Archive for April 2011

Cultural Typology VII: Sense of belonging to a professional class (guild member), and medical specialty

April 27, 2011

As I expressed in my post of February 11, 2011, About the Culture of Medicine & Physicians, physicians have constructed a corporative collectivity, the medical profession, more or less admired or chastised, but always cohesive in its control of their profession and trade. The profession claims to be the most reliable authority on the nature of the reality it facesIn other words, the ailments brought by the patients, and they are the ultimate judge of their practice and conduct. One must not forget that the physician is the preeminent practitioner of medicine, and represents it par excellence. Perhaps anecdotally, physicians are sometimes characterized as “knowledge expert physicians,” or medicine expert, vs. “manual dexterity expert physicians”, or surgeons, but this needs to be further explored. In summary, and as it has been expressed earlier, physicians have historically relied on their professional peers as their primary source of information related to new technologies.

In relation to this sense of belonging to a professional class, particularly specific work in this respect is the work of Ford and Menachemi in Florida.[1] They argue that, collectively, the medical community’s social mechanisms that influence adoption decisions view EHRs as a potential threat to professional autonomy. This may be particularly true among physicians in small practices that value the freedom and autonomy these provide. Lee also argued that EHRs are not an appealing technology since it does not add to their social approval. [2] Menachemi, et al, found that physicians caring for children in Florida (Child Health Providers-CHP), and especially pediatricians, were significantly slower than other doctors to adopt EHRs as well as other important electronic patient safety functionalities into their office practices.[3]However, collectively, CHP did not differ from other physicians in Florida with respect to the use of many IT applications. On the other hand, specifically general pediatricians were significantly less likely than other CHPs and other physicians to indicate personally and routinely using an EHR system in their practice. A possible explanation given by Menachemi, et al, was that general pediatricians have the lowest median incomes of all physicians and they may not be able to overcome many of the financial burdens necessary to adopt EHR. Menachemi asserts that no previous study has specifically examined a broad group of CHPs, and the results of the current study may serve as a benchmark for those interested in charting the progress over time that pediatricians and other CHPs are making toward the widespread adoption of EHRs.

Menachemi, et al, recommend some key policy actions to address this lack of use of EHRs by CHPs:

  1. Advocacy for an increase in the proportion of federal resources dedicated to EHR adoption that is child specific.
  2. Increased representation by child health experts in national IT and IT standards organizations;
  3. Increased attention by vendors to building pediatric specific functionalities into their products, such as weight-based dosing and growth charting; and
  4. Increased involvement by practicing child health providers in on-going efforts to reward the use of clinical IT in pay-for-performance programs and to design ways to overcome the non-financial barriers as well.

From a cultural perspective, on the other hand, in order to address the guild cultural element implied in the profession as a close-knit social network, Ford and Menachemi’s recommendation of using internal influences (e.g. social contagions) appear to be more powerful for accelerating the diffusion of EHRs. They recommend an interactive educational strategy that would be likely to be most influential in penetrating physicians’ social networks, particularly those in small practices. The first, and more basic, is medical education. Ford and Menachemi assert that many medical schools and residency programs do not currently employ or train future physicians in the use of EHRs. They also assert that training the future medical workforce to rely on EHRs and their decision-support tools can only serve to accelerate universal EHR adoption. Furthermore, the acculturating of medical students and residents to EHRs during this formative period signals that the profession values EHRs.

The second potential channel for influencing physicians’ social networks is through the continuing medical education (CME) requirement. However, they explain, CME interventions have not proven to be particularly effective in changing providers’ behaviors in other clinical areas.

The third active educational mechanism recommended by Ford and Menachemi for accessing physicians’ social networks is academic detailing that involves in-depth, one-on-one training sessions with physicians and is an effective mechanism for altering physicians’ behaviors. Ford and Menachemi argue that, collectively, the interactive educational approaches hold the greatest power to hasten universal EHR adoption, but they also carry the highest price tag and require major coordination efforts to implement. Addressing the physicians’ social networks to use the social contagion influence is not a “bullet proof” strategy either. Simon, et al, found that fewer than one in five physicians in their study reported that the state medical society or specialty organizations played a role in their decision of adopting EHRs. Perhaps this reflects a sort of “passive aggressively” by these medical societies, who legitimately, represent the financial interest of the guild that feels particularly threatened by the loss of autonomy of physicians that the EHRs impose.

