1. HOW THE USE OF INTEGRATED HEALTH INFORMATION TECHNOLOGY
EFFECTS THE PATIENT-PROVIDER RELATIONSHIP
By
Timothy E. Greiner
A Capstone Project Submitted to the Faculty of
Utica College
May 2015
in Partial Fulfillment of the Requirements for the Degree of
Master of Science in
Cybersecurity

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© Copyright 2015 by Timothy E. Greiner
All Rights Reserved

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Abstract
The purpose of this research was to examine how the uses of integrated health technologies have
affected the relationship between the patient and the provider. The relationship between the
patient and the provider has to continue to adapt and change due to the introduction of electronic
health records (EHRs), mobile health devices, and mobile device apps. With the passage of the
American Recovery and Reinvestment Act (ARRA) Health Information Technology for
Economic and Clinical Health Act (HITECH Act), health information technology (health IT) has
increased at a rapid rate. Health technology will also be changing the way in which patients and
providers interact. Through the use of mobile medical apps and mobile medical devices, patients
and other users can proactively self-manage their own health. Interoperability of mobile medical
apps, mobile medical devices, and EHRs will need to be achieved in the future as these
technologies become more integrated into the health care setting. When looking at the
implementation and management of health technologies, such as in Canada, it can help countries
observe plans and regulations that work successfully. This research has determined that proper
health IT regulations and future strategies will be key to a successful future of health IT.
Keywords, Professor Riddell, Cybersecurity Intelligence, health care, HITECH Act, electronic
health records.

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Table of Contents
List of Illustrative Materials.................................................................................................v
How the Use of Integrated Health Information Technology Effects the Patient-Provider
Relationship .........................................................................................................................1
Literature Review.................................................................................................................5
Electronic Health Records and Health IT ......................................................................5
Effects on patient-provider relationships ....................................................................8
Improvements of EHR.................................................................................................12
Improvements on patient-provider relationship........................................................12
Redesign Health IT Infrastructure................................................................................13
Health IT interoperability..........................................................................................13
Mobile Health Technologies........................................................................................15
Telemedicine.............................................................................................................16
Impact on rural healthcare.........................................................................................17
How health care providers use mobile devices and apps..........................................17
Use of mobile apps by patients and others................................................................19
Remote patient monitoring........................................................................................19
Management of Mobile Medical Apps ........................................................................21
Types of regulated apps ............................................................................................22
Types of non-regulated apps.....................................................................................22
Security of Mobile Health Care Devices .....................................................................23
HIPAA standards ......................................................................................................24
Canadian Health IT Implementation............................................................................26
Remote patient monitoring........................................................................................27
Improvements to EHR implementation ....................................................................28
Comparison of EHR Adoption.....................................................................................30
Mobile Health App Regulation....................................................................................33
Discussion of the Findings.................................................................................................35
Future Research and Recommendations............................................................................43
References………………………………………………………………………………..44

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List of Illustrative Materials
Figure 1 – How remote patient monitoring devices collect and transfer information…...18
Figure 2 - Predictions of mobile health apps used by doctors in 2015…………………..21
Figure 3 - Canadian report of interest in using digital health services if available...........27
Figure 4 – HIMSS Analytics EMR adoption comparison.................................................32

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How the Use of Integrated Health Information Technology
Effects the Patient-Provider Relationship
Over the past few years, the United States has seen a proliferation of information
technology (IT) and connected devices in society. As of January 2014, according to Pew
Research Center, 90 percent of American adults own a cell phone, 58 percent of American
adults have a smart phone, and 42 percent own a tablet (Pew Research Ceneter, 2014). This trend
is also reflective in the health care industry. The mobile health market is expected to increase by
61 percent to an estimated $26 billion by the end of 2017 (Crespo & McLaughlin, 2013). The
mobile health market refers to the use of mobile technologies, such as smartphones, tablets
computers, applications (apps), and other electronic devices, that are used for the purpose of
communication, providing, receiving, or managing health care (Ventola, 2014).
The increased use of mobile devices in health care has led to the rapid growth of medical
software apps. Mobile apps are software programs that are developed to run on mobile devices
such as tablets and smartphones (Ventola, 2014). Health care providers are able to use apps for
various purposes such as electronic prescribing of medications, diagnosis, medical treatment,
education and references, coding and billing (Murfin, 2013).
The way doctors use connected devices and mobile apps for patient care varies, but
Caradigm statistics show that 69 percent use mobile apps for protected health information (PHI)
of patients, 65 percent for non-PHI, 49 percent for education/training, 42 percent for clinical
notifications, and 39 percent for secure communications regarding patients (Rosin, 2014).
Smartphones and tablets have become the preferred computing devices for health care providers
who need fast access to information at the point of care (Ventola, 2014).

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The use of health information technology (health IT), including electronic health care
records (EHRs), has been increasing at a rapid rate. According to the report given to Congress
from the Department of Health and Human Services (HHS), 59 percent of hospitals and 48
percent of physicians had at least a basic EHR system in place in 2013 (HHS, 2014). The EHR
market in United States is forecasted a growth of 7.1 percent, growing $9.3 billion (Accenture,
2014). In 2009, prior to the adoption of the Health Information Technology for Economic and
Clinical Health Act (HITECH Act), only 12 percent of hospitals in the United States established
a basic EHR system (Office of the National Coordinator for Health Information Technology
(ONC), 2014, “Report to Congress,” para. 4).
The purpose of this research was to examine how integrated health technologies have
affected the relationship between the patient and provider in the health care sector. How have
mobile health technologies effected and changed the way in which a patient manages their
health? How has the relationship between the patient and provider transformed by the use
electronic health records and electronic health technologies? How does the Canada compare with
the United States on implementation and management of electronic health technologies?
While security and privacy are two major concerns when utilizing new information
technologies in health care, understanding how it will change the relationship between patients
and providers should also be a concern. How a patient interacted with their health care provider
for years has now been redefined with the introduction of integrated health technologies. A study
conducted 2013 by the Rand Corporation with support from the American Medical Association
(AMA) on physician satisfaction, suggest that health care providers are finding that EHRs are a
hassle and they take more time away from actually caring for the patients (Brink, 2014). While
other specialties will improve with health IT, there will be many specialties that may fade such

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as a patient-centered connection. Both patients and health care providers have concerns about the
adverse effects EHRs can have on the patient-provider relationship (Kazmi, 2013).
The relationship between the patient and the provider lies at the heart of health care
delivery. Maintaining and improving a strong relationship between the patient and provider is
important to the delivery of care (Kazmi, 2013). Communication skills have been shown to
influence patient satisfaction, which determines the effectiveness of health care delivery.
This is not the first time that new technology in health care has caused concern over
interference with patient-provider relationships. Physicians were concerned that the invention of
the stethoscope would depersonalize care in the 1700s and in the early 1900s doctors were
concerned that the sphygmomanometer would come between the patients and doctors (Bailey,
2011). However, the new technology being developed today will affect the relationship between
the patient and provider even further. EHRs must fit into the patient provider relationship, so the
focus can still be on the patient. According to ENT Today, a publication of the Triological
Society, one of the major ethical concerns about the adoption of EHR is the impact it will have
on the interaction and relationships between patients and providers (Kitsis & Shmerling, 2014).
The presence of a computer and other devices within the exam room can take away the focus
centered on the patient.
Mobile device management systems in health care IT have to be modified to attend to
these changes. In recent years doctors have been increasing their use of EHRs due to government
incentives, but they are also increasing their use of mobile technologies in health facilities.
Securing these devices and the data that they contain is a priority. Not only does this apply to
devices connected to health care networks but there are thousands of mobile device apps that
need to be regulated and managed. Patients and providers will take advantage of integrated

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technologies to improve health care communications, management of health care, health care
services and improve the accessibility of health information.
Internationally, the market for EHR is projected to reach $22.3 billion by the end of 2015.
In 2012 the global EHR market was $18.8 billion (USD) (Accenture, 2014). According to the
same data collected by Accenture, Canada’s EHR market is expected to grow 2.8 percent,
growing to $0.9 billion by the end of 2015, while the United States is forecasted a growth of 7.1
percent, growing $9.3 billion (Accenture, 2014). How does Canada compare with the United
States with the adoption and management techniques with health ITs and EHRs?
Since 2003 Canada Health Infoway published an EHR solutions blueprint. Canada Health
Infoway is a federally-funded organization that is working with the provinces’ government to
help develop, monitor, and enforce the use of information technology in Canada’s health care
system including all EHR, telehealth and telemedicine programs. Telehealth refers “to the use of
electronic information and telecommunications technologies to support long-distance clinical
health care, professional health-related education, public health, and health administration”
(Telehealth, n.d.).
As of October 2014, reported by Nuviun, Infoway has enrolled approximately 12,000
clinicians in jurisdictional EMR programs and 25,000 specialty health care provider clinics
across Canada (Enriquez, 2014). Canada Health Infoway launched other campaigns to ensure
that Canada’s health IT operates with as little complications as possible. The Better Health
Together campaign will highlight those patients who are benefiting from digital health programs
and services. Knowing is Better for Clinicians is an educational campaign that will demonstrate
the benefits of health IT systems and EHR among Canadian clinicians (Enriquez, 2014).

