c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 2 1 ( 2 0 1 5 ) 14–20

journal homepage: www.intl.elsevierhealth.com/journals/cmpb

Building a National Electronic Medical Record

Exchange System – Experiences in Taiwan

Yu-Chuan (Jack) Li a , Ju-Chuan Yen a , Wen-Ta Chiu b , Wen-Shan Jian c ,

Shabbir Syed-Abdul a , Min-Huei Hsu a,d,∗
a Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University,
Taipei, Taiwan
b Graduate Institute of Injury Prevention and Control, College of Public Health and Nutrition, Taipei Medical

University, Taipei, Taiwan

c School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
d Ministry of Health and Welfare, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: There are currently 501 hospitals and about 20,000 clinics in Taiwan. The National Health
Received 18 December 2014 Insurance (NHI) system, which is operated by the NHI Administration, uses a single-payer
Received in revised form system and covers 99.9% of the nation’s total population of 23,000,000. Taiwan’s NHI provides
26 April 2015 people with a high degree of freedom in choosing their medical care options. However, there
Accepted 28 April 2015 is the potential concern that the available medical resources will be overused. The number
of doctor consultations per person per year is about 15. Duplication of laboratory tests and
Keywords: prescriptions are not rare either. Building an electronic medical record exchange system is
Electronic medical record a good method of solving these problems and of improving continuity in health care.
Health information exchange In November 2009, Taiwan’s Executive Yuan passed the ‘Plan for accelerating the imple-
National Health Insurance mentation of electronic medical record systems in medical institutions’ (2010–2012; a 3-year
Health smart card plan). According to this plan, a patient can, at any hospital in Taiwan, by using his/her
health insurance IC card and physician’s medical professional IC card, upon signing a writ-
ten agreement, retrieve all important medical records for the past 6 months from other
participating hospitals. The focus of this plan is to establish the National Electronic Med-
ical Record Exchange Centre (EEC). A hospital’s information system will be connected to
the EEC through an electronic medical record (EMR) gateway. The hospital will convert the
medical records for the past 6 months in its EMR system into standardized files and save
them on the EMR gateway. The most important functions of the EEC are to generate an
index of all the XML files on the EMR gateways of all hospitals, and to provide search and
retrieval services for hospitals and clinics. The EEC provides four standard inter-institution
EMR retrieval services covering medical imaging reports, laboratory test reports, discharge
summaries, and outpatient records. In this system, we adopted the Health Level 7 (HL7)
Clinical Document Architecture (CDA) standards to generate clinical documents and Inte-
grating the Healthcare Enterprise (IHE) Cross-enterprise Document Sharing (XDS) profile for
the communication infrastructure.
By December of 2014, the number of hospitals that provide an inter-institution EMR
exchange service had reached 321. Hospitals that had not joined the service were all smaller
ones with less than 100 beds.