On the other hand, in relation to educational activities these have usually been delivered through the traditional physicians specialty groups. To this general rule there are exceptions. For example, the Clinical Directors Network, Inc. (CDN), based in New York and founded in 1985, deserves special attention. CDN was founded as a professional peer organization based on the demonstrated effectiveness of peer-initiated activities in promoting health care excellence, assuring and improving quality, and containing costs.[4] CDN operates by and for an extensive network or Community/Migrant Health Center (C/MHC) Clinical Leaders, not only physicians, in most of the states of the east coast, including Puerto Rico and U.S. Virgin Islands. Clinical directors in C/MHCs are clinicians who, usually by personal decision, accept the role of organizing and directing the clinical operation of a primary care center and are committed to make it work for the benefit of the patient. CDN offers its members access to peers who collect and share information, skills, and technical assistance. Within their communities, members introduce the latest developments in clinical and health services education, including Continuous Quality Improvement, re-engineering, managed care, practice-based research and electronic tools. CDN is the only practice-based research network in the country devoted to providing primary care research opportunities to medically underserved populations. With an extensive history in translation of clinical research into clinical practice this clinical network is a perfect example of the use of internal or social contagion factors that influence adoption decisions led by clinical directors. For example, their eClinician Project, a modest yet effective program provides free customized PDAs with clinical decision-support software to primary care clinicians working in New York City (NYC) Community Health Centers. A critical element of the project includes onsite and online training through Webcast Library to train clinicians on how to use electronic clinical decision-support tools. In addition, ongoing follow-up, new programs, e-health tools, and health alerts will be available to clinicians from the NYC Department of Health and Mental Hygiene Health Access Network.

This basic strategy of providing access to basic electronic tools and clinical decision tools, rewarding physicians for using computers to communicate with specialists and patients, and providing funding to help extend high-speed Internet access to doctors who do not have it, would be far more effective in facilitating physicians to adopt HIT than trying to “force physicians” to adopt full functional EHRs through external influences as might be the introduction of clinical reporting mandates.[5]

In relation to HIT as an industry, I would argue a most important working group is the Health Information and Management Systems Society’s (HIMSS) Physician Community (HPC). HPC was formed by the HIMSS and the Association of Medical Directors of Information Systems (AMDIS) to articulate a cohesive voice for HIMSS physicians and to provide leadership, guidance and domain expertise to HIMSS activities, industry initiatives, and collaborations with physician societies across the country.[6] The alliance between HIMSS and AMDIS formalizes all efforts with an enhanced and focused strategy for physicians engaged in HIT and management systems. HIMSS is the healthcare industry’s membership organization exclusively focused on providing leadership for the optimal use of healthcare IT and management systems for the betterment of healthcare with immense capacity to support their mission across the world. AMDIS, on the other hand, founded in 1997, is the premier professional organization for physicians interested in and responsible for healthcare information technology.[7 AMDIS Members are the thought leaders, decision makers and opinion influencers dedicated to advance the field of Applied Medical Informatics and thereby improve the practice of medicine.

Another key organization that is leading efforts in helping train clinicians and defining core competencies to develop physician medical informaticians, the American Medical Informatics Association (AMIA). As the professional home for biomedical and health informatics, AMIA is dedicated to promoting the effective organization, analysis, management, and use of information in health care in support of patient care, public health, teaching, research, administration, and related policy is a natural broker to engage as co-equal partners and collaborators physicians and healthcare practitioners in general, and other health/biomedical informatics and other relevant disciplines in an ongoing relationship to understand and solve problems of importance to health care.[8]

In relation to education and early adopters and the concept of social contagion, Geyer, in an expert opinion, presents another interesting strategy, that upon recruiting early adopters of technology to facilitate the adoption on HIT by physicians, nurses need to be trained first because they train MDs while assisting them during care duties.[9] In primary health care clinics that serve HIV/AIDS affected individuals, in multiple and diverse locations in the U.S., nurses play a critical role as early adopters of EHRs and facilitate that physicians appreciate and learn to use it most appropriately. This would be another internal influence to tap into.

[1] Ford, EW.,  Menachemi, N., Phillips, T., Predicting the Adoption of Electronic Health Records by Physicians: When Will Health Care be Paperless? J Am Med Inform Assoc. 2006;13:106–112.

