I am sharing my research on The Role of Electronic Health Records in Adopting a Patient-Centric Approach of care for Patients with Autism.
The Role of Electronic Health Records in Adopting a Patient-Centric Approach of care for Patients with Autism by Mr. Carlyle-Jude T. Deauna
Introduction
Patients with autism often lived with their parents where they are confined inside their homes. In their homes, their support from others is minimal. However, the increase in resources and in autism awareness brought changes for these patients. These patients are able to connect with others. These changes, which include using computer, networking with autism groups, and developing friendships with others, gradually evolved. These even brought changes from a physician-centered approach to patient-centered approach of care. Although confined, changes occurred.
There was a cultural shift from a physician-centric approach of care to a patient-centric approach of care. In the past, it was up to the physicians to make the decisions for the patients. Seldom do the patients have a say for what is being decided for them, especially when they are adminstered many medications.
In the early 1990s, Congress had passed “The Patient Self Determination Act”. This act required organizations to specifically inform patients on what is best for them. Also, this act allowed the patients to participate in the decision-making process. Furthermore, it informed the patients of best practices. Gradually, there was a slow process of shifting from the physician-centric care approach to patient-centric care approach.
This was true for most patients at that time. However, patients with autism were left out. Their parents were not able to participate in the decision-making process. Autism was a complicated matter that could not be understood by non-medical individuals. At that time, even medical personnel did not have a clear understanding what autism is or what autism is not. The diagnosis of autism was ambiguous.
The shifting did not end from the physician-centric approach to the patient-centric approach. Other things happened, too. There was a change from the traditional single physician to a team approach of managing patients. In addition, technology was progressing, allowing collaboration to occur between specialists. This became the norm. However, those patients with autism were again left behind. Their care was still under their primary care physicians devoid of other support networks.
Then, the concept of patient-centered care evolved and the term “patient-centered care” was introduced. Healthcare organizations approved the concept of patient-centered care. These changes brought about what the health care delivery system is now. Fortunately, some of these changes affected the patient management of those with autism. Their primary care physicians still took care of them. But, they are being referred to other specialists just like the rest of the patients.
Autism is lifetime. These patients have accumulated many records since their diagnosis. The advent of EHRs made the records possible to be integrated. With the evolution of EHRs, the functions of EHRs became defined. These functions were ideal for organizing the records accumulated by the patients. For the last 15 years, physicians began to learn how to use EHRs. It was around 2000 when the Institute of Medicine gave the eight core functions of the EHR. They are the following:
1) Listing Data and Health Information—included in these functions are diagnoses, allergies, medications, and laboratory results;
2) Managing Results —results from the computers can be easily accessed;
3) Managing Orders—including the Computerized Provider Order Entry (CPOE) systems, which can improve the processes of workflow by automatically generating orders and increasing the efficiency of orders filled;
4) Supporting Decision Making—including support systems for improving preventive healthcare such as vaccinations prompts and reminders for vaccinations and screening;
5) Allowing Interoperability and Communication—wherein connectivity is improved by Electronic Health Record systems populated with data coming from the different Information Systems;
6) Improving Patient Support—including patients’ conditions being monitored by using electronic devices;
7) Reporting Administrative Procedures—including the claims and billing matters;
8) Coordinating Public Health—where improvement of surveillance practices can prevent outbreaks of diseases.
(Gartee and Beal 2-4)
Indented Quote
There is a current program that supports providers to adapt “Meaningful Use”. The providers should use a certified EHR though. This program motivated the providers to adopt the EHRs. The adoption, in return, resulted in the increase of more physicians using EHRs. Those who adopted the EHRs were mostly outpatient physicians. Therefore, these data supported the inclusion of patients with autism in this study. Outpatient physicians are usually chosen by the patients and their parents.
The patients and their parents are able to do this better because of their exposure to the use of computers and related technologies. Our society has become an information-based society. The availability of computers and technology allowed patients to have their information accessed online. These information can be shared anywhere. Even though the patients changed their residence, their information still can be integrated with the new records produce a very timely opportunity for these patients.
