific duties include recruitment, training and personnel development. This manager will be expected to conduct employee training and to identify the employees whose input is needed for the successful adoption of the HIS. Furthermore, the HR manager will be charged with the responsibility of identifying the needs of the practitioners and ensuring that the HIS satisfies these needs. Knowledge in human resource management is the primary expertise that this manager possesses. Providing details regarding the financial health and operations of the organization is the main mandate of the accounts manager. As he participates in the adoption of the HIS, the accounts manager will need to ensure that adequate funds are available. Furthermore, this manager will monitor the implementation process carefully to ensure that all funds are utilized responsibly. The knowledge that the accounts manager possesses in financial issues is his main expertise. This knowledge will prove vital during the implementation of the HIS.
D. Plan for Evaluating Success of Implementing a System
The implementation of a HIS does not mark the end of the process. It is important to conduct an evaluation. The purpose of the evaluation is to determine if the implementation was performed successfully. An evaluation plan allows organizations to establish if the implementation process occurred smoothly and that all the objectives were achieved. The plan should incorporate the values and standards that professional organizations expect healthcare providers to uphold. The American Nurses Association (ANA) is among the professional bodies which oversee the operations of nurses. Ensuring patient safety through the delivery of quality care is one of the values that this organization promotes. This value will be part of the evaluation plan. The HIS will be examined to determine the impact that it has on patient outcomes. If it is found that the HIS has led to an improvement in quality of care and patient wellbeing, it will be fair to conclude that the implementation of the HIS was successful. Performance needs assessment is another professional standard that healthcare providers should strive to uphold (Snyder et al., 2011). As part of its evaluation, the organization will seek to determine if the HIS has met its needs. For example, it could be that the organization sought to minimize the cost of delivering care. A reduction in costs will indicate that the HIS has successfully met the organization’s needs.
The evaluation plan described above needs to be framed in terms of professional standards. The American Nurses Association (ANA) and the American Nursing Informatics Association (ANIA) are among the professional organizations which have developed guidelines for nursing practice. In its code of ethics and conduct, ANIA identifies safety as among the standards that should guide the operations of nursing practitioners (ANIA, 2015). This standard is indeed relevant to the adoption of HIS. For a HIS to enhance patient safety, it needs to possess certain features. For example, the HIS should have a friendly user interface that allows practitioners to minimize errors. Facilities should only adopt HIS that is user-friendly, compatible, scalable and interoperable if it wishes to ensure the safety of patients. Once it has established that the HIS system possesses these features, facilities should proceed to confirm that patient safety has been enhanced as part of the evaluation process. To do this, the facility could assess the number of medication errors that the practitioners have committed. A low number of errors would indicate that the HIS has helped to minimize errors, thereby promoting patient safety.
As noted above, ANA has adopted standards which govern nursing practice. As regards HIS, this organization urges facilities to ensure interoperability. In its positions statement, the ANA calls on nurses and medical institutions to adopt standard terminology and processes for their HIS (ANA, 2018). Essentially, through this statement, the organization encourages interoperability. As it adopts HIS, the facility needs to begin by confirming with the vendor of the system that features that allow for cross-department adoption and collaboration are included in the system. For example, the system should be such that it allows access by multiple users from different locations. Having confirmed that the HIS is capable of interoperability, the facility should then proceed to investigate if the benefits of this feature have been realized. In an earlier discussion, it was noted that enhanced collaboration is among the main benefits of HIS with regard to interoperability. Whether this benefit has been realized is the main method that will be used to assess that the system is in line with the standards of ANA. For example, by consulting its practitioners, the facility can determine if collaboration has been enhanced.
In conclusion, health information systems have transformed the delivery of medical services. Organizations which have adopted these systems have enjoyed a number of benefits. These benefits include enhanced patient outcomes and improved organizational efficiency. While the HIS is beneficial, it also presents drawbacks which could discourage its adoption. As they adopt HIS, organizations should ensure that they comply fully with the provisions of the HITECH and HIPAA act. It is particularly vital for these organizations to safeguard patient privacy at all costs. During the adoption of HIS, organizations need to develop multidisciplinary teams which bring together personnel from different background and with varying expertise. The integration of information technology will continue to drive healthcare delivery.
References
AlHazme, R. H., Haque, S. S., Wiggin, H., & Rana, A. M. (2016). The impact of health
Information technologies on quality improvement methodologies’ efficiency, throughput
And financial outcomes: a retrospective observational study. BMC Medical Informatics
& Decision Making, 16 (154). DOI: 10.1186/s12911-016-0395-z
American Nurses Association (ANA). (2018). Inclusion of recognized terminologies supporting
nursingPractice within electronic health records and other health information technology
Solutions. Retrieved http://nursingworld.org/practice-policy/nursing-excellence/official-position-statements/Inclusion-of-Recognized-Terminologies-Supporting-Nursing-Practice-within-Electronic-Health-Records/
American Nursing Informatics Association (ANIA). Addressing the safety of electronic health
Records. Retrieved https://www.ania.org/about-us/position-statements/addressing-safety-electronic-health-records
Bowles, K. H., Dykes, P., & Demiris, G. (2015). The use of health information technology to
Improve care and outcomes for older adults. Research in Gerontological Nursing, 8 (1),
5-10.