[2] Lee, FW. Adoption of Electronic Medical Records as a Technology Innovation for Ambulatory Care at the Medical University of South Carolina. Contemporary Issues in Health Information Management. August 2000;21(1):pp 1-20

[3] Menachemi. N., L Ettel, DL., Brooks, RG., Simpson, L., Charting the use of electronic health records and other information technologies among child health providers. BMC Pediatrics 2006, 6:21

[4] Clinical Directors Network Web site, Accessed on January 6, 2009

[5] iHealthBeat. Experts Warn Against Large Investment in Existing HER Systems. January 5, 2009. California Health Care Foundation web site Accessed on January 6, 2009

[6] HIMSS website. Accessed on December 1, 2008

[7] AMDIS website. Accessed on December 1, 2008

[8] AMIA website. Accessed on December 1, 2008

[9] Geyer, S., Physicians: The Key to IT Success. Trustee; Feb 2004; 57, 2;

Cultural Typology VI: Provision of Quality Services

April 23, 2011

The IOM report “Crossing the Quality Chasm” was a call for action to improve the American health care delivery system as a whole, in all its quality dimensions, for all Americans.[1]  According to the report, what is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns, or toward applying advances in information technology to improve administrative and clinical processes.

Although conventional wisdom would indicate that EHRs should help improve quality in health care, this has yet to be proved. Diamond and Shirky (2008) assert that the challenge of thinking of health IT as a tool to improve quality requires serious attention to transforming the U.S. health care system as a whole, rather than simply computerizing the current setup.[2]  Computers, they say, are only amplifiers, and if an inefficient system is computerized, it will simply make it inefficient faster. The NRC Report even expresses that current implementations of health care IT do not take advantage of human-computer interaction principles, leading to poor designs that can increase the chance of error, add rather than reduce work, and compound the frustrations of executing required tasks.[3] As a result, the report explains, they can introduce new forms of error that are difficult to detect. Along these lines the IOM’s report, “To Err is Human: Building a Safer Health System,” explains that automation makes the system “opaque” to people who manage, maintain, and operate these, therefore, contributing to the accumulation of latent errors that could lead to unsuspected system failures.[4]

Likourezos, et al, surveying Emergency Medicine (EM) physicians and nurses at a large urban teaching hospital found that clinicians positively perceive the EMR as helpful in their daily work.  Despite reported potential benefits to the work environment and patient care, the clinicians in this study perceived the EMR to currently have minimal impact upon patient care.  Both physicians and nurses reported their beliefs that the EMR will not yet improve the quality of care, will not reduce costs, will not decrease waiting times, will not lessen the number of laboratory tests, will not reduce the number of emergency department (ED) visits, and will not attenuate ED overcrowding.  They also expressed fears about security, privacy, and confidentiality issues. On the other hand, Hackbarth and Milgate (2005) assert that the market does not reward quality improvement, one of the primary reasons for investing in the technology.[5] Furthermore, they state that the cost savings for better quality often accrue to the insurer, not the physician practice. For example, if better preventive care leads to fewer hospitalizations, it is the payer that reaps the benefits.

DoBias, (2006) in a joint project between the Robert Wood Johnson Foundation and the federal government’s health information technology office, entitled “Health Information Technology in the United States: The Information Base for Progress”, cited experts declaring that for doctors, EHR adoption “is not a financial play for them right now.  Most docs who do it say they do it because it’s the right thing to do.  We know that the patient gets most of the benefit, the health plans get the rest, and the doctor is the one who has to pay for it.” [6] All this only nurtures the cynicism with which EHRs are seen by many physicians while, as Ford (2006) asserts, the physician community does not, in general, have a strong grasp of the quality improvement processes that are being targeted at them.[7]

In order to address this cultural factor, Miller declares that quality performance incentives and support can, over time; help transform many physicians from inefficient, low-level EMR users to efficient, advanced users thereby increasing the likelihood of generating quality and financial benefits.[8],[9] However, for this to happen, as Miller discusses, we would have to work on at least three areas:

a) Increase communitywide data exchange: This would mean ubiquitous, secure electronic exchange of clinical data among providers that would help lessen the disruption from parallel electronic and paper-based medical record systems, and that would also allow clinicians to view all of their patients’ data, regardless of provider and care site. Miller expresses that a prime beneficiary of these initiatives will be solo/small-group practices that otherwise lack the leverage and resources to establish ubiquitous data exchange.

b) Provide financial payback to practices for achieving quality improvement through the use of full-fledged EMR or, alternatively, programs may selectively promote particular IT capabilities for quality improvement.