∗
Corresponding author. Tel.: +886285906300.
E-mail addresses: jakk88@gmail.com (Y.-C. Li), 701056@gmail.com (M.-H. Hsu).
http://dx.doi.org/10.1016/j.cmpb.2015.04.013
0169-2607/© 2015 Elsevier Ireland Ltd. All rights reserved.
 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 2 1 ( 2 0 1 5 ) 14–20
Inter-institution EMR exchange can make it much easier for people to access their own med-
ical records, reduce the waste of medical resources, and improve the quality of medical care.
The implementation of an inter-institution EMR exchange system faces many challenges.
This article provides Taiwan’s experiences as a reference.
1. Introduction
The WHO defines eHealth as “the use of information and
communication technologies (ICT) for health” [1]. Examples
include treating patients, conducting research, educating the
health workforce, tracking diseases and monitoring public
health. Because eHealth can increase the accessibility of med-
ical care and reduce costs, it can have a far-reaching impact,
particularly for developing countries and disadvantaged eth-
nic groups [2]. The WHA held on May 23, 2005 in Geneva passed
a eHealth Resolution (WHA 2005) urging member countries
to create eHealth development plans and an implementation
focus [3].
Electronic medical records constitute a critical compo-
nent of eHealth. As governments commit to national EMR
systems, there is increasing international interest in devel-
oping effective implementation strategies. Coiera identifies
three approaches to national EMR implementations, which
he categorizes as ‘top-down’, ‘bottom-up’ and ‘middle-out’
[4,5]. A top-down approach is directed by government, with
the central procurement of standardized healthcare IT sys-
tems to replace existing diverse systems and the aim of
centrally stored and shared EMRs. He gave England’s National
Programme for Information Technology (NPfIT) as an exem-
plar of this approach [6]. In contrast, the bottom-up model
relies on local healthcare organizations taking responsibility
for making their existing and any newly acquired healthcare
IT systems compliant with interoperability standards. Multi-
ple EMRs are held locally, but the intention is that data will
become accessible from other settings as diverse local sys-
tems become integrated over time. Coiera presented the USA
as an example of this approach. The middle-out approach has
elements of both the top-down and bottom-up strategies. It
combines local consultation, systems choice and investment
with central government support and nationally agreed inter-
operability standards and goals. Local healthcare providers
retain responsibility for choosing their EHR systems and
for complying with national standards in order to exchange
information with other healthcare providers. Coiera identi-
fied the Australian strategy of focusing on standards rather
than government implementations of IT as an example of the
middle-out approach [7].
Jha examined rates of electronic health record (EHR) use
in ambulatory care and hospital settings, along with activities
in health information exchange (HIE) in seven countries: the
United States (U.S.), Canada, United Kingdom (UK), Germany,
Netherlands, Australia, and New Zealand (NZ). They found
that many countries have achieved high levels of ambulatory
EHR adoption but lagged with respect to inpatient EHR and
HIE [8].
15
© 2015 Elsevier Ireland Ltd. All rights reserved.
In recent years, Taiwan’s government has aggressively
developed various forms of eHealth, including tele-health [9],
HIE, and other services. HIE is one of the core components of
eHealth. It can help a medical team make better and more
appropriate clinical decisions by utilizing the ICT technology
to transmit, in real time, patient’s health care information to
any medical team that requires it. Past research indicated that
an EMR system can help to increase the quality of medical
care, enhance patient safety, lower medical costs, and so on
[10,11].
This article will share Taiwan’s implementation expe-
riences through its development strategies and current
achievements in promoting a nationwide EMR exchange sys-
tem.
2. Background
There are currently 501 hospitals and about 20,000 clinics in
Taiwan. Medical expenses account for about 6–7% of the coun-
try’s GDP, which is lower than the levels of OECD and regional
countries. The National Health Insurance system, which is
operated by the National Health Insurance Administration,
uses a single-payer system and covers 99.9% of the nation’s
total population of 23,000,000 [12]. Taiwan’s National Health
Insurance provides people with a high degree of freedom
in choosing their medical care options, low medical service
costs, and excellent quality. It has received a higher than
80% satisfaction rate from the people, and is well praised by