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The market for health IT is expected to grow in the coming years, so it is important to
understand how health IT will be effecting patients and providers. According to a research
published by Accenture, the projected annual growth of the EHR market in the United States of
2015 will increase 7.1 percent and total $9.3 billion (Accenture, 2014). By 2017 it has been
reported by mobile industry analysts at Research2Guidance that 1.7 billion people will have
downloaded health apps. Furthermore, 3.4 billion people will have a smartphone or tablet with
access to mobile health apps while 50 percent of those people will have downloaded mobile
health apps. (Comstock, 2013).
Literature Review
Electronic Health Records and Health IT
In 2009, the Health Information Technology for Economic and Clinical Health Act
(HITECH) was introduced as part of the American Recovery and Reinvestment Act (ARRA)
which is meant to encourage entities in health care to make better use of health IT and EHRs
(ONC, 2014, “Report to Congress”). Congress and President Barack Obama passed HITECH
and ARRA in order to accelerate health IT, by making this technology more efficient and less
prone to error. Health IT’s aim to achieve more efficiency in accessible health information,
improve quality health care given by physicians, increase organization/accuracy, and also
decrease medical errors.
The coordination and implementation of nationwide health IT efforts, is led by the Office
of the National Coordinator for Health Information Technology (ONC). ONC operates and
maintains HealthIT.gov to provide patients and providers on current issues related to health IT.
Although ONC was created in 2004, it was legislatively mandated with the passage of the
HITECH Act of 2009 (ONC, 2014, “About ONC,” para. 1). Located within the U.S. Department

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of Health and Human Services (HHS), both ONC and HHS have the responsibility of advancing
health IT.
Through ONC and HHS, they developed an interoperability roadmap to advance the uses
of health IT. Interoperability in health care describes “the ability of different information
technology systems and software applications to communicate, exchange data, and use the
information that has been exchanged.” (HIMSS.org, 2013) In order to transform health care
delivery to provide better care and in turn make people healthier, advancing health IT
interoperability is key.
In part of the HITECH act, the government allocated $19.2 billion to expand the use of
EHRs and other health care technologies (Berger, Muchanan, Rasouli, & Serafini, 2012). EHRs
are at the forefront of the health IT infrastructure. EHRs and other supporting health technologies
are intended for health care institutions to share medical data, exchange health information, and
access health information much easier.
Under the meaningful use act, the United States government has given financial
incentives to health care providers to use certified EHRs. For health care providers to receive
financial incentives from the Center for Medicare & Medicaid, they must show meaningful use
of EHRs through three stages. Providers must show that they are using certified EHR
technologies that can be measured significantly in quality (American Academy of Physical
Medicine and Rehabilitation [AAPM&R], 2015).
EHRs have begun to replace paper records in all sections of the health care. An EHR is a
comprehensive record of patient’s medical history. This includes but is not limited to contact
information, health care professional visits, insurance information, family history, information on
any diseases or conditions, medications, and records of surgeries or procedures performed. EHRs

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collect, store, and share a patient’s health information. To improve care, the health care industry
has followed the trend of the rest of society by becoming more technologically advanced.
According to a research published by Accenture, the projected annual growth of the EHR market
in the United States of 2015 will increase 7.1 percent and total $9.3 billion (Accenture, 2014).
Significant progress and advancement has been made over the past few years at making
health care delivery system digital. According to the ONC, over one-half of office-based
professionals and more that 80 percent of hospitals are meaningfully using EHRs (ONC, 2014).
The HHS also reported that all 50 states have some sort of health information exchange services
available to support care and half of hospitals are able to electronically search for patient
information from sources beyond their organization or health system (HHS, 2014).
According to the report given to Congress from the Department of Health and Human
Services, 59 percent of hospitals and 48 percent of physicians had at least a basic EHR system in
place in 2013. In 2009, prior to the adoption of the HITECH Act, only 12 percent of hospitals in
the United States established a basic EHR system. There have also been an increased number of
health care providers who have received incentive payments for meaningful use of EHR systems.
As of June 2014, 92 percent of eligible hospitals and 75 percent of eligible professionals received
incentive payments (ONC, 2014).
In today’s health care environment, there are a number of health care providers (e.g.,
hospitals, pharmacies, labs, doctor’s offices) that rely on EHRs and other supporting technology
to deliver your valuable health data. Not only are the health agencies reliant on health
information to provide proper and quality care, but patients want the same access to their
information. New integrated health care information technology has promoted wellness and self-

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care for patients. The use of health IT and EHRs give the ability to monitor health outcome in
real time, despite all the privacy and security concerns.
Adopting EHR and other health IT, does not mean that it will be effective at what is was
intended to accomplish. There are key barriers that EHRs still needs to over-come. There is a
lack of electronic health information consistency and standardization. According to the
Department of Health and Human Services, electronic health information is “inconsistently
expressed through technical and medical vocabulary, structure, and format, thereby limiting the
potential uses of the information to improve health and care.” (ONC, 2014, “Report to
Congress,” para. 5). There is a growing concern of the possibilities that health IT and EHRs will
adversely affect the patient-provider relationship.
Effects on patient-provider relationships. The introductions of integrated health
technologies and EHRs have transformed the way that the patient and provider interact. Patients
are concerned that the increased presence and increase use of health IT will interfere with the
relationship they have with their health care provider. Doctors are concerned that new integrated
health care technologies with interfere with the patient-provider relationship (Lovett, 2014). The
use of EHRs by doctors may also alter human reasoning and decision processes that are involved
with providing health care (Flanagan, Russ, & Saleem, 2014).
EHRs must fit into the patient provider relationship, so the focus can still be on the
patient. According to ENT Today, a publication of the Triological Society, one of the major
ethical concerns about the adoption of EHR is the impact it will have on the interaction and
relationships between patients and providers (Kitsis & Shmerling, 2014). The presence of a
computer and other devices within the exam room can take away the focus centered on the
patient.

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With the adoption of health IT and EHRs, it has put more control in the patient’s hands.
Patients are able to actively engage in their own health care, which will change the patient-
provider relationship to a more patient-provider partnership (Consumer Reports, 2013). The
notion of mutual participation between the patient and the provider is not new. In 1956 Thomas
Szasz and M.H. Hollender proposed the idea of mutual doctor and patient participation in their
work. A contribution to the philosophy of medicine: the basic model of the doctor-patient
relationship. The proposed models of the doctor-patient relationship presented by Szasz and
Hollender in 1956 are still remain appropriate in today’s health care structure.
Szasz and Hollender proposed three models of the doctor-patient relationship. The three
models are activity-passivity, guidance-co-operation, and the model of mutual participation. The
model of mutual participation gives the patient a greater degree of responsibility and emphasizes
the importance of the doctor-patient relationship in the quality of care (Kaba & Sooriakumaran,
2006). Thus, the concept of a mutual patient-provider partnership has merely adopted to fit the
integrated technologies in the health care sector.
A study conducted by the AMA in 2013, many physicians reported that the EHR has
given them less quality time to interact with their patients (Lovett, 2014). “Time spent looking
for information and documenting information in the EHR means time not spent in meaningful
communication, and the presence of the EHR can detract from connecting with patients.”
(Denton, 2014). Patients want to feel valued but physicians are concerned that EHRs can
negatively affect the patient’s experience.
When technology diminishes the patient-provider relationship, it can create future
concerns and issues. If a patient is dissatisfied and feels the provider has spent more time with
technology rather than focusing on them, the patient may not return for future appointments. A

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dissatisfied experience by a patient can ultimately damage the reputation of the health care
provider which will cause a decline in revenue for the provider (Lovett, 2014).
To balance technology and human touch during a patient’s health visit, Mike Lovett, the
executive vice president and general manager at NextGen Healthcare, suggests organizations
evaluate four questions to keep patients center of visit amongst health technologies:
1. What are patient perceptions of the EHR?
2. Does the EHR make patient care processes smoother?
3. Does patient engagement feel authentic?
4. Is the physician involved in EHR design? (Lovett, 2014).
Although integrated health technologies such as EHRs were developed to manage health
information more smoothly, if it is not used properly it can complicate the process. According to
the AMA Journal of Ethics the most common concerns with health care information technology
has more to do with the design principles and implementation, rather than the technology itself.
Knowing the patient’s perceptions of EHR usage can help the health organization locate areas of
improvement. Physicians and other health care providers are the primary users of EHRs but most
are not involved in the design of EHRs. The AMA is responding to physicians’ need for better
designed EHR systems, by issuing eight priorities to improve usability.
With the adoption of EHRs and other telehealth devices the Federation of State Medical
Boards (FSMB) developed a “Model Policy for the Appropriate Use of Telemedicine
Technologies in the Practice of Medicine” and the AMA issued “Coverage of and Payment for
Telemedicine,” as a guideline for state medical boards. Some state medical boards in certain
states have strict in-person requirements to establish a patient-provider relationship, but the

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FSMB and AMA guidelines suggest that a patient-provider relationship can be established via
telehealth technology (Amundsen and Johnson, 2014).
The FSMB realizes the importance of the collaborative effort and relationship between
the patient and the provider has on the health and well-being of the patient. Once a physician
agrees to undertake treatment of the patient, the relationship has been established between the
patient and provider, whether or not they have meet in person. According to FSMB the physician
should be discouraged from giving medical advice and/or care using telemedicine technologies
without:
 Fully verifying and authenticating the location and, to the extent possible, identifying the
requesting patient
 Disclosing and validating the provider’s identity and applicable credential(s)
 Obtaining appropriate consents from requesting patients after disclosures regarding the
delivery models and treatment methods or limitations, including any special informed
consents regarding the use of telemedicine technologies (Federation of State Medical
Boards, 2014).
The FSMB states guidelines for a patient’s medical records. According to FSMB the
medical record should include copies of all patient-related electronic communications, including
patient-provider communication, prescriptions, laboratory/test results, evaluations, past care, and
instructions obtained or produced in connection with utilization of telemedicine technologies
(Federation of State Medical Boards, 2014).