Information Age is helping in the diagnosis of autism. For a long time, autism was an enigma. Today, although the cause of autism is still unknown, there is an increase in the knowledge of autism and its awareness. But, there are still many questions that are left unanswered. The availability of technology brought about by the Information Age can be utilized to answer the unanswered questions. More studies should be done.
Autism is a developmental disorder. It significantly affects communication and social interaction. Usually, patients are diagnosed before the age of three. As stated earlier, autism is lifetime. Mostly the diagnosis is based on the physician’s opinion. The physicians’ opinion is affected by the observation given by the parents. Studies demonstrated that parents are accurate in reporting their observations. Therefore, it is best that parents become active participants in the diagnosis process. Observation of the parents such as patients having delayed speech, unresponsiveness, and poor eye contact were classic signs included in the diagnosis of autism before.
In neuropsychiatry, meeting diagnostic criteria allows a neuropsychiatrist to make a diagnosis of autism. The neuropsychiatrist is a physician who went for further medical training in the treatment and management of the nervous system and mental disorders. A Diagnostic and Statistical Manual of Mental Disorders (DSM), 4th Edition (DSM-IV) was published before. According to the DSM-IV, the following criteria must be met for the diagnosis of autism.
They are the following:
There must be a total of six (or more) from the qualitative impairment in social interaction (1), qualitative impairments in communication (2), and repetitive patterns of behavior (3). From
(1), (2), and (3), with at least (1) having two manifestations and from (2) and (3) having one each.
For (1), the manifestations are:
(a) impaired nonverbal behaviors like eye contact
(b) poor development to relate with peers
(c) lack of sharing enjoyment with others
(d) lack of reciprocity
For (2), the manifestations are:
⦁ lack of communication
⦁ those with speech have impairments in sustained conversations in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
⦁ repetition of words
⦁ lack of social play
For (3), the manifestations are:
⦁ preoccupation with one interest
⦁ adherence to routines
⦁ repetitive mannerisms
⦁ preoccupations with parts of inanimate objects
⦁ There are delays in of these areas before the age of 3:
⦁ interaction, using language, and symbolic play
⦁ Other childhood disorders are ruled out.
(Buckendorf 10-11)
Other questions are answered by designing an information system. In another article “Health Informatics: A Roadmap for Autism Knowledge Sharing” by Ron Oberleitner, it was pointed out that there is a need for an Autism Information Management System (AIMS) (323). It will be designed to make patient registries interoperable. The interoperability will provide a platform where information can be shared. This answers another question on what an information system should do.
In this same article, it demonstrated further that the concept of “Parent/Provider Person-Centric Information Environment”. The concept is that the environment should be a web-based EHR. The concept should be designed and maintained where the options are enhanced. The design should be able to reach out to health professionals, researchers, and educators. The objective of AIMS is to build this EHR, which is patient-based, coexisting with relevant projects, and fully integrated. This is a solution.
To solve other problems, non-governmental organizations (NGOs) and Federal Agencies, responsible for funding AIMS, should be given the ability to access the information generated. The data generated should be evaluated and monitored. The services of the AIMS should be supported. These goals are achievable by making AIMS able to electronically transfer information. The electronic transfer of information is a solution.
Another problem that needs to be solved is security. A Master Patient Index (MPI), that will be used to identify these patients, is a security solution. The MPI should be protected and solve the issue of confidentiality. Information overload should be included in the design because autism produces lots of records. It is recommended that algorithms would be used. The algorithms should be rule-based. The use of alerts, which are automated, should be able to assess and notify the providers. These approaches will make AIMS possible. It will increase the options of treatment and information sharing. This will assist in further diagnosis and treatment of autism.
Further solutions can be found by further research. Studies and research that support the partnerships of the patients, the parents, the physicians, the clients’ nurses, and public health will allow the acceptance of a patient-centric approach of care. These roles should be factors in the adoption of a patient-centric approach for patients with autism.