other countries [13,14]. However, the fast aging population,
increased demands on medical services and medicinal sup-
plies, as well as rising medical costs, have presented huge
challenges to the long-term operation of the National Health
Insurance system. Because the system has no gate keeper,
the number of doctor consultations per person per year is
about 15. Duplication of laboratory tests and prescriptions
are not rare either [15]. Building an electronic medical record
exchange system is a good method to solve these problems
and to improve the continuity in providing medical care.
The promotion of eHealth in Taiwan and the launch of
National Health Insurance are closely related. The electronic
insurance claiming system was the first step for many med-
ical institutions in going electronic. Because of the National
Health Insurance Administration’s active promotion efforts,
electronic claims quickly reached 100% in 2000, the sixth year
after the launch of the National Health Insurance program.
Moreover, because of the catalytic effect of the electronic
claiming, many medical institutions started to digitize other
functions as well. The promotion of the Health Insurance IC
card (Health Smart Card) is another important milestone of
eHealth in Taiwan [16]. At the start of the National Health
16 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 2 1 ( 2 0 1 5 ) 14–20
Fig. 1 – All the hospitals and clinics are connected with the National Health Insurance Administration through Virtual
Private Networks (NHI VPN).
Insurance, paper-based health insurance cards were issued to
each insured person. On the back of the paper-based health
insurance card, there were six spaces with codes. During each
doctor consultation, the medical institution would stamp one
of these spaces. However, even though this method could
prevent fraudulent claiming, it also wasted paper and prin-
ting costs. In 2004, the Health Insurance IC card was issued
to replace the paper-based insurance card. Not only can the
Health Insurance IC Card prevent fraudulent filing, but it can
also log medical information. In addition, all the hospitals
and clinics are connected with the National Health Insur-
ance Administration through Virtual Private Networks (VPNs)
(Fig. 1). This infrastructure later became an important compo-
nent in implementing the nationwide EMR exchange system.
3. Design considerations
Taiwan’s government started promoting an EMR system in
2000. At the beginning it conducted trials with a single indi-
vidual hospital or in a small area. Though the results indicated
that inter-institution EMR technology was feasible, because
the trials were focused on an individual hospital or a small
area, they did not provide global infrastructure planning
and good EMR exchange and communication mechanisms.
Considering the high initial costs of building an EMR system
and the absence of immediate benefits, there were few incen-
tives for medical institutions to implement an EMR system and
EMR exchange. Thus, the nationwide implementation faced a
great challenge.
Medical institutions in Taiwan can be classified as primary
care clinics and hospitals. The hospitals can be further divided
into district hospitals, regional hospitals, and medical centers
according to their level of medical techniques, and capacity
to provide medical services (from the lowest to the highest).
The Taiwan Joint Commission on Hospital Accreditation con-
ducts a re-assessment of a hospital’s classification once every
3 years. Since the launch of the National Health Insurance
plan, the insurance claims have been almost completely dig-
itized. Relevant information is automatically uploaded to the
data center at the National Health Insurance Administration
within 24 h after each doctor consultation and a summary
report of all medical expenses is filed with the agency once
every month.
In addition to the health insurance IC cards for the gen-
eral population, the Ministry of Health and Welfare also issued
medical personnel IC cards and established an electronic cer-
tification center providing an electronic signature service. The
Ministry of Health and Welfare also established the ‘Reg-
ulations Governing the Creation and Management of EMR
Systems at Medical Institutions’ as the legal guidelines for the
implementation of EMR systems by medical institutions.
In November 2009, The Executive Yuan passed the ‘Plan for
accelerating the implementation of electronic medical record
systems in medical institutions’ (2010–2012; a 3-year plan).
When the plan is fully implemented, a patient will be able
to, at any one hospital, by using his or her health insur-
ance IC card and physician’s medical certificate IC card, upon
signing a written agreement, retrieve complete important
medical records for the past 6 months from other participat-