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Improvements of EHR
If the priorities listed by the AMA were implemented, it could translate into more EHR
adoption by doctors and improve relationships with patients. The AMA lists the following as
usability priorities:
1. Enhance physicians’ ability to provide high-quality patient care
2. Support team-based care
3. Promote care coordination
4. Offer product modularity and configurability
5. Reduce cognitive workload
6. Promote data liquidity
7. Facilitate digital and mobile patient engagement
8. Expedite user input into product design and post-implementation feedback.
(American Medical Association, 2014).
Improvements on patient-provider relationship. One solution that will maintain the
best patient-provider relationship and presents the fewest ethical concerns is a listen-now-type-
later approach (Kitsis & Shmerling, 2014). This approach will maintain the best patient-provider
relationship but will require change to the provider’s procedure due to the introduction of health
technologies.
Another solution that has been proposed is to have a medical transcriber alongside the
doctor to document the information provided. Transcribers are trained in medical terminology.
They will record the visit of the patient. Although this proposed solution would maintain the
necessary focus the doctor has on the patient, it will come with more ethical concerns and
problems such as a violation of the patient’s privacy. If this solution was to take place, patients

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may be hesitant to speak of sensitive or embarrassing problems in front of the transcriber (Brink,
2014).
To establish and maintain effective communication between the patient-provider, EHRs
and other health technologies must be redesigned. The design must minimize the disruptions that
occur during the patients’ visit. Patients want to feel understood, valued, and validated during a
health visit. It is important that future physicians and doctors are trained on the use of these new
integrated technologies but also be trained on how to listen to the patient.
David Denton, a board-certified pediatrician and member of American Academy of
Pediatrics, states that if the design of EHR was changed, it can minimize disruption during the
patient’s visit (Denton, 2014). Doctor’s spend too much time looking for charts and relevant
information about the patient scattered throughout the chart. A summary page with pertinent
patient information would save more time for the doctor to listen to the patient.
RedesignHealth IT Infrastructure
The U.S. Department of Health and Human Services (HHS) has taken responsibility to
develop a plan to advance connectivity of electronic health information and interoperability of
health IT. Interoperability within the health IT infrastructure will change the effectiveness of
health IT. The plan has been outline in the document Connecting Health and Care for the
Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure.
Health IT interoperability. Through ONC and HHS, they developed an interoperability
roadmap to advance the uses of health IT. Interoperability in health care describes “the ability of
different information technology systems and software applications to communicate, exchange
data, and use the information that has been exchanged.” (HIMSS.org, 2013). In order to
transform health care delivery to provide better care and in turn make people healthier,

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advancing health IT interoperability is key. Mobile health devices are an integrated part of the
health IT structure and have the ability to communicate with other health devices. Thus,
interoperability in mobile information technology is crucial to the advancement of health IT.
The U.S. HHS and the ONC has taken responsibility to develop a plan to advance
connectivity of electronic health information and interoperability of health IT. The plan has been
outline in the document A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure.
The ONC and HHS drafted a three stage agenda, starting with three-year, six-year, and ten-year
agendas. The three-year agenda is the first step to send, receive, find, and use health information
to improve health care quality (ONC, 2014). To achieve this, HHS and ONC plan to improve
upon the existing health information networks so patients and providers can appropriately make
use of interoperability health systems.
The six-year agenda hopes to enable individuals to actively participate in managing their
care by enhancing interoperability between health IT devices and systems. Through the use of
health IT tools and mobile applications to integrate data contained in EHRs, the ONC and HHS
hope that individuals will set better health goals and meet those goals. The ONC and HHS states
that interoperability will enable individuals to contribute to their EHR for use by care team
members. This includes remote monitoring of health care with interoperability of medical
devices, home monitoring tools, and other health IT (ONC, 2014).
The ten-year agenda plans to have individuals manage health information from their own
electronic mobile devices and share that information across a variety of platforms. The ONC
states, “The nation’s health IT infrastructure will facilitate health improvement through active
individual health management.” (ONC, 2014). By year ten, ONC believes that more advanced
and more functional tools will support future health research and health of the public.

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Looking into the future, by 2024, ONC hopes that individuals, care providers,
communities and researchers should have a large amount of interoperable health IT products and
services (ONC, 2014). By 2017, ONC is considering to promote linking of mobile apps to EHR
systems. Patients will be able to have access and be able to contribute to their EHR as developers
add application interfaces to the EHR systems (Conn, 2014).
The National Institute of Standards and Technology (NIST) is responsible to set the
standards for EHRs under the HITECH Act (Ciampa & Revels, 2014). Defined under the
HITECH Act, NIST works with the health industry to create health IT standards and testing
infrastructure (Brady, 2014). NIST promotes interoperability through testing and their developed
standards. The focus on refining current health IT standards and the development of standards
needed for the future will shape emerging health technologies (Brady, 2014). To ensure the
interoperability of EHR systems, developers use NIST interoperability standard ISO1 V2.1,
which provides specific data and communication format requirements (Ciampa & Revels, 2014).
Mobile Health Technologies
The increased use of mobile technologies has demonstrated the potential for mobile
communications to improve health care services, improve health information accessibility, and
improve communications. According to Manhattan Research/Physician Channel Adoption study
in 2012, 87 percent of doctors were using a smartphone or tablet device in the workplace
(Ventola, 2014). The mobile health market is expected to increase by 61 percent to an estimated
$26 billion by the end of 2017 (Crespo & McLaughlin, 2013).
Mobile health technologies include smart phones, tablets, medical software applications,
social networking applications, and other telecommunication technology. The introduction of
integrated technologies in health care have been developed with the intent to improve quality of

21. 16
health, reduce medical errors, broadening the access to health care, and reduce the cost of
interventions (Ventola, 2014).
The introduction of mobile health technologies in recent years has not only given the
patient more control over their personal health but has also challenged the way providers and
regulatory agencies must manage these new systems. Since not all health care for the patient is
given at one location and is often dispersed between multiple locations and systems, it is
important for health care professionals to have collaboration, communication, and security.
Mobility has become an important feature to both patients and providers for the delivery of
health care (Gerogiou, Prgomet, and Westbrook, 2009).
Telemedicine. Telemedicine and telehealth are closely related terms but refer to different
areas of medical technology. Telemedicine has a more narrow scope than of telehealth, and
refers to the use of electronic communications and information technologies to provide services
to patients in distant locations. Telemedicine includes the use of telecommunication technology,
smart phones, mobile devices and wireless tools that are used to improve a patient’s health (The
American Telemedicine Association, 2012).
Telehealth also refers to the use of electronic information and telecommunications
technologies to support long distant care but includes health related education, public health and
health administration (ONC, 2014). According to the American Telemedicine Association both
telemedicine and telehealth are considered to be part of “Patient consultations via video
conferencing, transmission of still images, e-health including patient portals, remote monitoring
of vital signs, continuing medical education, consumer-focused wireless applications and nursing
call centers, among other applications.” (American Telemedicine Association, 2012). Telehealth
plays a vital role in communication between the patient and the provider, especially for rural

22. 17
health care, remote patient monitoring, communication between providers and communication
between patient and provider (Lustig, 2012).
Impact on rural health care. There are many benefits in establishing and adapting
mobile health and telehealth management. The advancements of mobile health technologies has
broadened the reach to improve health in the developing world and rural areas. “Evidence-based
models facilitated by these technologies can improve access to and quality of health care across
the geographic and economic spectrum” (Lustig, 2012, p. 15). The Federal Communications
Commission (FCC) established the Rural Health Care Program which consists of three programs:
the Healthcare Connect Fund, the Telecommunications Program, and the Rural Health Care Pilot
Program. These programs are to provide eligible health care providers with telecommunication
services necessary to improve the quality of health care available (FCC, 2015).
Under the Healthcare Connect Fund, Eligible rural health care providers will be able to
receive a 65 percent discount on expenses. Expenses can include telehealth and telemedicine
services/equipment, network equipment, and broadband services. The expansion of telehealth
given under the Rural Health Care Program, will allow patients to access remote patient
monitoring, enhanced exchange of EHRs, connect rural health care providers to medical
specialists at larger health care providers, and connect telehealth applications over the broadband
network (FCC, 2015).
How health care providers use mobile devices and apps. Health care providers use
mobile devices and apps for varies purposes. Mainly providers will use mobile devices and apps
for:
 Information and time management
 Electronic health record access and maintenance

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 Communications and consulting
 Reference and information gathering
 Clinical decision making
 Remote patient monitoring
 Medical education and training (Ventola, 2014).
Consumers and health care professionals alike are taking advantage of mobile device
health care management. According to a study conducted by research2guidance, 15 percent of
the mHealth apps are primarily designed for health care professionals (Jahns, 2013). Figure 1
shows the predictions from research conducted by MedData Group on the most used health care
apps by health care professionals in 2015. There were 375 physicians around the United States
that were polled. MedData suggested that the “findings reflect a general sense that health IT
services are picking up steam among doctors, patients, and corporations…” (Huang, 2015).
E-prescribing is predicted to be the most used health care app in 2015 among surveyed
doctors at 50 percent. Use of EHR health apps among doctors is 38 percent.
Figure 1. Doctors predictions for health care app use in 2015. (MedDataGroup, 2015).

24. 19
According to Manhattan Research survey of 3,066 practicing physicians in 2014, more
than one third recommended that a patient use a health app (Comstock, 2014). Data from the
research groups has suggested physicians’ awareness and engagement with mobile tools is on the
rise (Comstock, 2014).
Use of mobile apps by patients and others. Patients, including those interested in
managing their own health, are using health care apps for many different reasons. Health care
apps can fall into different categories such as clinical assistance apps, monitoring apps, reminder
apps, reference apps, health life apps, efficiency/communication apps, general facility
information apps, patient portal apps, specialty apps (Zwerneman, 2014). The top five interests
when downloading and using mobile health apps were released from a study of 1,015 nationally
representative Americans 18 and older by Makovsky/Kelton survey. Interests include 47 percent
tracking diet/ nutrition, 46 percent medication reminders, 45 percent tracking symptoms, and 44
percent tracking physical activity (Pennic, 2015). Mobile Future and Infield Health issued a
report showing that 247 million Americans have downloaded a health app (Spalter, 2014).
Remote patient monitoring. One of the most beneficial and unique uses of mobile
technologies is the remote monitoring of patients by health care providers. Remote monitoring
“is a type of remote health care in which patients use mobile medical devices to share their
condition with care providers.” (Rouse, 2014). For many patients, they require daily monitoring
and daily communication with doctors. Remote monitoring devices and mobile apps can keep
constant monitoring on patients when doctors cannot spend 24 hours a day directly with one
patient.
According to a study done by Kalorama Information, they have predicted that the market
for advanced patient monitoring systems will reach $20.9 billion by 2016 (Lewis, 2012). By