BODY
The Role of EHR for the Patients
Those patients who use the Web 2.0 technologies are capable of establishing connections with other patients. Being connected with others brought these patients outside their confinement. These patients have been by themselves for a long time. Now, they have the opportunity to express themselves using social media.
They are capable of exchanging ideas with other patients. They are also capable of developing friendships. Although not easy, it is highly probable. The patient centric approach will be a reality for these patients. These patients will be able to promote care collaboration between their other caregivers and providers. Also, with the use of other Web 2.0 technologies such as telemedicine and blogs, it will promote other opportunities for the patients to share online. At this point in time, Web 2.0 technologies are already in place in many of these health care organizations. Web 2.0 can be used to their advantage.
These technologies can be used to educate the patients. By doing so, they can understand better what good health is. This will benefit the patients at any range that he or she is on the autism spectrum. Most of these patients are treated as outpatients. They are educated in an office-based clinic. However, some of them are seen in the hospital setting. For example, Franciscan Hospital for Children and the Massachusetts General Hospital in Boston have specialties in treating patients with autism only.
Patients, either seen in the clinic or hospital, have an information system common to both. This commonality is the pharmacy information system. Pharmacy information system is used by pharmacists to dispense and manage medicines for their health organizations. Usually, these patients have many medications, which they take for the rest of their lives. It is best for them to learn how this information system works. By learning new skills, they will have the opportunity to search for their own medications.
These patients are taking psychotropic medications. Psychotropic medications are used to treat psychotic conditions for psychiatric patients. Also, polypharmacy is significant. Polypharmacy is when drugs are used simultaneously and overlapped with other drugs for 30 days or more. In the article “Psychotropic Medication Use and Polypharmacy in Children With Autism Spectrum Disorders” by Donna Spencer, it examined 33,565 patients, who were found out to be using psychotropic medications at a 64%. rate. The article also showed evidence of polypharmacy at a 35% rate. (Spencer 833)
The medications involved are those used as stimulants and nonstimulants for Attention Deficit Disorder (ADD), anticonvulsants, antidepressants, antipsychotics, anxiolytics, lithium, and anticholinergic. (Spencer 835)
The logic is to minimize the use of antipsychotics. Also, polypharmacy should be avoided. The use of an integrated pharmacy information system will minimize antipsychotic use and avoid the condition of polypharmacy. This system that supports pharmacists for the management and dispensing of medications is often interfaced with the other systems in the EHR. The patients can be involved with the use of the pharmacy information system, which is favorable for the adoption of the patient-centric approach.
The patient-centric approach will allow learning the pharmacy information system of the patients possible. It will be challenging but doable. For this to work, they need a simple terminology guide that includes the name of the drugs and describe the action of the drugs. This will give the patients the edge to learn such terms which are in Latin and Greek. This advantage is crucial for implementing the treatment plan that involved the patients for a long time now since they were diagnosed with autism at a young age. It is evidenced that the efficacy of these drugs are based on what they observed in these patients primarily. Therefore, this is vital for the patients’ management.
The evidence for the efficacy of multidrug treatments of these patients was described as “woefully inadequate”, which should not be. The medications are used for these patients again and again, although “woefully inadequate”. Added research is definitely necessary as soon as possible. These patients use these drugs practically every day. The reason behind its use should be defined and should be supported by scientific studies. Using these drugs for trial-and-error should be avoided in these patients. A patient-centric approach can bring about a more systematic insight of the medications given.
(Spencer 839)
Feedback from the patients is one of the best criteria for gauging the efficacy of the drug or the medication being given to them. Although difficult to achieve, it is attainable. If enough opportunity of learning the pharmacy information system is done, then these patients can be partnered with their providers. They can give their input, even on a daily basis. The availability of the EHR integrated with the pharmacy information system will be a factor for achieving this. A “normal” everyday functioning of these patients is very possible. Feedback from the patients is very helpful with ongoing research, too. These studies are happening right now.