Miller warns about the correct use of financial incentives avoiding mandating programs that micro-manage how clinical care must occur and/or setting arbitrary short deadlines for full EMR use. Ford (2006) also warns that despite positive incentives, some physicians see pay-for-performance programs as a third-party attempt to overly influence medical practice, decrease costs, and increase profits for payers.[10]

Miller also asserts that Government or other funders may not need to directly subsidize the cost of acquiring EMR since, in their study, most practices could secure capital for purchasing the technology. As the Center for Studying Health System Change has found out, the recent federal regulatory changes geared to facilitate hospitals help physicians financially to acquire EHRs, at least initially, appear to have had a modest impact in encouraging hospitals to support physician adoption of EHRs.[11],[12] On the other hand, vendors already have strong market incentives for developing easy-to-use EMR, while physicians’ attitudes toward health IT and the EMR are already on a favorable trajectory with increasing use of personal digital assistants (PDAs) and the Internet by physicians. Miller believes that policy funds could be better used for rewarding quality improvement, for example, rather than for replacing available capital.

Hackbarth goes further asserting that additional quality payments could help shift the return on investment (ROI) calculations that practices must make when deciding whether to invest in IT. In addition to improving the ROI, he explains, focusing on quality objectives provides guidance to physicians and vendors about how the IT systems should be designed and used and ensures that Medicare achieves the desired policy intent. On the other hand, Hackbarth argues, although cost savings may result from physicians’ adoption of IT, it would be problematic to base policies on assumptions that those savings would be realized given the sizable barriers to effective implementation and use of IT. Hackbarth believes that these incentives for IT adoption should be funded without further increases in Medicare expenditures.

Ford explains that in other mature health care systems where various forms of EHRs have been widely adopted, such as Australia and Western Europe, there have been significant governmental efforts to partner with physicians or subsidize the cost of the new technology, respectively. On the other hand, the policy mechanism most commonly discussed for increasing EHRs in the U.S. is through external influences like the introduction of clinical reporting mandates. As Ford explains, while such programs may be of some use, they may not advance the goal of full EHR adoption significantly, because U.S. providers tend to respond negatively to such mandated-use policies, particularly in comparison to their international counterparts.

c) Support for complementary changes in physician practices, especially solo/small-group practices that require support to carry out the time-consuming workflow and other complementary changes needed to generate financial and quality benefits from “out-of-the-box” EHRs.


[1] National Academy of Sciences. Crossing the Quality Chasm: A New Health System for the 21st Century. Executive summary downloaded from on December 1, 2008

[2] Diamond, CC., Shirky, C. Health Information Technology: A Few Years of Magical Thinking? Technology and standards alone will not lead to health IT adoption, let alone transform health care. Health Affairs 27, no. 5, 2008:w383–w390

[3] Committee on Engaging the Computer Science Research Community in Health Care Informatics; National Research Council. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. Willam W. Stead and Herbert S. Lin, editors. National Academies of Sciences web site. ;

[4] The National Academy of Sciences. To Err Is Human: Building a Safer Health System. 2000. The Nat’l Acad. of Sciences Web site Accessed on Dec 11, 2009

[5] Hackbarth, G., Milgate, K. Using Quality Incentives To Drive Physician Adoption Of Health Information Technology. Health Affairs;24(5):1147-1149

[6] DoBias, M., EHR adoption `pitifully behind’; Study: Only 10% of physicians use IT to its fullest. Modern Healthcare, October 16, 2006:8

[7] Ford, EW.,  Menachemi, N., Phillips, T., Predicting the Adoption of Electronic Health Records by Physicians: When Will Health Care be Paperless? J Am Med Inform Assoc. 2006;13:106–112.

[8] Margalit, RS., Roter, D., Dunevant, MA., Larson, S., Reis, S.,

Electronic medical record use and physician–patient communication: An observational study of Israeli primary care encounters. Patient Education and Counseling. Elsevier 2006;61:134–141

[9] Hackbarth, G., Milgate, K. Using Quality Incentives To Drive Physician Adoption Of Health Information Technology. Health Affairs;24(5):1147-1149

[10] Ford, EW.,  Menachemi, N., Phillips, T., Predicting the Adoption of Electronic Health Records by Physicians: When Will Health Care be Paperless? J Am Med Inform Assoc. 2006;13:106–112.