25. 20
2018, remote patient monitoring will save the world’s health care systems $36 billion according
to the projection by Juniper Research (Comstock, 2013). Patients who will greatly benefit from
the increase of patient monitoring systems are patients with chronic disease. “The 100 million
Americans with chronic disease account for about 75 percent of health care expenditures”
(Lustig, 2012, p.12). When remote patient monitoring systems are utilized for chronic disease
care management, there has been a reduction of hospital visits, readmissions, length of stay, and
costs; improvement in some physiologic measure; high rates of satisfaction; and better adherence
to medication (Lustig, 2012).
To provide the best quality of care, care should also be monitored even outside of the
doctor’s office. In a 2012 eHealth survey conducted by Ruder Finn found that 33 percent of
patients want their physicians to have access to remote monitoring technologies (Morrissey,
2014). Remote patient monitoring devices will enable the patient to stay connected with their
provider even at home, broadening the patient and provider relationship. According to a survey
of 3,066 practicing physicians in the United States conducted by Manhattan Research, 20 percent
of doctors are engaged in remote patient monitoring. Those doctors who are engaged in remote
patient monitoring, were monitoring an average of 22 patients a month (Comstock, 2014).
Xavier Sevilla, MD and vice president for clinical quality improvement at Catholic
Health Initiatives, states that “when patients are at home they are still our patients, and we are
still responsible for providing care and delivering health to them.” (Morrissey, 2014). Remote
patient monitoring devices can wirelessly transmit patient vital signs such as heart rate,
respiration, ECG, blood pressure, blood glucose, body temperature, body weight, and posture.
An example of how a remote patient monitoring device collects health information on the
patient and then sends that data to the provider is shown in figure 2. The example used in figure

26. 21
2 is of ZephyrLIFE home patient monitoring device, BioPatch. The patient being monitored will
wear the BioPatch and other sensors to gather health information. That information will then be
sent to a mobile device with the ZephyrLIFE app, which will then gather and securely transmit
the information where a health care provider will monitor the patient (Zephyr Technology
Corporation, 2015).
Figure 2. Example of how remote patient monitoring devices collect and transfer information. Zephyrlifehome.
Management with Mobile Medical Apps
A major part of mobile health technologies includes mobile apps. Mobile apps have given
people the opportunity to manage their own health and wellness, promote healthy lifestyle
choices, and provide access to health information (FDA, 2014). According to the report mHealth
App Developer Economics 2014, published by research2guidance, by the year 2018 half of the
3.4 billion mobile device users will have downloaded mobile health apps.
The emergence of mobile health technologies and mobile apps has created a challenge for
the FDA. The FDA is responsible for oversight of mHealth devices and mHealth apps.
According to a policy adviser to the FDA, the FDA is unable to keep pace with regulating the

27. 22
hundreds of mobile medical apps that are produced each month (Barajas, 2014). The FDA states
that a mobile medical app “is a mobile app that meets the definition of a device in section 201(h)
of the FD&C Act and either is intended:
 To be used as an accessory to regulated medical device; or
 To transform a mobile platform into a regulated medical device” (FDA, 2015).
According to the FDA a mobile app is considered a medical device if that mobile app is
intended for use in performing a medical device functions. As of February 2015, there are 116
apps on the FDA cleared mobile medical applications list (FDA, FDA Examples of MMAs the
FDA Has Cleared or Approved, 2015).
Types of regulated apps. Under current law, the FDA will have regulatory oversight of
mobile apps that are considered medical devices. Such as mobile apps that transform a mobile
platform into a regulated medical device (i.e. electronic stethoscope, electrocardiograph,
accelerometer, monitor electrical activity of brain, measure blood glucose, measure degree of
tremor, analyze eye movements). Mobile apps that connect to an existing device type for
purposes of controlling its operation (i.e. apps that alter function of an infusion pump, apps that
act as wireless remote control devices for computed X-Ray machines, apps that calibrate or
control cochlear implant, apps that deflate or inflate blood pressure cuff). Apps that are used in
active patient monitoring or analyzing patient-specific medical device data is also subject to
FDA regulation (FDA, Mobile Medical Applications, 2015).
Types of non-regulated apps. Mobile apps that are intended for educational and
reference purposes for health care providers and patients are not regulated by the FDA. Mobile
apps that are generic aids (i.e. communication through email, providing maps to medical
facilities, using HIPPA compliant app for secure communications, using mobile platform to

28. 23
record audio and take notes). Also apps that perform general office operations in health care
setting (i.e. billing codes, manage doctor shifts, help patients track, review and pay medical bills
online, analyze insurance claims). The FDA does not regulate mobile apps that are not
considered to be a medical device or apps that pose no threat to the users if they fail (FDA,
Mobile Medical Applications, 2015) (Hickey, 2015).
Security of Mobile Health Care Devices
There is a continuing debate over the development of the standards to assure the security
of health data during storage and transmission (Kayl, Luxton, and Mishkind, 2012). The
increased use of integrated health technologies has raised new concerns about security and
privacy of these devices. The communication capabilities, portability, user patterns and
preferences has increased the complexity of protecting patient data (Kayl, Luxton, and Mishkind,
2012). The introduction of mobile health apps has created a new area of mobile health that must
be protected. Health data can be stored, processed and transmitted between patients and multiple
health care providers.
According to ONC, five steps have been outlined to help develop and implement mobile
device policies and procedures to safeguard PHI in health care organizations:
1. Decide – Decide whether mobile devices will be used to access, receive, transmit or store
patients' health information or used as part of your organization's internal networks or
systems.
2. Assess – Consider how mobile devices affect the risks to the health information your
organization holds.
3. Identify – Identify your organization's mobile device risk management strategy, including
privacy and security safeguards.

29. 24
4. Develop, Document and Implement – Develop, document and implement the
organizations mobile device policies and procedures to safeguard health information.
5. Train – Conduct mobile device privacy and security awareness and training for providers
and professionals (ONC, Five Steps Organizations.., 2013).
HIPAA standards. Health Insurance Portability and Accountability Act (HIPAA) sets
the standard for protecting sensitive patient data including PHI and PII. Under HIPAA there
are four rules:
1. HIPAA Breach Notification Rule
2. HIPAA Enforcement Rule
3. HIPAA Privacy Rule
4. HIPAA Security Rule (Leyva, 2013).
According to the HHS, under the HIPAA Security Rule, is a set of security standards that
aim to protect health information that is held or transferred in electronic form (HHS, 2003, The
Security Rule, para. 1). There are administrative, physical, and technical safeguards to ensure
that the confidentiality, integrity and security of electronic PHI (HHS, 2003, The Security Rule,
para. 5). To ensure covered entities are compliant, the HIPAA Security Rule requires covered
entities to conduct a risk analysis to identify risks and vulnerabilities (ONC, 2013, Privacy &
Security and Meaningful Use, para. 12).
Under the HIPAA Privacy Rule there are a set of standards to “protect individuals’
medical records and other PHI and applies to health plans, health care clearinghouses, and those
health care providers that conduct certain health care transactions electronically”
(HHS, 2003, The Privacy Rule, para. 1). The goal of the HIPAA Privacy Rule is to ensure that
individuals’ health information is properly protected but also the flow of health information

30. 25
needs to provide and promote high quality care (HHS, 2003, Summary of the HIPAA Privacy
Rule, para. 2). Even when using mobile devices, individuals and organizations that meet the
definition of a covered entity and who transmit health information in electronic form, must
comply with the HIPAA rules of privacy and security (ONC, 2014).
In 2013, the Omnibus HIPAA Rule was announced by HHS, to implement a variety of
provisions that the HITECH Act established (HHS, n.d.). Omnibus Rule strengthened privacy
and security protections of health information. HIPAA requires that Covered Entities and their
business associated must protect the privacy and security of PHI.
According to HIPAA certain mobile health apps must be compliant to HIPAA standards
of privacy and security. Mobile apps must be HIPAA compliant if PHI directly identifies an
individual that is or can be transmitted to a covered entity. Any app that is used to record and
share patient information with a covered entity, than it must be HIPAA compliant. Apps that
record user’s weight, access medical reference information, and other apps that do not transmit
PHI may not have to HIPAA compliant (Wang, 2014).
If the mobile health app is required to be HIPAA compliant, the app must:
 Encrypt the data that is being stored
 Secured access to PHI via unique user authentication
 Safety updates to protect from breaches
 Option to mobile wipe device if device is lost
 Data backup in case of lost device, device failure, and other disaster

31. 26
Canadian Health IT Implementation
The United States and Canada have many differences in the way that providers deliver
health care and the way patients receive health care, but how has Canada implemented their
transition to a technological health care industry and the management of EHRs? Leading the
way to develop and implement health IT and EHRs across Canada, is Canada Health Infoway.
Canada Health Infoway is a federally-funded organization that is working with each Territorial
and Provincial government in Canada to help develop, monitor, and enforce the use of health
care information technology. This is including all EHR, telehealth and telemedicine programs in
Canada. Beginning in 2003, Canada Health Infoway published an EHR solutions blueprint.
In 2014, the National Physicians Survey conducted a study of 10,000 physicians from
around Canada. The survey showed that 75 percent of doctors across Canada have reported that
they are using EHRs. The number of doctors who have chosen to go digital has tripled since
2007. According to the same study done by the National Physicians Survey, they found that
those doctors who reported seeing better or much better quality has reached about 65 percent
(The Canadian Press, 2014).
According to Canada Health Infoway, 89 percent of Canadians feel that it is important
that they have full advantage of digital health tools and capabilities personally. Although an
overwhelming majority of Canadians feel it is important to take full advantage of digital health
tools, >90 percent of patients do not have the access to digital health tools (Canada Health
Infoway, Mobile Health Computing Between Clinicians and Patients, 2014). The Conference
Board of Canada says that if patients were able to access health information online it would have
avoided 47 million in-person health care visits.

32. 27
The Harris-Decima annual tracking survey in the report Mobile Health Computing
Between Clinicians and Patients, reported on the interest of digital health services of Canadians
if those services were available. Shown in figure 3, 62 percent of respondents would most likely
view their information in EHR if that service was available to them. In addition, 61 percent
would most likely make appointments with health care providers electronically, 59 percent
would send an electronic request for prescription renewal, and 42 percent would consult with
health care providers online (Infoway, Mobile Health Computing Between Clinicians and
Patients, 2014).
Figure 3. Chart showing Canadian report of interest in using digital health services if available
Remote patient monitoring. According to the study, Connecting Patients with
Providers, published by Canada Health Infoway and commissioned to Ernst & Young LLP,
remote patient monitoring is growing in Canada (Canada Health Infoway, Connecting Patients
with Providers, 2014). The study found that approximately 5,000 patients are enrolled in 19
remote patient monitoring programs across seven provinces around Canada. The study also
suggested four success factors within remote patient monitoring program design.