The Role of EHR for the Patients’ Parents
The benefits of EHRs for the patients’ parents can be derived from the use of the Personal Health Record (PHR). PHRs are applications done electronically for the purpose of accessing and sharing the patient’s health information with providers and caregivers. The benefits of using PHRs can be accessed and shared by the parents if there is good usability available.
In the article “Usability and perceived usefulness of personal health records for preventive health care: A case study focusing on patients’ and primary care providers’ perspectives” by A. Ant Ozok et al., it evaluated the usability of the PHRs and how it improved the patients’ preventive care. A multi-method study approach was done. The results of this study showed that PHRs have to be easy to use. Actually, this is the most important characteristic of usability. Nielsen (1993) stated an HIT system can be used easily but usability should be defined first.
(Ozok 615)
Usability has other characteristics. In addition to being learned easily and efficiently, it needs to have great memorability. Memory is the ability to retain and retrieve information for a long time. With memorability, the parents can learn the PHRs. Likewise, it has to have high-level of satisfaction for the parents. When satisfied in using the PHRs, these parents will be constant users of this system. Finally, the number of errors should be at the minimum. If this is can be done, the parents themselves will appreciate the PHR.
The results of the qualitative analysis showed both positive and negative perceptions about the system. Positive perception improved the communication with the providers. Meanwhile, negative perceptions need to be improved. One of the negative perceptions that needs to be improved is the ambiguity of the autism medical terminology. This can be avoided by learning medical terminology. Learning medical terminology can be made simple. This can be done by relating the anatomy and the physiology of the body to the terms. Anatomy is the study of structures; Physiology is the study of the functions of the human body.
With regards to satisfaction, the article showed that it had a rating of 82%, which was high. These outcomes resulted in having fewer mistakes. It also resulted in better correspondence. In this way, PHRs, of the patients, is the right system to share. With high satisfaction together with the rest of the characteristics of usability, the patient-centric approach is enhanced.
The PHRs will allow for a more patient-centric approach. With good medical terminology guidelines supported by high usability, parents will be able to partner up with the providers and caregivers. The patient-centric approach will benefit the parents the most. They can advocate better for their children. For a very long time, the parents are by themselves, too. Just like their children, the role of EHRs is becoming clearer.
The dramatic changes are happening for the parents. They can have healthy lifestyles. They have more time. They spend less energy. They have additional resources available to fulfill the demands of their children. The routines demanded by the patients can easily be established. An example of this is when patients are seen routinely by their physicians at their clinics. Parents will experience less resistance if routines are established.
Trust can be established and the patient-centric approach will be reinforced. Building a communication line will cement the patients, the parents, the providers, and the caregivers together. The communication line is the PHR. Trust is built and commitment is seen, leading to the reinforcement of patient-centric approach. The role of the EHRs for the adoption of the patient-centric approach is clear.
The Role of EHR for the Patients’ Physician
The clinicians can take advantage of the EHRs, too. With the EHRs, they can get access to information anywhere at anytime. They can report significant clinical information and upgrade it whenever necessary. Also, the EHRs will allow the clinicians to access complete and well-organized medical records. These records are usually legible for other clinicians to read. Their practices are made safer because errors such as juxtaposition, omission, and commission are avoided. When the patients meet with their providers, orders are made. Clinicians give their orders verbally or write the orders themselves. This is no longer happening on providers using EHRs. EHRs are now integrated with the Computerized Provider Order Entry (CPOE).
The CPOE is the electronic application of the physicians’ orders. It has been proven to have increased the safety of the patient. The CPOE gives the physicians the capability to use a Decision Support System (DSS). DSS is part of the CPOE, which improves diagnosis and the medical care of the patients by alerts, reminders, and guidelines provided by the support system .