ing hospitals. The Ministry of Health and Welfare also set
 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 2 1 ( 2 0 1 5 ) 14–20
Fig. 2 – According to Taiwan’s regulations, medical records created by computers should include digital signatures in order
to satisfy the definition of an EMR.
up an EMR Development Committee in 2010 to draft poli-
cies for promoting EMR systems, establish relevant exchange
and communication standard specifications, approve annual
plans and assess the results. The EMR Development Commit-
tee consists of 20 members, including six government officials
(30%), 10 representatives from industry (including hospitals)
(50%), and four members from academic research institutions
(20%). The deputy minister of the Ministry of Health and Wel-
fare serves as the chairperson of the committee.
Concerning the protection of the privacy of health infor-
mation, Taiwan does not have a set of regulations such as
those of the HIPAA in the U.S [17,18]. However, there are clear
regulations included in the Medical Affair Act, and various
specialized medical personnel laws such as the Physicians Act.
Taiwan has strict specialized laws for personal data protec-
tion, which also contain regulations related to medical records
and other health information.
4. Description of method/system
Digitalization of hospitals is the foundation for implementing
inter-institution EMR exchange. Led by the National Health
Insurance, hospital digitization has been widely adopted in
Taiwan. Most hospitals can reach levels 3 and 4 of the HIMSS
EMR Adoption Model [19]. According to Taiwan’s regulations,
medical records created by a computer system should include
digital signatures in order to satisfy the definition of an EMR
[20,21] (Fig. 2). EMR systems implemented by Taiwan’s hospi-
tals use a template-based filing system. The admission note,
discharge summary, operation note, etc., each count as one
template [22]. A hospital in Taiwan could use hundreds of
different medical record templates. Each and every template
used by a hospital needs to be reported to and filed with the
local health bureau. Once the filing is completed, the hos-
pital is qualified to connect with the national EEC and no
longer needs to print out paper-based medical records. The
EMR systems in the hospitals should comply with require-
ments related to the regulations governing the creation and
management of EMRs. The standard concerning the format
17
and content of an EMR template used within the hospital
is not mandatory. Most hospitals have established their own
medical records management committees. The content and
format of the paper-based medical records and EMRs should
be approved by such a committee at each hospital.
Each hospital’s information system does not connect
directly with the EEC. Instead, an EMR gateway connects a
hospital’s information system to the EEC. Hospitals convert
the past 6 months’ medical records in their EMR systems into
standard files and save them on their EMR gateways. The most
important functions of the EEC are to generate an index of
all the XML files on the EMR gateways of all hospitals, and to
provide search and retrieval services for all hospitals and clin-
ics. There are two versions of the EMR gateway. The one used
by hospitals is the standard version and is capable of storing
a hospital’s own EMR XML files to be retrieved by other hospi-
tals and clinics; it is also capable of retrieving others hospitals’
EMRs. Clinics use the simpler version, called Light Gateway,
which is only capable of retrieving EMRs from other hospitals
[23].
Currently, only four standard EMR exchange formats have
been established, including medical imaging reports, lab-
oratory test reports, discharge summaries, and outpatient
records. The inter-institution exchange service is limited to
these four types of medical records.
The EMR exchange mechanism allows a patient, using a
health insurance IC card, to ask a doctor at hospital A to
retrieve his or her medical records from hospital B. The patient
scan sign a written agreement to authorize the doctor at hospi-
tal A to retrieve his/her medical records from hospital B (Fig. 3).
After retrieving the records using the indexing system, if the
doctor wants to save the records at hospital A, he must ask for
further consent from the patient.
In this system, we used the HL7 CDA, Release 2 standards
to generate clinical documents and the IHE XDS profile for
the communication infrastructure [24,25]. The EMR gateway
received clinical documents from the hospital information
system, registered the metadata to the document registry
(EEC), and stores them for 6 months. EEC stores metadata
about each document stored in a repository (EEC gateway),
18 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 2 1 ( 2 0 1 5 ) 14–20