33. 28
1. Engagement and collaboration
2. Patient recruitment and retention
3. Benefits measurement
4. Integrate care and care-coordination (Canada Health Infoway, Connecting Patients
with Providers, 2014).
Improvements to EHR implementation. Dr. Jennifer Zelmer, Executive Vice President
of Canada Health Infoway, states that the slow movement of digital health tools to Canadians is
due to getting the basic infrastructure into place. Also organizing how patients will connect with
their doctors and ways doctors will connect with other members of the health care team have
been slow moving. Dr. Zelmer also stated how digital health care is a fundamentally different
way of providing care; it is a big culture change for patients and health care providers (Zelmer,
2015).
There are two reasons why Canada is lacking with the usage of EHRs according to
Medconnex. The Canadian government has not been encouraging practitioners to begin using
EHRs. While some of the provincial governments across Canada have been slow to adopt these
technologies, there are some provincial governments which have been more proactive at
adopting. The other problem is that Canadian “practitioners are entrenched in their opposition to
the usage of electronic health records.” (medconnex, 2013, para. 2).
Dr. Garey Mazowita, the president of the College of Family Physicians of Canada,
suggested how it may not be such an easy transition for doctors who had a paper-based practice
that are moving to a mobile and digital practice (The Canadian Press, 2014). According to the
same study conducted by The National Physicians Survey, 52 percent those doctors who

34. 29
adopted EHRs reported technical glitches, 46 percent had compatibility issues with other
systems, and 26 percent complained of firewall or security problems.
In 2014 the Canadian Medical Association released the report, How can Canada Achieve
Enhanced use of EMRs, on methods to which EMRs can be accelerated in Canada. One method
discussed to accelerate use of EMRs in Canada is the pay-for-performance mechanisms such as
the Meaningful Use provisions the United States has used. Canada Health Infoway has invested
to increase the adoption and interoperability of EMRs but “has not yet gone to the extent of
paying for the use of EMRs in a particular fashion or to achieve quality milestones.” (Canadian
Medical Association, 2014).
Conclusions drawn from the Canadian Medical Association states that for the United
States approach to achieving enhanced use of EMRs to be effective in Canada, it must be
adapted for a Canadian context. While there are pro’s and con’s to the use of pay-for-
performance mechanisms, it may not be the right path for Canada to take to accelerate the use of
EMRs. According to the study, pay-for-performance to enhance the use of EMRs has risks:
 Cost to the health care systems increase
 The impact on other aspects of the health care system not covered by pay-for-
performance provisions
 The impact on the morale of the overall care teams, specifically those care providers not
covered by pay-for-performance incentives
 The potential to create disparities in a health care system as funds flow to high
performers (Canadian Medical Association, 2014).

35. 30
To form the basis of a Canadian EHR system, the C. D. Howe Institute highlighted five
principles. The C. D. Howe Institute is an independent not-for-profit research institute. Their five
steps are
1. Shared electronic records should be regarded as essential to care;
2. Features of electronic records systems that get in the way of effective clinical practice
should be regarded as safety issues that need to be resolved as a priority;
3. Clinicians should have a single point of access to electronic records about patients they
are treating, regardless of where the record was created;
4. Patients and their caregivers should not find relevant data inaccessible, expensive to
access or at risk of loss because of commercial or financial decisions made by EHR
system vendors; and
5. Patients should ultimately be able to access their EHRs online (Protti, 2015).
To raise awareness among Canadian clinicians and patients, Canada Health Infoway has
established two educational campaigns. Knowing is Better for Clinicians was designed
around Canadian clinicians to raise awareness about the benefits of interconnected health
IT systems and EHRs (Enriquez, 2014). Designed around Canadian patients, Canada
Health Infoway created Better Health Together Campaign to raise awareness of the
benefits of using digital health. This campaign features Canadians sharing their stories
about their experience with using digital health (Canada Health Infoway, Better Health
Together, n.d.).
Comparison of EHR Adoption
Healthcare Information and Management Systems Society (HIMSS) Analytics developed
the EMR Adoption Model in 2005 which tracks the adoption of EMR applications within

36. 31
hospitals and health systems around the world. HIMSS is a not for profit organization founded in
1961, that focuses on improving health care quality through the use of information technology
(HIMSS, 2014). The HIMSS Analytics EMR Adoption Model is an 8 step process to reach a
total paperless environment for health care providers. The 8 step process allows health care
organizations to analyze their level of EMR adoption and track progress against other
organizations across the country (HIMSS Analytics, 2015).
All providers and organizations are eligible to participate in the HIMSS Analytics annual
study for free. Once the provider has participated, the provider can obtain their EMR adoption
model score and become operational stage by stage working towards the final 7th stage (HIMSS
Analytics, 2015). The stages 0 through 7, cumulative capabilities, and percent of organization
step completion are show in figure 4. Figure 4 compares the EMR adoption model between the
United States and Canada for 2014.
According to the data, 2014 final numbers show that only 3.6 percent of 5,467 US
hospitals in the HIMSS Analytics Database received a stage 7 award, which is complete use of
electronic records. For the same time period, Canada showed only .2 percent of 641 hospitals at
complete electronic records. There are currently 29.5 percent of US hospitals that were in stage 5
at the end of 2014 that take part in the HIMSS Analytics. The majority of US hospitals that take
part in HIMSS Analytics were in stage 5. Stage 5 consists of a closed loop medication
administration, which requires the coupling of data between the different sections of the hospital
to ensure point-of-care patient safety of medication.
During the same time period there were .6 percent of Canadian hospitals that have
reached stage 5. The majority of Canadian hospitals that take part in HIMSS Analytics were in
stage 3, at 31.7 percent. Stage 3 consists of nursing and clinical documentation that is taken

37. 32
electronically. Error checking with order entries and access to medical images outside of the
radiology department via the hospitals intranet is also included within stage 3.
Figure 4. HIMSSAnalytic EMR adoption comparison
To solve the issues of low adoption of EHRs in Canada Joe Natale, the chief commercial
officer at Canada’s leading EHR developer Telus, said it should come from the private sector.
Natale says that the provinces in Canada should permit competition to the existing suppliers of
EHR systems. With competition of EHR system developments, it should produce EHRs that will
be more suitable to the users. Natale also suggests that the Canadian government needs to do
more to provide incentives for practitioners to use EHRs, such as meaningful use incentives used
in the United States (medconnex, 2013, para. 6). The provincial governments should also publish
standards to ensure that EHR and other health technologies meet certain requirements.
There are many challenges at adopting an EHR strategy for Canada. According to the
white paper published by Francis Lau, Morgan Price and Jesdeep Bassi, the benefits of EHR will
be dependent on the type of investments made, the system being adopted, the contextual factors
involved, the way these factors interact, and the time for the system to become balanced (Bassi,
Lau and Price, 2014). There is a need for a coordinated EHR strategy in Canada and can be
Stage CumulativeCapabilities USEMRAdoptionModel CanadaEMRAdoptionModel
2014Q3 2014Final 2014Q3 2014Final
Stage7 CompleteEMR;CCDtransactionstosharedata;Datawarehousing;DatacontinuitywithED,ambulatory,OP 3.40% 3.60% 0.00% 0.20%
Stage6 Physiciandocumentation(structuredtemplates),fullCDSS(variance&compliance),fullR-PACS 16.50% 17.90% 0.60% 0.60%
Stage5 Closedloopmedicationadministration 29.50% 32.80% 0.60% 0.60%
Stage4 CPOE,ClinicalDecisionSupport(clinicalprotocols) 14.50% 14.00% 3.40% 3.90%
Stage3 Nursing/clinicaldocumentation(flowsheets),CDSS(errorchecking),PACSavailableoutsideRadiology 23.90% 21.00% 32.10% 31.70%
Stage2 CDR,ControlledMedicalVocabulary,CDS,mayhaveDocumentImaging;HIEcapable 5.30% 5.10% 29.50% 29.60%
Stage1 Ancillaries-Lab,Rad,Pharmacy-AllInstalled 2.50% 2.00% 14.60% 14.40%
Stage0 AllThreeAncillariesNotInstalled 4.40% 3.70% 19.10% 19.00%
n=5,453 n=5,467 n=638 n=641
DatafromHIMSSAnalyticsDatabase2014

38. 33
formulated according to investment, adoption and value. Investment at the macro level includes
funding programs, health care standards, policy, socioeconomic and political trends should align
closely with EHRs to maximize benefits. An example of these benefits is the meaningful use
incentive program used in the United States.
At the micro level, providers will only adopt an EHR if the system is well designed. The
EHR system must be easy to use but also be easy to learn with continued training and support.
The system must also be secure and reliable. For a successful adoption and implementation into
an organization, it must be well managed and monitored, as it will affect the value of an EHR
system. The people, organization who is adopting the EHR system and all details of the
implementation stage must be coordinated.
According to Bassi, Lau, and Price there are ten EHR implementation steps that are
proposed if Canada were to move forward to develop their EHR strategy. The steps include
“decide on a long-term EHR investment, define EHR value, align the health care reforms, align
incentives, engage stakeholders in aligned projects, adopt national EHR standards, develop
regional data sharing infrastructures, integrate evaluation, build EHR leadership, and invest in 3-
4 short/intermediate term goals.” (Bassi, Lau & Price, 2014).
Mobile Health App Regulation
Mobile health is challenging the effectiveness of health and privacy regulation in Canada
(Hines, 2014). Manufactures and mobile health app developers are having a difficult time
determining the legislation that they must comply to. The rapid expansion of health technologies
has raised new questions for regulators in Canada.
Health Canada is in charge of regulating the medical device industry under the Medical
Device Regulations of the Food and Drug Act (Jeswiet & McAllister, 2003). Under the Food and