According to the textbook “HEALTH CARE INFORMATION SYSTEM: A PRACTICAL APPROACH FOR HEALTH CARE MANAGEMENT” by Karen A. Wager, it was written that CPOE reduced prescription errors by 80%. The medication errors were reduced by 43%. Drug reactions that can be detrimental to the patient was avoided by 37.5%. These events were reduced just because the CPOE was used instead of the handwritten format. (Shamliyan, Duval, Jing, & Kane, 2008). The results included pediatric cases in an outpatient setting. With these data, it can be inferred that patients with autism were included in this study. This showed that medication errors and adverse drug reactions are also reduced by the patients’ physicians by using CPOE.(123)
Other benefits of using CPOE are well-documented. Studies have been made to prove this. The study, though, was based on the trends created by physicians using EHRs. An increase in the use of the EHRs meant an increase in the use of CPOE. CPOE is a system that is integrated with the EHR.
In this figure, it showed that office-based physicians have used any EHR systems from 18.2% (2001) to 71.8% (2012). This was a 53.6% increase. With this increase, it can be inferred that patients with autism have their paper-formatted medical records converted into the electronic format. This transformation is a major contributor for the shift in physician-centric approach to a patient-centric approach. With a 53.6% increment of the EHR system usage, this is a huge opportunity for patients with autism and their parents to be involved in the EHR system.
The role of the EHR is with the patients’physician is the most important aspect taken when safety is considered. It made the workflow for the patient management focused. Because of the EHR, the patients’physicians can track their orders better. The CPOE, used with the PIS, further ensures the safety of these patients. It should always be remembered that most of these patients are medicated with many drugs.
The Role of EHR for the Clients’ Nurses
The EHR is used by the clients’ nurses as a tool to facilitate and to communicate patient care. The clients’ demand for nursing care is on a constant basis. When trust is established between the clients and the nurses, the stress is diminished.
The EHR gives the nurses more chances to access the clients’ records. With these chances, the nurses are able to focus more on their clients. Additionally, the nurses are able to document better because they can do it now in real-time. The nurses are able to implement the Clinical Care Classification (CCC) model.
The CCC model is integrated with the EHR. It is capable of providing better care by allowing more interaction between the clients and the nurses. Also, the CCC system can be individualized, making the plan specific for a particular client. Accommodation of the clients’ needs are better addressed. Autism is a spectrum; therefore, the treatment should be ideally individualized. The CCC system can do just that.
The CCC system is a way of documenting the process of nursing in the EHRs. Based on previous studies, the CCC system was designed by nurses for other nurses to use; however, it can be used by nurses with their clients in an interactive process. There are six steps to follow in the CCC model. This was adapted from the Standard of Care of the American Nurses Association in 1998. The six steps are the following:
⦁ Assessing the health data of the clients
⦁ Analyzing the assessed data, thereby determining the diagnosis
⦁ Identifying outcomes, expected from individual clients
⦁ Developing a plan of care for the purpose of intervention
⦁ Implementing the interventions recognized in the care plan
⦁ Evaluating how the clients made progress towards attaining the expected outcomes
(Gartee 191)
These six steps permit nurses to be more competent. They can be shared with the clients and their parents, permitting the patient-centric approach to thrive. Because of this, the nurses have more time to spend with their clients. Time is important for client education. This is now possible. With the CCC in place, the learning process is doable. The individualized plan can be properly implemented and evaluated.
There were reasons why positive reactions occurred. The reasons are: 1) Increased data was made available; 2) Redundancy was reduced; 3) Information access was faster. The use of VLER was found out to augment trust and assurance, which are important factors for the success of a patient-centric approach of nursing care. The CCC can be integrated with a VLER-like system, further improving the coordination of health care delivery for these clients. A coordinated and integrated system of clients and parents, together with their caring nurses, will definitely benefit clients with autism.