Fig. 3 – The EMR exchange mechanism allows a patient, using a health insurance IC card, to ask a doctor at hospital A to
retrieve his/her medical records from hospital B.

including its source or location. There may be multiple reposi-
tories of documents indexed, but only one registry per clinical
domain. Patient identification service was carried out by the
NHI administration (Fig. 4).
5. Lessons learned
Inter-institution EMR exchange can make it much easier for
people to access their own medical records, reduce the waste
of medical resources, and improve the quality of medical care.
An EMR system that complies with the regulations of the law is
the most important infrastructure [26]. By December of 2014,
the number of hospitals that provide an inter-institution EMR
exchange service had reached 321. The hospitals that had not
joined the service were all smaller ones with less than 100
beds.
Inter-institution EMR exchange is the Holy Grail for the
promotion of eHealth. It took 10 years to make the inter-
institution EMR exchange possible in Taiwan. During this
period of time, essential components were completed one by
one – from the popularization of hospital information systems
to the development of EMR’s basic modules, the setup of a
Healthcare Certification Authority (HCA), and the establish-
ment of regulations governing the creation and management
of EMR systems at medical institutions. The inter-institution

Fig. 4 – IHE XDS is adopted as the technical frameworks.

 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 2 1 ( 2 0 1 5 ) 14–20
EMR exchange in Taiwan uses the health insurance IC card
as the certification for data retrieval. It also utilizes the VPN
technology used previously for filing health insurance claims,
thus reducing repeated investment costs.
Digitization of hospitals is an important foundation for
promoting EMR exchange. The implementation of inter-
institution EMR exchange is only possible when good EMR
systems are available at all hospitals. EMR systems offer good
incentives to hospitals by eliminating the need to print paper
records, thus saving the costs of purchasing paper and prin-
ting. They can also help to reduce other administrative costs.
In Asia, there are many large hospitals with more than 1000
beds which also serve more than 10,000 outpatients each day.
Using paper medical records, the task of accurately retrieving
10,000 medical records, distributing them to each doctor, col-
lecting them afterwards, and putting them back in the storage
room, takes a huge amount of manpower. The implemen-
tation of EMR systems can save a lot of labor. According to
the experience in Taiwan, hospitals have a strong incentive to
introduce an EMR system because it is a highly cost effective
investment.
It is more difficult to encourage hospitals to participate in
an EMR exchange than to implement an EMR system, because
sharing medical records with other hospitals or clinics does
not produce a financial incentive [27,28]. Since Taiwan uses
a single-payer system, 90% of the revenue of most hospitals
comes from health insurance payments. Hospital accredita-
tion classifies hospitals into three classes, and the amount
of health insurance payments varies between the classes.
Through the accreditation and health insurance payments,
the government is able to demand that hospitals take steps
to improve the quality of medical care and patient safety. In
order to encourage hospitals to share medical records through
the EMR exchange system, at the early stage, the government
used the subsidy approach by providing direct subsidies to par-
ticipating hospitals. However, in order to ensure the ongoing
operation of inter-institution EMR exchange, the government
must have regulatory powers over the hospitals backed by laws
and institutions. The implementation of inter-institution EMR
exchange can only be successfully accomplished by properly
exercising the ‘carrot and stick approach’.
6. Availability of software
The ‘EMR Exchange Gateway (EEC GW)’ software can be down-
loaded free from the EEC’s website (http://eec.mohw.gov.tw)
and installed on computers owned by medical institutions.
Most regular personal desktop computers (PCs) are sufficient
to meet the hardware requirements. After installing the EEC
GW software, the hospital can go to the EEC’s website to apply
for the interfacing process. The system only operates on an
NHI VPN.
7. Future plans
After the implementation of the inter-institution EMR
exchange is complete, the Ministry of Health and Welfare will
start to promote Personal Health Records (PHRs) and various
19
other value-added applications such as developing a self-
managed health management app based on the PHR [29]. A
PHR will be integrated with an EMR and data from tele-health
services in order to satisfy the 4P characteristics (preventive,
predictive, participatory, and personalized) of the next gener-
ation of medical care service [30,31].
Conflict of interests
The authors declare that there is no conflict of interests
regarding the publication of this article.
references
[1] B. Kijsanayotin, N. Kasitipradith, S. Pannarunothai, eHealth
in Thailand: the current status, Stud. Health Technol.
Inform. 160 (Pt 1) (2010) 376–380.
[2] T. Lewis, C. Synowiec, G. Lagomarsino, J. Schweitzer,
E-health in low- and middle-income countries: findings
from the Center for Health Market Innovations, Bull. World
Health Organ. 90 (5) (2012) 332–340.
[3] Resolution WHA58.28, eHealth, in: Fifty-eighth World Health
Assembly. Resolutions and Decisions, Geneva, 16–25 May