39. 34
Drugs Act, “software that is intended or represented for the use in the diagnosis or treatment of
an abnormal physical state of a patient meets the definition of a medical device” (Health Canada,
2010). Medical software regulated as a medical device “provides the only means and opportunity
to capture or acquire data from a medical device for aiding directly in diagnosis or treatment of a
patient” and it also replaces a diagnostic or treatment decision made by a physician” (Health
Canada, 2010).
Health Canada regulates medical device software and has issued guidance over class I
and class II software. Class I medical device software is to be used for tasks such as viewing
images, or other real time data, adjunct to the monitoring device itself, for the purpose of aiding
in treatment or diagnosis of a patient. Class II medical device software is an adjunct to another
medical device and is involved in data manipulation, data analysis, data editing, image
generation, determination of measurements, identification of a region of interest in an image, or
identification of results from a monitor that are outside of an established range (Health Canada,
2010).
There are some issues regarding the regulation of medical device software in Canada.
Health Canada regulates medical devices that are imported for sale or sold in Canada. Questions
such as “does the app qualify as a diagnostic device? Could the app can be downloaded for free?
Or, what if the software is hosted by a server in another country?” have risen (Hines, 2014).
To keep up with the increased flow of mobile health apps in the market, health Canada is
working with regulators from the U.S., Brazil, Japan, Australia, China, European Union and
World Health Organization (Sher, 2014). The current regulations create an uncertainty for app
developers and manufacturers on which statutes and jurisdiction they fall under. Furthermore,
certain medical apps used in Canada can be free of regulation, free from licensing requirements,

40. 35
premarket approval, mandatory problem reporting and recalls because of loopholes in current
regulations (Hines, 2014).
Discussion of the Findings
The purpose of this research was to examine how integrated health technologies have
affected the relationship between the patient and provider in the health care sector. How have
mobile health technologies effected and changed the way in which a patient manages their
health? How has the relationship between the patient and provider transformed by the use
electronic health records and electronic health technologies? How does the Canada compare with
the United States on implementation and management of electronic health technologies?
Information technology has revolutionized everyday life, even in all aspects of health
care. Since the introduction of the ARRA and HITECH Act in 2009, the health care sector has
evolved technologically in many ways. The health care sector was allotted billions of dollars of
funding to increase the adoption and make better use of health IT. The increased use of
integrated health IT was proposed to transform the way health care is delivered, received and
managed. The delivery of health care is intended to be more efficient and less prone to error. Not
only did health IT and the HITECH Act aim to improve efficiency, quality and safety of health
care. Additionally, to actively engage patients in their health care with increased privacy and
security.
One of the main goals of the HITECH Act was to expand national EHRs. Since 2009 the
percentage of health care providers that have implemented EHRs and health IT has been
increasing steadily. The HITECH Act and ARRA contain incentives to expand and accelerate the
adoption EHRs and health IT, but providers must also meaningfully use these technologies to
receive those incentives. Providers, such as eligible health care professionals and hospitals, were

41. 36
able to receive incentives for achieving meaningful use of EHRs. To receive these incentive
payments, providers must follow through three stages of meaningful use that shows they are
using certified EHR technology efficiently.
Health IT and EHRs have transformed the way in which patients receive care,
communicate and interact with their providers, and even manage their health. Instead of only
communicating at each hospital or office visit, patients and providers now communicate though
information technology. Before the introduction of health IT, effects on communications
between patients and providers were minimal. Face to face patient provider communication has
become less common. Communication between health care providers and the patients will be
increasingly mediate through information technology and electronic devices.
With the many benefits that health technologies offer, there are also adverse effects that
come with them. The introduction of integrated health care technologies has physicians and
patients trying to understand the effects, while invest in EHR systems, patients portals, telehealth
platforms, mobile health, and social media. A main concern among patients and health care
providers is how EHR use will affect their relationship. Both patients and providers often worry
that the EHRs can negatively affect the patient experience and the relationship between them.
Doctors are going to refine their communication skills in order to fit the adoption of EHR and
other supporting technology into their care. Adoption of EHRs must fit in the patient provider
relationship because the relationship effects patient satisfaction which then effects the efficacy of
health care delivery.
There is a great importance on communication and information sharing between
healthcare providers but also between the patient and the provider. In a poorly integrated and
poorly designed health IT system, the effects will be seen with quality of care that the patient

42. 37
will receive. During the health visit patients want to feel understood, valued, and validated.
Patients want to feel comfortable expressing their health concerns with their doctor. When a
doctor is more focused on typing in the EHR and reviewing a patients EHR, the patient can feel
disconnected. This often leaves the patient feeling that the provider is not entirely invested to the
needs of the patient.
The health information that is stored in the EHR is essential to the work the physicians
and other health providers. Some physicians can be overwhelmed with the introduction of health
IT and new work load, which often changes how their medical practice conducts business. The
use of EHRs have the potential to store and organize the clinical information for each patient, but
the amount of information and data that needs to be filed can detract from the quality of the visit.
EHRs can take up much of the time and focus of the doctor in the exam room. Time that should
be spent listening and treating the patient is spent imputing and going through the extensive
information contained in the EHR.
Integrated health technologies have put more responsibility in the hands of the patient.
The patient is able to manage their health with more control. The doctors no longer have full
control over how a patient receives healthcare, but ultimately, a good patient-provider
relationship will be more beneficial for the patient’s health. The combination of technology and
health care are operating on the presumption that they will improve health communication,
strengthen healthcare quality, and improve the management of PHI and PII. With the vast
amount of PHI and PII that health technologies store and transmit, it is important for all patients
and providers to be informed of how it can and will affect them going into the future.
The negative perceptions by patients can also result in adverse impacts to the health care
organization. When patients have negative experiences due to EHRs in the exam room and

43. 38
doctors centered focus on EHRs, patients may not return or even leave the health organization
for another. Not only is it important for the health of the patient for effective communication
with the provider, but it is also important to the health care organization to ensure effective
communication is being established.
Patient satisfaction is highly influenced and dependent on how skilled the health care
provider is at communicating. When the patient can also effectively communicate their concerns
and issues with their provider, it can create a more satisfying and beneficial experience for all
involved. Both the patient and provider will benefit from effective communication. Mutual trust
and respect between the patient and provider will also create a more beneficial relationship.
The use of and adoption of health IT and EHRs are going to continue to increase over the
next few years due to government incentives. It is important that health care providers realize the
adverse effects that EHRs and other integrated health technologies can have on their
relationships with patients. Once a health care provider can conceive those adverse effects, they
can begin to improve their implementation of EHRs. With many other sectors inside of the
United States moving to a digital architecture, it was inevitable that the health care sector would
soon follow. Healthcare IT will likely be used well into the future, just as other sectors have gone
digital, so the health care sector has to be prepared to manage these systems properly.
The increased use of mobile devices such as, smartphones and tablet computers, have a
major impact on the way in which its users stay connected and manage daily activities. Growing
reliance on mobile devices has altered the way daily activities are now taking place. The
integration of mobile devices into the health care sector, has transformed the way in which a
patient receives, manages and monitors their health. Health care professionals have also made
use of mobile devices in providing health care.

44. 39
Mobile devices have become frequently used in the health care setting which has led to
the growth of mobile health apps. Health care technologies and health apps have been
developing at a rapid pace, offering complete and extensive management of health information to
its users. Health care providers are using mobile devices and apps to manage a patient’s health,
monitor a patient’s health, medical education, reference gathering, health record access,
information/time management, creation of mobile health tools, and keep continual
communication with their patients.
Prior to the development and integration of mobile devices and health apps in health care,
communication would only take place through clinical visits, telephone calls, emails, and paper
mail. Health care and health monitoring could only take place from clinical visits. Mobile
devices and the health apps that they run, are enabling a better quality of care for both patients
and doctors. Patients and doctors are in the process of experiencing the innovative ways that
mobile technologies are improving health care and the delivery of health care.
Mobile health apps are helping people a more proactive approach at managing their own
health and wellness, gain access to useful health information, and encourage a healthier life style.
Health apps have inspired people to take more control to monitor and manage their health.
Annually the number of mobile health users has increased. It is expected to reach one billion
users in the coming years. Mobile health technologies are going to continue to have a major
effect on patient health care. Health care professionals and patients alike are now managing
health care with the use of health IT and mobile technologies.
Mobile health apps are a key tool that patients can use to manage their health. Patients
should become aware of the type of apps that are most appropriate for their needs, by doctors
recommending certain types of health apps. It is also just as important that doctors encourage

45. 40
those patients who want to take a proactive role self-heath management with mobile apps. The
partnership between doctors and patients about mobile health apps, can create better use of such
apps. If a patient downloads the wrong app or misuses an app, without doctor recommendations,
the user can be misled about particular aspects.
Mobile health care has also changed the dynamic of remote patient monitoring. Mobile
devices have made it possible for doctors to remotely monitor their patients from a far distance.
The patient can interact and send vital information to their doctor via mobile devices and mobile
health apps. This is a major advancement that can help those patients who have chronic diseases
that require constant monitoring. Monitoring between visits is also important for patient health.
During this interim period, patients may be less focused on their healthcare responsibilities.
Health IT can encourage patients to stay in touch with their doctor and keep up with health
regimens.
Proper security management and regulation of the thousands of mobile apps that can be
downloaded to a mobile device is critical because of the large amounts of PHI and PII that they
can contain. The FDA has oversight of mobile medical apps as a medical device and the apps
that will present a great risk to patients if they fail to work as they were intended. The FDA also
takes oversight of the mobile medical apps that cause mobile platforms to impact the
functionality of traditional medical devices. Multiple countries have seen the complexity with
regulating mobile apps and have been working together to standardize regulation.
While managing health IT, interoperability is a key step that will support the increased
use of health IT. The newly developed standards and guidelines of interoperability by the ONC
and NIST is important for the long term success of health IT. With the many benefits that
modern health IT provides, it has become clear that health IT is going to be continually