The role of EHR in Public Health
The EHR is useful for patients with autism when incorporated with public health. The Americans with Disability Act incorporates patients with autism as patients with disabilities. In the article Health Information exchange: persistent challenges and new strategies by Joshua R. Vest and Larry D. Gamm, it stated how information sharing had been a problem for health care organizations in general, including public health. (Vest and Gamm 288) This article stated further that there are simple solutions available though. With a large portion of the patients’ records still in paper-based format, timely solutions are needed.
Solutions were found out to be from previous strategies adapted before. One of these solutions is using previous experiences learned. Incorporating these ideas from the status quo can be a source of the solutions. Another solution is adopting a business model that is focused on cost-effectiveness. A solution related to public health is keeping the patients healthy. Patients with autism are included with this solution. These public health practices should be connected to the best technology to ensure success. Finally, a solution, is involving the participation of the federal, state, and local governments. These will lead to good results.
As the digital age continues to progress, achieving a coordinated HIE with public health will be a reality. Patients with autism will benefit from this integration because public health issues will be brought to the awareness of the public. With the patient-centric approach, public health issues become clearer. Patients with autism, who need lifetime support, will need a Public Health Information System (PHIS) integrated with their EHRs. A component of PHIS includes the patients’ childhood immunization records.
The patients’ childhood immunization records are records of immunization needed to protect the children against diseases that may harm or disable these children. The following is a list of vaccines that are recommended for children and adolescents with autism. This is from the Center for Disease Control (CDC, 2005):
⦁ Diphtheria
⦁ Haemophilus influenza type B (Hib)
⦁ Hepatitis (for selected populations)
⦁ Hepatitis B
⦁ Inactivated poliovirus
⦁ Influenza (for selected populations)
⦁ Measles
⦁ Meningococcal (for selected populations)
⦁ Mumps
⦁ Pertussis
⦁ Pneumococcal (for selected populations)
⦁ Rubella
⦁ Tetanus
⦁ Varicella
(Nies 273)
The integration of childhood immunizations is necessary to avoid missing boosters. According to the US Government’s objective, 95% of children from kindergarten to the first grade should be 95% vaccinated. A fully integrated EHR with PHIS will give patients with autism further advantages. In the past, a significant number of these patients missed their vaccinations and their boosters just because of inadequate records and follow-ups.
Issues in public health will not be complete without obesity being mentioned. Obesity is the main concern of public health at this time.
There are approximately nine million children over six years old who are considered obese. This data was taken years ago and therefore, this number had increased. The obesity rate within this age group—2 to 5 years—had doubled. The obesity rate for adolescents from 12 to 19 years old had doubled over the past 30 years , too.
(Nies 614)
These children are prone to the complications of obesity, which are preventable. The complications of obesity include diabetes, hypertension, and others. Therefore, children with autism can avoid these complications. These are all preventable. The role of EHRs led to more patient-centric approaches being adopted these days. A patient-centric approach will help in the health maintenance of these patients. When the patients are involved with their parents, providers, and caregivers, these complications can be avoided in the future. The role of the EHRs with public health is a reality today.
CONCLUSION
The role of EHRs, in the adoption of patient-centric approach for patients with autism, cannot be overemphasized. There are many. Despite the fact that the EHRs have their own advantages, they also have their disadvantages, too. One of the real concerns of EHRs is the cost of its conversion. High costs are involved. Training is needed and maintenance is necessary. Also, constant updates are needed.
When one’s personal information is published online, there is likelihood that it can be hacked. Violation of the Health Insurance Portability and Accountability Act (HIPAA) can happen. This is not good for the patients with autism. Their privacy, which is their right, should not be made public. There should be a limited access to their multitude of records. Their confidentiality should be respected.
Although the patients with autism have disabilities, safeguards should be implemented to secure their EHRs. Their EHRs can be secured by security programs. These can be done by designing controls where only authorized persons can access his or her records. Their EHRs can be secured by technical means. These can be done by using user-based accounts where codes are encrypted. A security access, that will allow opening accounts remotely, should be provided. Patients with autism should be able to access their accounts anywhere and anytime.