El-Kareh, R., Hasan, O., & Schiff, G. D. (2013). Use of health information technology to
Reduce diagnostic errors. BMJ Quality & Safety, 22, ii40-ii51.
Encryption: protect your patients and your practice. (2013). American Optometric
Association. Retrieved June 13, 2018 from
https://www.aoa.org/news/practice-management/encryption-protect-your-patients-and-your-practice
Hammami, R., Bellaaj, H., & Kacem, A. H. (2013). Interoperability of healthcare information
Systems. IEEE Explore. DOI: 10.1109/SNCC.2014.6866536
Hessels, A., Flynn, L., Cimiotti, J. P., Bakken, S., & Gershon, R. (2015).Impact of heath
Information technology on the quality of patient care. OJNI, 19. Retrieved June
13, 2018 from http://www.himss.org/impact-heath-information-technology-quality-patient-care
Higgins, T. C., Crosson, J., Peikes, D., McNellis, R., Genevro, J., & Meyers, D. (2015). Using
Health information technology to support quality improvement in primary care. Retrieved
June 12, 2018 from https://pcmh.ahrq.gov/sites/default/files/attachments/Using%20Health%20IT%20Technology%20to%20Support%20QI.pdf
Jardim, S. V. (2013). The Electronic Health Record and its Contribution to Healthcare
Information Systems Interoperability. Procedia Technology , 9 , 940-948. doi:10.1016/j.protcy.2013.12.105
Konnikova, M. (2016). The future of fraud-busting. The Atlantic. Retrieved June 13, 2018
From https://www.theatlantic.com/magazine/archive/2016/03/the-future-of-fraud-busting/426867/
Kruse, C. S., Smith, B., Vanderlinden, H., & Nealand, A. (2017). Security techniques for
Electronic health records. Journal of Medical Systems, 41 (8), 127.
Kwon, J., & Johnson, M. E. (2013). Security practices and regulatory compliance in the
Healthcare industry. Journal of American Medical Informatics Association, 20 (1),
44-51.
Lavin, M. A., Harper, E., & Barr, N. (2015). Health information technology, patient safety, and
Professional nursing care documentation in acute care settings. Online Journal of Issues
In Nursing, 20 (2), 6.
Lee, J., McCullough, J. S., & Town, R. J. (2013). The impact of health information technology
On hospital productivity. RAND Journal of Economics, 44 (3), 545-568.
Minshall, S. (2013). A review of healthcare information system usability & safety. Studies in
Health Informatics & Technology, 183, 151-6.
Mutale, W., Chintu, N., Amoroso, C., Awoonor-Williams, K., Phillips, J., Bayness, C.,
Michael, C., Taylor, A., & Sherr, K. (2013). Improving health information systems for
Decision making across five Sub-Saharan countries: implementation strategies from the
African Health Initiative. BMC Health Services Research. DOI: 10.1186/1472-6963-13-S2-S9
Rittenhouse, D. R., Ramsay, P. P., Casalino, L. P., McClellan, S., Kandel, Z. K., & Shortell, S.
M. (2017). Increased health information technology adoption and use among small
Primary care physician practices over time: a national cohort study. Annals of Family
Medicine, 15 (1), 56-62.
Salleh, M. I. M., Zakaria, N., & Abdullah, R. (2016). The influence of system characteristics on
Health providers’ performance: empirical evidence from Malaysia. Journal of infection
And Public Health, 9 (6), 698-707.
Sittig, D. F., Belmont, E., & Singh, H. (2018). Improving the safety of health information
Technology requires shared responsibility: it is time we all step up. Healthcare, 6 (1),
7-12.
Taitsman, J. K., Grimm, C. M., & Agrawal, S. (2013). Protecting Patient Privacy and Data
Security. New England Journal of Medicine,368 (11), 977-979. doi:10.1056/nejmp1215258
Wanderer J.P., Ehrenfeld J.M. (2014) Benefits and Drawbacks of Health Information
Technology. In: Ehrenfeld J., Cannesson M. (eds) Monitoring Technologies in Acute Care Environments. Springer, New York, NY
Zhang, X., & Zhang, T. (2013). Achieving scalability in a distributed health record system.
IEEE Explore. http://ieeexplore.ieee.org/stamp/stamp.jsp?tp=&arnumber=6661719&isnumber=6661709