46. 41
developed and integrated into the health care architecture. The increased use of mobile devices
and mobile medical apps in health care are also changing the way health care professionals and
patients interact.
With all the health IT that is being developed and integrated into health care every day,
interoperability is going to be key to the success of integrated technologies. Common standards,
common language for communications and common policy will increase the potential of
interoperability. Common standards in health IT will allow important information to be shared
among health care providers and health care providers can easily share that information with
patients, regardless of the app or mobile device.
It is important to look at how other countries are managing and implementing health IT.
While rate of adoption of health IT may happen at different rates for other countries, it can be
beneficial to see the programs that other countries are using to help expand health IT. Each
country has a different form of health care but looking at programs that other countries have
implemented, can give detail of what works within their health care sector. Satisfaction among
doctors and patients can also be seen when looking at such programs. Programs can then be
altered to fit their system.
The programs and rate of which health IT is being adopted in Canada was reviewed in
this paper. Although Canada has not implemented EHRs and digital health tools into their health
care system at the same rate as the United States has, Canada has great potential for increased
adoption. The low adoption rates are due to a lack of basic infrastructure to accelerate the use of
digital health tools. The United States government has encouraged the use of EHRs through
financial incentive programs from the Center for Medicare & Medicaid. The Canadian
government does not offer such a program to encourage the use of EHRs with incentives. The

47. 42
Canadian Medical Association discussed using incentive programs, similar to the United States
approach, in Canada to achieve enhanced use of their EHRs. For the United States approach to
be effective in Canada, it must fit in the Canadian health care architecture.
The Canadian government should provide incentives to health care providers to increase
the adoption of EHR systems. Integrated health IT, including EHRs, are the new innovative ways
to improve the quality of health care. Therefore, it is important for the future of Canadian health
care to successfully implement health IT in the coming years.
The modernization of health care around the United States and Canada relies on the
foundation of health IT. Significant changes to health care have been made with the introduction
of integrated health IT. Although health IT will not eclipse the benefits of doctor visits, it has
drastically affected the way patients communicate, manage health, deliver, and receive health
care. New health IT is being developed at a rapid pace and there will continue to be significant
beneficial uses and challenges associated with the technology. Not only have the delivery of
health care and the management of health care been changed but the relationships between health
care providers and patients have been affected. Health care providers will have to make changes
to their communication techniques to compensate for the presence of EHRs and other health IT
tools. As the adoption of health IT increases, the healthcare sector must focus on interoperability
of health technologies.
Future Research and Recommendations
After discussing the findings of this research, there are other avenues of future research
that can be conducted. The final rule for Meaningful Use stage 3 has yet to be proposed but will
affect the interoperability of health IT, among eligible health care providers that follow the
Meaningful Use policy. Stage 3 plans to further advance the interoperability of EHRs and a

48. 43
range of health IT that will affect how patients and providers connect. New mobile health apps
are being developed that are affecting the connection between patients and providers but also
how a person can self-manage their own health. Further research on those mobile health apps
that have been approved by the FDA should be conducted to look at how it affects both patients
and providers. Research on the effects of quality of care that is provided by mobile health apps
should also be conducted. The quality of care provided from the use of a mobile health app can
then effect the relationship that the patient has with their doctor, relying less on the doctor for
quality care. One should also look at how the growth of cloud computing/storage has changed
the data architecture in health IT and if the cloud has been implemented for the use of EHRs and
health apps.

49. 44
References
AAPM&R - American Academy of Physical Medicine and Rehabilitation. (n.d.). Retrieved
March 8, 2015, from https://www.aapmr.org/research/meaningful-use/Pages/default.aspx
About ONC. (2014, August 11). Retrieved February 5, 2015, from
http://www.healthit.gov/newsroom/about-onc
American Medical Association. (2014, September 16). AMA News Room. Retrieved February
22, 2015, from http://www.ama-assn.org/ama/pub/news/news/2014/2014-09-16-
solutions-to-ehr-systems.page
American Telemedicine Association. (2012). What is Telemedicine? Retrieved February 10,
2015, from http://www.americantelemed.org/about-telemedicine/what-is-
telemedicine#.VT8AYZOuk4Q
Amundsen, C., & Johnson, J. (2014, July 17). Telemedicine Guidelines Leave Plenty Of
Questions - InformationWeek. Retrieved February 15, 2015, from
http://www.informationweek.com/healthcare/policy-and-regulation/telemedicine-
guidelines-leave-plenty-of-questions/a/d-id/1297353?page_number=1
Bailey, J. (2011). Does Health Information Technology Dehumanize Health Care? AMA Journal
of Ethics, 13(3), 181-185. Retrieved from http://journalofethics.ama-
assn.org/2011/03/msoc1-1103.html
Barajas, J. (2014, July 7). FDA regulation can’t keep pace with new mobile health apps.
Retrieved February 6, 2015, from http://www.pbs.org/newshour/rundown/fda-regulation-
unable-keep-pace-new-mobile-health-apps/

50. 45
Bassi, J., Lau, F., & Price, M. (2014). Creating Strategic Change In Canadian Healthcare
[White Paper]. Retrieved February 12, 2015, from School of Health Information Science,
University of Victoria. http://moniesonhealth.com/resources/2014-WhitePaper-Lau.pdf
Berger, M., Muchanan, E., Rasouli, B., & Serafini, M. (2012, October 17). The HIT Workforce
Shortage: An Alliance for Health Reform Toolkit. Retrieved February 3, 2015, from
http://www.allhealth.org/publications/Health_information_technology/HIT_Workforce_S
hortage_119.pdf
Brady, K. (2014, December 18). Standards & Testing. Retrieved February 18, 2015, from
http://www.nist.gov/healthcare/testing/
Brink, S. (2014, March 11). Survey: Health Records Hassle Is Top Area of Doctor
Dissatisfaction. Retrieved February 23, 2015, from http://health.usnews.com/health-
news/hospital-of-tomorrow/articles/2014/03/11/survey-health-records-hassle-is-top-area-
of-doctor-dissatisfaction
Canada Health Infoway. (n.d.). Better Health Together. Retrieved February 12, 2015, from
https://www.infoway-inforoute.ca/en/our-partners/canadians/better-health-together
Canada Health Infoway, (2014). Connecting patients with providers. Retrieved from website:
https://www.infoway-inforoute.ca/en/component/edocman/1890-connecting-patients-
with-providers-a-pan-canadian-study-on-remote-patient-monitoring-executive-
summary/view-document
Canada Health Infoway. (2014, April 1). Mobile Health Computing Between Clinicians and
Patients [White Paper]. Retrieved February 23, 2015, from https://www.infoway-
inforoute.ca/en/component/edocman/1883-mobile-health-computing-between-clinicians-
and-patients-white-paper-full-report/view-document

51. 46
Canadian Medical Association. (2014, May 1). How can Canada achieve enhanced use of
electronic medical records. Retrieved February 24, 2015, from
https://www.cma.ca/Assets/assets-library/document/en/advocacy/Enhanced-Use-of-
EMRs-Discussion-Paper-Final-May-2014.pdf
Ciampa, M., & Revels, M. (2013). Regulatory Compliance: Regulations. In Introduction to
healthcare information technology (First ed., pp. 11-13). Boston, MA: Course
Technology.
Comstock, J. (2013, July 17). Remote patient monitoring to save $36B by 2018. Retrieved
February 14, 2015, from http://mobihealthnews.com/23880/remote-patient-monitoring-
to-save-36b-by-2018/
Comstock, J. (2014, May 29). Mobihealthnews. Retrieved from
http://mobihealthnews.com/33594/survey-one-third-of-docs-recommended-a-health-app-
to-patients/
Comstock, J. (2014, March 14). Report: 1.7b to download health apps by 2017. Retrieved
February 5, 2015, from http://mobihealthnews.com/20814/report-1-7b-to-download-
health-apps-by-2017/
Conn, J. (2014, November 19). Healthcare providers deploy apps and devices to engage patients
and cut costs. Retrieved March 2, 2015, from
http://www.modernhealthcare.com/article/20141129/magazine/311299980
Crespo, M., & McLaughlin, P. (2013, May 21). The proliferation of mobile devices and apps for
health care: Promises and risks. Retrieved from http://www.bna.com/the-proliferation-
of-mobile-devices-and-apps-for-health-care-promises-and-risks/

52. 47
Denton, D. (2014, August 21). EHR Must Fit Into Doctor-Patient Relationship -
InformationWeek. Retrieved February 21, 2015, from
http://www.informationweek.com/healthcare/electronic-health-records/ehr-must-fit-into-
doctor-patient-relationship/a/d-id/1298168
Enriquez, J. (2014, September 10). How Digital Health Is Thriving In Canada. Retrieved
February 19, 2015, from http://nuviun.com/content/how-digital-health-is-thriving-in-
canada
Federal Communications Commission. (2015, March 11). Rural Health Care Program. Retrieved
March 28, 2015, from http://www.fcc.gov/encyclopedia/rural-health-care
Federation of State Medical Boards. (2014, April 1). Model Policy for the Appropriate Use of
Telemedicine Technologies in the Practice of Medicine. Retrieved March 3, 2015, from
http://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/FSMB_Telemedicine_Policy
.pdf
Food and Drug Administration. (2015, February 1). Examples of MMAs the FDA Has Cleared
or Approved. Retrieved March 14, 2015, from
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ConnectedHealth/M
obileMedicalApplications/ucm368784.htm
Food and Drug Administration. (2014, June 4). Mobile Medical Applications. Retrieved March
3, 2015, from
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ConnectedHealth/M
obileMedicalApplications/ucm255978.htm
Georgiou, A., Prgomet, M., & Westbrook, J. (2009). The Impact of Mobile Handheld
Technology on Hospital Physicians' Work Practices and Patient Care: A Systematic