2005, World Health Organization, Geneva, 2005, Available
from: http://apps.who.int/iris/bitstream/10665/20378/1/
WHA58 28-en.pdf [accessed 7.03.12].
[4] E. Coiera, Building a National Health IT System from the
middle out, J. Am. Med. Inform. Assoc. 16 (3) (2009) 271–273.
[5] Z. Morrison, A. Robertson, K. Cresswell, S. Crowe, A. Sheikh,
Understanding contrasting approaches to nationwide
implementations of electronic health record systems:
England, the USA and Australia, J. Healthc. Eng. 2 (1) (2011)
25–42.
[6] A. Robertson, K. Cresswell, A. Takian, D. Petrakaki, S. Crowe,
T. Cornford, et al., Implementation and adoption of
nationwide electronic health records in secondary care in
England: qualitative analysis of interim results from a
prospective national evaluation, BMJ 341 (2010) c4564.
[7] T.D. Gunter, N.P. Terry, The emergence of national electronic
health record architectures in the United States and
Australia: models, costs, and questions, J. Med. Internet Res.
7 (January–March (1)) (2005) e3.
[8] A.K. Jha, D. Doolan, D. Grandt, T. Scott, D.W. Bates, The use
of health information technology in seven nations, Int. J.
Med. Inform. 77 (December (12)) (2008) 848–854.
[9] M.H. Hsu, T.B. Chu, J.C. Yen, W.T. Chiu, G.C. Yeh, T.J. Chen,
et al., Development and implementation of a national
telehealth project for long-term care: a preliminary study,
Comput. Methods Programs Biomed. 97 (3) (2010) 286–292.
[10] K. Hayrinen, K. Saranto, P. Nykanen, Definition, structure,
content, use and impacts of electronic health records: a
review of the research literature, Int. J. Med. Inform. 77 (5)
(2008) 291–304.
[11] D. Blumenthal, M. Tavenner, The meaningful use regulation
for electronic health records, N. Engl. J. Med. 363 (6) (2010)
501–504.
[12] K. Davis, A.T. Huang, Learning from Taiwan: experience with
universal health insurance, Adv. Intern. Med. 148 (4) (2008)
313–314.
[13] U.E. Reinhardt, Humbled in Taiwan, BMJ 336 (7635) (2008) 72.
[14] J.F. Lu, W.C. Hsiao, Does universal health insurance make
health care unaffordable? Lessons from Taiwan, Health Aff.
(Millwood) 22 (May–June (3)) (2003) 77–88.
20 c o m p u t e r m e t h o d s a n d p r o g r a m s i n b i o m e d i c i n e 1 2 1 ( 2 0 1 5 ) 14–20
[15] Y.T. Yeh, M.H. Hsu, C.Y. Chen, Y.S. Lo, C.T. Liu, Detection of
potential drug-drug interactions for outpatients across
hospitals, Int. J. Environ. Res. Public Health 11 (2) (2014)
1369–1383.
[16] M.H. Hsu, J.C. Yen, W.T. Chiu, S.L. Tsai, C.T. Liu, Y.C. Li, Using
health smart cards to check drug allergy history: the
perspective from Taiwan’s experiences, J. Med. Syst. 35 (4)
(2011) 555–558.
[17] P.P. Gunn, A.M. Fremont, M. Bottrell, L.R. Shugarman, J.
Galegher, T. Bikson, The Health Insurance Portability and
Accountability Act Privacy Rule: a practical guide for
researchers, Med. Care 42 (4) (2004) 321–327.
[18] C.M1 Yang, H.C. Lin, P. Chang, W.S. Jian, Taiwan’s perspective
on electronic medical records’ security and privacy
protection: lessons learned from HIPAA, Comput. Methods
Programs Biomed. 82 (3) (2006) 277–282.
[19] L. Pettit, Understanding, EMRAM and how it can be used by
policy-makers, hospital CIOs and their IT teams, World
Hosp. Health Serv. 49 (3) (2013) 7–9.
[20] Y.C. Yu, T.W. Hou, T.C. Chiang, Dual function seal: visualized
digital signature for electronic medical record systems, J.
Med. Syst. 36 (October (5)) (2012) 3115–3121.
[21] T.L. Chen, F.Y. Lin, Electronic medical archives: a different
approach to applying re-signing mechanisms to digital
signatures, J. Med. Syst. 35 (4) (2011) 735–742.
[22] W.S. Jian, C.Y. Hsu, T.H. Hao, H.C. Wen, M.H. Hsu, Y.C. Li,
et al., Building a portable data and information
interoperability infrastructure-framework for a standard
Taiwan Electronic Medical Record Template, Comput.
Methods Programs Biomed. 88 (2) (2007) 102–111.
[23] U. Iqbal, C.H. Ho, Y.C. Li, P.A. Nguyen, W.S. Jian, H.C. Wen,
The relationship between usage intention and adoption of
electronic health records at primary care clinics, Comput.
Methods Programs Biomed. 112 (December (3)) (2013)
731–737.
[24] R.H. Dolin, L. Alschuler, S. Boyer, C. Beebe, F.M. Behlen, P.V.
Biron, et al., HL7 clinical document architecture, release 2, J.
Am. Med. Inform. Assoc. 13 (1) (2006) 30–39.
[25] G. Duftschmid, C. Rinner, M. Kohler, G. Huebner-Bloder, S.
Saboor, E. Ammenwerth, The EHR-ARCHE project: satisfying
clinical information needs in a Shared Electronic Health
Record system based on IHE XDS and Archetypes, Int. J. Med.
Inform. 82 (December (12)) (2013) 1195–1207.
[26] M.L. Kiah, A. Haiqi, B.B. Zaidan, A.A. Zaidan, Open source
EMR software: profiling, insights and hands-on analysis,
Comput. Methods Programs Biomed. 117 (2) (2014) 360–382.
[27] C. Saunders, R.E. Scott, Applying change management
metaphors to a national e-Health strategy, Stud. Health
Technol. Inform. 206 (2014) 62–69.
[28] J.M. Grossman, T.S. Bodenheimer, K. McKenzie,
Hospital-physician portals: the role of competition in
driving clinical data exchange, Health Aff. (Millwood) 25 (6)
(2006) 1629–1636.
[29] W.S. Jian, S. Syed-Abdul, S.P. Sood, P. Lee, M.H. Hsu, Y.C. Li,
et al., Factors influencing consumer adoption of USB-based
Personal Health Records in Taiwan, BMC Health Serv. Res. 12
(2012) 277.
[30] E. Younesi, M. Hofmann-Apitius, From integrative disease
modeling to predictive, preventive, personalized and
participatory (P4) medicine, EPMA J. 4 (1) (2013) 23.
[31] C. Pearce, M. Bainbridge, A personally controlled electronic
health record for Australia, J. Am. Med. Inform. Assoc. 21
(July–August (4)) (2014) 707–713.