[11] Department of Health and Human Services, “The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care: A Framework for Strategic Action” (Washington, D.C.: July 21, 2004).

[12] Grossman, JM., Cohen, G. Issue Brief, Findings from HSC. No 123. September 2008 Center for Studying Health System Change.

Cultural Typology V: Personal Relationship with the Patient; an Ethical Conundrum?

April 22, 2011

The personal relationship between the patient and the physician is the essence of medicine, an ethical relationship based on trust. One could argue that the EHR could challenge privacy and confidentiality, core values of the physician/patient relationship.(1,2) In particular, Rosenthal describes the perception of the physicians that the EHRs are an intrusion into the practitioner-patient relationship.(3) This has also been the case in Israel, an almost fully immersed EMR environment, where physicians use computers in the examination room and report that it can negatively affect patient centered practice. The computer became a “third party” in the clinical encounter requiring particular attention and diminishing the dialogue with the patient, particularly in the psychosocial and emotional realm.(4) In a hospital in Oman, physicians were generally satisfied with EMR, but most of them believed the system did not protect confidentiality because other physicians and nurses could access all clinical notes about patients and the physician could alter what they documented in some sections of the clinical data because it is not protected.(5)

Safeguarding the privacy and confidentiality of patients within the new IT environment, a tremendously volatile environment, poses many problems that are far from being clear, much less resolved.(6) On the one hand, as patients become tech-savvy, they will demand that their physician use current IT options.(7) On the other hand, Lupton would argue that this expectation must be seen within other conflicting expectations; first, frequently physicians are forced to deal with patients’ expectations of their “omnipotence.” Secondly, the physician often does not want to share the uncertainty of their treatment. Last, but critically important, are the demands from hospitals and payers to deal with the patient quickly and efficiently.(8)

To add complexity, the traditional paper chart in the physician’s office allows the physician to maintain certain anonymity, certain invisibility, in terms of what is his/her rationale for the treatment of a patient. The perception by the physician of a possible “oversight” by many others accessing an electronic version of “his” patient’s medical record is a powerful disincentive to the adoption of the EHRs. In addition, one aspect that has was not found addressed in the literature reviewed is that it also challenges the basis of medicine as a trade in which the value of a practice is determined in terms of the number of patient charts (confidential information the physician has of his/her panel of patients) kept in the not-so-easy-to-read paper chart, and locked in a private record room.

In order to address this cultural element, revisiting and, perhaps, redefining the social contract that throughout history society has developed with physicians seem most appropriate at this historical juncture. The EHRs is only pinpointing, like never before, the difficult issue of providing access to the patient of his/her medical information, arguably his/her property.


1. Mackenzie, K., The Key to PHR Success isn’t What You Think. HealthLeaders Media Website. November 4, 2008. Accessed on November 9, 2008.

2. Simon, SR., Kaushal, R., Cleary, PD., et al. Correlates of Electronic Health Record Adoption in Office Practices: A Statewide Survey. J Am Med Inform Assoc. 2007;14:110 –117.

3. Rosenthal, DA., Layman, EJ.,  Utilization of Information Technology in Eastern North Carolina Physician Practices: Determining the Existence of a Digital Divide.  Perspectives in Health Information Management 5; 3; Winter 2008 pp.  1-20

4. Margalit, RS., Roter, D., Dunevant, MA., Larson, S., Reis, S., Electronic medical record use and physician–patient communication: An observational study of Israeli primary care encounters. Patient Education and Counseling. Elsevier 2006;61:134–141

5. Farsi, MA., West Jr, DJ., Use of Electronic Medical Records in Oman and Physician Satisfaction. J Med Sys; 2006, 30(1): 17–22

6. GAO, Health Information Technology; Efforts Continue but Comprehensive Privacy Approach Needed for National Strategy. Tuesday, June 19, 2007. Downloaded on December 18, 2008