53. 48
Review. Journal of the American Medical Informatics Association, 16(6), 792-801.
Retrieved February 23, 2015, from http://jamia.oxfordjournals.org/content/16/6/792.long
Health Canada. (Dec. 3, 2010). Notice: Software Regulated as a Class I or Class II Medical
Device (File No. 10-125797-779). Retrieved March 7, 2015, from
http://www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/md-im/activit/announce-
annonce/md_notice_software_im_avis_logicels-eng.pdf
Health Canada. (2013, September 25). Software Regulated as a Medical Device- Frequently
Asked Questitons. Retrieved March 14, 2015, from http://www.hc-sc.gc.ca/dhp-mps/md-
im/activit/announce-annonce/md_qa_software_im_qr_logicels-eng.php
Hickey, K. (2015, February 10). FDA opens the doors for mHealth apps -- GCN. Retrieved
February 27, 2015, from http://gcn.com/articles/2015/02/20/fda-app-regulation.aspx
HIMSS. (2015, January 1). About Health Information Managment Systems Society. Retrieved
March 10, 2015, from http://www.himss.org/aboutHIMSS/
HIMSS. (2015). HIMSS Analytics Stage 7 Award Paperless and Proud of IT. Retrieved March
13, 2015, from http://app.himssanalytics.org/hc_providers/stage7Award.asp
HIMSS Analytics. (2015). Provider Solutions. Retrieved March 13, 2015, from
http://www.himssanalytics.org/provider-solutions#block-himss-general-himss-prov-sol-
emram
Hines, M. (2014, November 1). The development of mhealth technology is challenging the
effectiveness of current regulation. Retrieved February 12, 2015, from
https://www.gowlings.com/KnowledgeCentre/article.asp?pubID=3789#”11”

54. 49
Huang, G. (2015, January 28). Mobile health adoption growing among doctors, for apps and
content. Retrieved from http://www.meddatagroup.com/mobile-health-adoption-growing-
among-doctors-for-apps-and-content/
Insight Driven Health: Getting EMR Back in the Fast Lane. (2014, February 10). Retrieved from
http://www.accenture.com/us-en/Pages/insight-getting-emr-back-fast-lane-summary.aspx
Jahns, R. (2013, March 7). Research2guidance. Retrieved March 4, 2015, from
http://research2guidance.com/the-market-for-mhealth-app-services-will-reach-26-billion-
by-2017/
Jeswiet, J., & McAllister, P. (2003). Medical device regulation for manufacturers. Journal of
Engineering in Medicine, (6), 459-67. Retrieved March 3, 2015, from
http://www.ncbi.nlm.nih.gov/pubmed/14702983
Kaba, R., & Sooriakumaran, P. (2007). The Evolution of The Doctor-patient Relationship.
International Journal of Surgery, 5(1), 57-65. Retrieved February 17, 2015, from
http://www.journal-surgery.net/article/S1743-9191(06)00009-4/fulltext
Kazmi, Z. (2013). Effects of exam room EHR use on doctor-patient communication: A
systematic literature review. Informatics in Primary Care, 21(1), 30-39. Retrieved
February 8, 2015, from
http://docserver.ingentaconnect.com/deliver/connect/bcs/14760320/v21n1/s6.pdf?expires
=1428532987&id=81413283&titleid=6073&accname=Guest
User&checksum=FCE3F5411BC12A229E74B625A8800504
Kitsis, E., & Shmerling, R. (2014, October 1). Ethics Forum: Electronic Health Records Raise
Concerns about Physician-Patient Relationship. Retrieved March 5, 2015, from
http://www.the-

55. 50
rheumatologist.org/details/article/6808071/Ethics_Forum_Electronic_Health_Records_R
aise_Concerns_about_Physician-Patient_Re.html
Lewis, N. (2012, July 24). Remote Patient Monitoring Market To Double By 2016 -
InformationWeek. Retrieved March 21, 2015, from
http://www.informationweek.com/mobile/remote-patient-monitoring-market-to-double-
by-2016/d/d-id/1105484?
Leyva, C. (2013, February 3). HIPAA Omnibus Rule. Retrieved February 13, 2015, from
http://www.hipaasurvivalguide.com/hipaa-omnibus-rule.php
Lovett, M. (2014, November 14). Is your EHR damaging the patient-provider relationship?
Retrieved February 10, 2015, from http://www.healthcareitnews.com/blog/your-ehr-
damaging-patient-provider-relationship
Lustig, T. (2012). The role of telehealth in an evolving health care environment workshop
summary. Washington, D.C.: National Academies Press.
AAPM&R - American Academy of Physical Medicine and Rehabilitation. (2015, January
1). Retrieved February 5, 2015, from http://www.aapmr.org/research/meaningful-
use/Pages/Stages-of-Meaningful-Use.aspx
Luxton, D., Kayl, R., & Mishkind, M. (2012). MHealth Data Security: The Need for HIPAA-
Compliant Standardization. Telemedicine and E-Health, 18(4), 284-288. Retrieved March
9, 2015, from http://southmed.usouthal.edu/library/classes/mi-
mobile/mHealthDataSecurity.pdf
MedConnex. (2013, December 23). The usage of electronic health records in canada. Retrieved
from http://www.medconnex.com/post/the-usage-of-electronic-health-records-in-canada

56. 51
Morrissey, J. (2014, July 8). Remote patient monitoring: How mobile devices will curb chronic
conditions. Retrieved February 8, 2015, from
http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/chronic-
care/remote-patient-monitoring-how-mobile-devices-will-curb-c?page=full
Murfin, M. (2013). Know your apps: An evidence-based approach to evaluation of mobile
clinical applications. Journal of Physcian Assistant Education, 24(3), 38-40. Retrieved
from http://www2.paeaonline.org/index.php?ht=a/GetDocumentAction/i/152769
ONC. (2013, January 15). Five steps organizations can take to manage mobile devices used by
health care providers and professionals. Retrieved February 16, 2015, from
http://www.healthit.gov/providers-professionals/five-steps-organizations-can-take-
manage-mobile-devices-used-health-care-pro
Pennic, F. (2015, February 24). 66% of Americans Would Use Mobile Health Apps to Manage
Their Health. Retrieved from http://hitconsultant.net/2015/02/24/66-of-americans-would-
use-mobile-health-apps/
PewResearchCenter. (n.d.). Mobile technology fact sheet. Retrieved from
http://www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/
Protti, D. (2015, March 1). Missed Connections: The Adoption of Information Technology in
Canadian Healthcare [PDF]. Retrieved March 28, 2015, from
http://www.cdhowe.org/pdf/commentary_422.pdf
Rosin, T. (2014, November 07). Clinicians' use of mobile devices in hospitals: 17 statistics,
consequesnces and concerns. Retrieved from
http://www.beckershospitalreview.com/healthcare-information-technology/clinicians-
use-of-mobile-devices-in-hospitals-17-statistics-consequences-and-concerns.html

57. 52
Rouse, M. (2014). What is remote patient monitoring (RPM)? - Definition from WhatIs.com.
Retrieved February 25, 2015, from http://searchhealthit.techtarget.com/definition/remote-
patient-monitoring-RPM
Saleem, J., Flanagan, M., Russ, A., McMullen, C., Elli, L., Russell, S., … Frankel, K. (2014).
You and me and the computer makes three: variations in exam room use of the electronic
health record. Journal of the American Medical Informatics Association, 21, 147-151.
Retrieved from http://jamia.oxfordjournals.org/content/21/e1/e147
Sher, J. (2014, December 12). Medical apps draw scrutiny. Retrieved January 16, 2015, from
http://www.lfpress.com/2014/09/11/health-canada-concerned-about-explosion-of-
medical-apps
Spalter, J. (2014, April 28). Mobile Health Tools Make Big Impact. Retrieved from
http://www.huffingtonpost.com/jonathan-spalter/mobile-health-tools-
make_b_4861181.html
Standards & Testing. (n.d.). Retrieved April 27, 2015, from
http://www.nist.gov/healthcare/testing/index.cfm
telehealth. (n.d.) Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied
Health, Seventh Edition. (2003). Retrieved April 9 2015 from http://medical-
dictionary.thefreedictionary.com/telehealth
The Canadian Press. (2014, December 2). More doctors keep patient records electronically,
survey suggests. Retrieved February 19, 2015, from
http://www.cbc.ca/news/health/more-doctors-keep-patient-records-electronically-survey-
suggests-1.2857225

58. 53
U.S. Department of Health and Human Services, The Office of the National Coordinator for
Health Information Technology. (2014). Connecting health and care for the nation: A 10-
year vision to achieve an interoperable health it infrastructure. Retrieved from
http://www.healthit.gov/sites/default/files/ONC10yearInteroperabilityConceptPaper.pdf
U.S. Department of Health and Human Services , Office of the National Coordinator for Health
Information Technoloy. (2014). Update on the adoption of health information technology
and related efforts to facilitate the electronic use and exchange of health information.
Retrieved from website:
http://www.healthit.gov/sites/default/files/rtc_adoption_and_exchange9302014.pdf
U.S Department of Health and Human Services. (2003, January 1). Summary of the HIPAA
Privacy Rule. Retrieved March 9, 2015, from
http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html
U.S. Department of Health and Human Services, (2003). Summary of the HIPAA Security Rule.
Retrieved March 9, 2015, from
http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html
U.S. Food and Drug Administration, (2015). Mobile medical applications. Retrieved from
website: http://www.fda.gov/downloads/MedicalDevices/../UCM263366.pdf
Ventola, C. L. (2014). Mobile Devices and Apps for Health Care Professionals: Uses and
Benefits. Pharmacy and Therapeutics, 39(5), 356–364.
Wang, J. (2014, July 11). HIPAA Compliance: What Every Developer Should Know. Retrieved
February 24, 2015, from
""HYPERLhttp://www.informationweek.com/healthcare/security-and-privacy/hipaa-
compliance-what-every-developer-should-know/a/d-id/1297180?page_number=2

59. 54
Zelmer, J. (2015, January 30). Interview by D Taylor [Web Based Recording]. Would you like
access to your digital health records, or would you worry about privacy?. Retrieved from
http://www.cknw.com/2015/01/30/your-health-first/
Zephyr. (2015). Zephyr life home- remote patient monitoring system. Retrieved from
http://zephyranywhere.com/healthcare/zephyrlife-home/
Zwerneman, H. (2014, July 31). Everything You Need to Know About Mobile Health Apps.
Retrieved from http://blog.capterra.com/everything-need-know-mobile-health-apps/