There is a need for innovations that will allow for more adoption of the patient-centered care approach. The patients with autism have routines. These routines can be used for their advantages. These routines can be established and be connected with AIMS. Therefore, AIMS should be made operational as soon as possible.
Patients with autism can establish “connections” with inanimate objects and with systems such as the EHRs. The EHRs can be their “companions”. They can even have the pharmacy information systems as their “friends” that they can play with, just like any video games and other softwares.
The patients’ parents can understand better their children’s conditions with the availability of a reliable terminology guide. They can learn and understand the PHIs. If they can learn and understand the PHI of their children, they can advocate better for their children these days.
The patients’ physician can be partners with their patients. This can done by using certified EHRs. Certified EHRs have highly functioning CPOE. The CPOE, which minimizes errors, can avoid the conditions of polypharmacy today. Patients who are under psychotropic medications can now be observed more closely. The safety of the patient is prioritized. The adoption of the patient-care approach, made possible by certified EHRs, allows a safer method of ordering medications for these patients.
The clients’ nurses have the capacity to utilize their CCC model, wherein they can now monitor the orders and even monitor those drugs administered to their clients. The CCC model can be integrated with a VLER like health information exchange system that will allow for the exchange of information to the different providers and caregivers. They can better educate their clients with autism and give their nursing care needs constantly. The patient-centered approach, cemented by trust, will bring more competence to the nursing care.
Public health issues—immunization and obesity—can now be followed up with accuracy. The PHIS developed can be integrated with EHRs. The integration of these systems make public health issues of yesteryears manageable. All these benefits were augmented because of the adoption of the patient-centric approach. They became realities for most of these patients. The increase in the number of primary care physicians using EHRs will further boost the adoption of a patient-centric approach. The many forgotten patients with autism are now coming into light. This is good news.
Works Cited
⦁ Bansal, Gaurav, Fatemeh “Mariam” Zahedi, and David Gefen. "The Impact of Personal Dispositions on Information Sensitivity, Privacy Concern and Trust in Disclosing Health Information Online." Decision Support Systems 49.2 (2010): 138-50. Web. 3 Nov. 2014.
⦁ Bartos, Christa E., Brian S. Butler, Louis E. Penrod, Douglas B. Fridsma, and Rebecca S. Crowley. "Negative CPOE Attitudes Correlate with Diminished Power in the Workplace." AMIA 2008 Symposium Proceedings Page (n.d.): 36-40. American Medical Informatics Association. Web.
⦁ Buckendorf, G. Robert., and John Liedel. Autism: A Guide for Educators, Clinicians, and Parents. Greenville, SC: Thinking Publications, 2008. Print.
⦁ Byrne, Colene M. "The Department of Veterans Affairs' (VA) Implementation of the VLER." (n.d.): n. pag. Web. Oct. 2014.
⦁ Chabner, Davi-Ellen. The Language of Medicine. St. Louis, MO: Saunders/Elsevier, 2007. Print.
⦁ Durkin, Maureen S., Deborah A. Bilder, Sydney Pettygrove, and Walter Zahorodny. "The Validity and Usefulness of Public Health Surveillance of Autism Spectrum Disorder." Autism (2014): 1-2. Web.
⦁ Fombonne, Eric. "Validation of the Diagnosis of Autism in General Practitioner Records." (n.d.): 1-9. Web. Oct. 2014.
⦁ Friedenberg, Jay, and Gordon Silverman. Cognitive Science: An Introduction to the Study of Mind. Thousand Oaks: SAGE, 2012. Print.
⦁ Gartee, Richard, and Sharyl Beal. Electronic Health Records and Nursing. Upper Saddle River, NJ: Prentice Hall, 2011. Print.
⦁ Hirdes, John P., Brant E. Fries, John N. Morris, Knight Steel, Vince Mor, Dinnus Frijters, Steve Labine, Corinne Schalm, Michael J. Stones, Gary Teare, Trevor Smith, Mounir Marhaba, Edgardo Pérez, and Palmi Jónsson. "Integrated Health Information Systems Based on the RAI/MDS Series of Instruments." Healthcare Management Forum 12.4 (1999): 30-40. Web.