7. Randeree, E., Exploring Physician Adoption of EMRs: A Multi-Case Analysis. J Med Syst. 2007, 31:489–496

8. Lupton, D. Medicine as Culture. Sage, 2nd ed., 2003

Cultural Typology IV: Physicians’ resistance

April 21, 2011

A strong sense of autonomy, can also be projected, and/or interpreted, as “resistance to change”.  Physician resistance is a “cultural element” that recurs throughout the literature as either physicians’ resistance to EHRs or change per se.[1] However, if as Lee argued that physicians are resistant to the social change that will result from the EMR, and as Anderson argued that although physicians support computer applications that enhance their ability to manage medical information they tend to view with ambivalence computer applications that affect their role as medical decision makers; it seems physicians have much reason if one also considers Campbell’s identified adverse consequences of HIT: [2], [3],[4],[5]

a) There will be more/new work for clinicians;

b) Unfavorable workflow issues develop as rigidly modeling work processes according to the “letter of the law”, and organizational policies and procedures are implemented that dramatically highlight mismatches between intended and actual work processes in real-world settings;

c) There will be “never-ending system demands” with the new hardware and software implementation tasks, and maintenance issues;

d) The paper persistence will be a real issue. Interestingly, in the Sultanate of Oman in the Arabian Peninsula, the persistence of paper provoked poor utilization of the system mainly during physician rounds because some physicians used both the paper and also the EMR. They worked double keeping notes that were transferred at a later time into the EMR system.[6]

e) There will untoward changes in communication patterns and practices;

f) Negative emotions will be a disturbing important issue that needs to be addressed promptly;

g) HIT is no panacea and new kinds of errors will be generated;

h) There will certainly occur unexpected changes in the power structure. This issue will require special attention because while at the same time one is monitoring clinician’s behaviors, this may induce changes in the power structure and culture of the organization. This is especially problematic in health care, as Campbell assertively expresses, where lines of authority emanate from traditional educational hierarchies, differences between general practitioners and specialists, and among others other differential factors. It is also true that traditionally, physicians report loss of professional autonomy when computerized systems prevent them from ordering the types of tests or medications they prefer, or force them to comply with clinical guidelines they may not embrace, or when these limit their narrative flexibility through structured rather than free-text clinical documentation.

i) Finally, the over-dependence on the technology poses its own challenges; As HIT diffuses and becomes entrenched within organizations, clinical care delivery becomes inextricably dependent upon it.

There is no magic bullet to address physician resistance other than to learn and implement good strategies to manage change. On the other hand, because of the physician’s preeminence in the health care system, their resistance is more evident, voiced more prominently, and is certainly more critical than that of other members of the health care team.  It is important to remember that the IOM study of patient records concluded that the majority of barriers to the implementation of EMR systems are behavioral and organizational rather than technical. Wears and Berg (2005) also remind us that roughly 75% of all large IT projects in health care fail basically due to inattention to the problems associated with the introduction of computer technology into complex work environments. One would have to remember that health care is probably the most complex enterprise of modern society.[7]  Harrison, et al, (2007) in a viewpoint paper, argue that many unintended and undesired consequences of HIT flow from interactions between the HIT and the health care organizations’ socio-technical system, its workflow, culture, social interactions and technologies.[8]  They assert that these socio-technical interactions have been richly documented in the literature but that, unfortunately, many IT users and even IT specialists are unfamiliar with it or its practical implications.


[1] Randeree, E., Exploring Physician Adoption of EMRs: A Multi-Case Analysis. J Med Syst. 2007, 31:489–496

[2] Lee, FW. Adoption of Electronic Medical Records as a Technology Innovation for Ambulatory Care at the Medical University of South Carolina. Contemporary Issues in Health Information Management. August 2000;21(1):pp 1-20

[3] Anderson, J.G. “Computer-based Patient Records and Changing Physicians’ Practice Patterns.” Topics in Health Information Management 15, no. 1 (1994): 10-23.

[4] Anderson, J.G., et al. “Why Doctors Don’t Use Computers: Some Empirical Findings.” Journal of the Royal Society of Medicine 79, no. 3 (1986): 142-144.

[5] Campbell, EM., Sittig, DF., Ash, JS., Guappone, KP., Dykstra, RH. Types of Unintended Consequences Related to Computerized Provider Order Entry. JAMIA. 2006;13(5):547-556

[6] Mohammed Al Farsi · Daniel J.West Jr. Use of Electronic Medical Records in Oman and Physician. Satisfaction J Med Sys (2006) 30(1): 17–22

[7] Wears, RL., Berg, M. Computer Technology and Clinical Work; Still Waiting for Godot. JAMA, 2005, 293(10): 1261-1263

[8] Harrison, MI., Koppel, R., Bar-Lev, S. Unintended Consequences of Information Technologies in Health Care – An Interactive Sociotechnical Analysis. JAMIA. 2007;14(5):542-549