⦁ "Home - Franciscan Hospital for Children." Franciscan Hospital for Children Home Comments. N.p., n.d. Web. 23 Nov. 2014. <http://franciscanhospital.org/>.
⦁ Hsiao, Chun-Ju. "Trends in Electronic Health Record System Use Among Office-based Physicians: United States, 2007-2012." (n.d.): 1-17. Print.
⦁ Jha, Ashish K., Catherine M. Desroches, Eric G. Campbell, Karen Donelan, Sowmya R. Rao, Timothy G. Ferris, Alexandra Shields, Sara Rosenbaum, and David Blumenthal. "Use of Electronic Health Records in U.S. Hospitals." New England Journal of Medicine 360.16 (2009): 1628-638. Web.
⦁ Liptak, Gregory S., Tami Stuart, and Peggy Auinger. "Health Care Utilization and Expenditures for Children with Autism: Data from U.S. National Samples." Journal of Autism and Developmental Disorders 36.7 (2006): 871-79. Web.
⦁ Macharia, Paul. "Open Data Kit, A Solution Implementing a Mobile Health Information System To Enhance Data Management in Public Health." (2013): n. pag. Web. Sept. 2014.
⦁ Mamishev, Alexander, and Murray Sargent. Creating Research and Scientific Documents with Microsoft Word. Redmond, WA: Microsoft, 2013. Print.
⦁ "Massachusetts General Hospital." Home. N.p., n.d. Web. 23 Nov. 2014. <http://www.massgeneral.org/>.
⦁ McGonigle, Dee, and Kathleen Garver. Mastrian. Nursing Informatics and the Foundation of Knowledge. Burlington, MA: Jones and Bartlett, 2015. Print.
⦁ McNellis, Carol Anne, and Todd Harris. "Residential Treatment of Serious Behavioral Disturbance in Autism Spectrum Disorder and Intellectual Disability." Child and Adolescent Psychiatric Clinics of North America 23.1 (2014): 111-24. Web.
⦁ Morrell, Maureen F., and Ann Palmer. Parenting across the Autism Spectrum: Unexpected Lessons We Have Learned. London: Jessica Kingsley, 2006. Print.
⦁ Nies, Mary A., and Melanie McEwen. Community/public Health Nursing: Promoting the Health of Populations. 4th ed. N.p.: n.p., n.d. Print.
⦁ Oberleitner, Ron. "Health Informatics: A Roadmap for Autism Knowledge Sharing." (n.d.): n. pag. Web. Sept.-Oct. 2014.
⦁ Ozok, A. Ant, Huijuan Wu, Melissa Garrido, Peter J. Pronovost, and Ayse P. Gurses. "Usability and Perceived Usefulness of Personal Health Records for Preventive Health Care: A Case Study Focusing on Patients' and Primary Care Providers' Perspectives." Applied Ergonomics 45.3 (2014): 613-28. Web.
⦁ Schwalbe, Kathy. Information Technology Project Management. Boston, MA: Course Technology, 2011. Print.
⦁ Spencer, D., J. Marshall, B. Post, M. Kulakodlu, C. Newschaffer, T. Dennen, F. Azocar, and A. Jain. "Psychotropic Medication Use and Polypharmacy in Children With Autism Spectrum Disorders." Pediatrics 132.5 (2013): 833-40. Web.
⦁ "Study Shows Benefits of Using Clinical Decision Reminders With EHRs - IHealthBeat." Study Shows Benefits of Using Clinical Decision Reminders With EHRs - IHealthBeat. IHealthBeat, 18 Apr. 2011. Web. 23 Nov. 2014. <http://www.ihealthbeat.org/articles/2011/4/18/study-shows-benefits-of-using-clinical-decision-reminders-with-ehrs>.
⦁ Vest, Joshua R. "Health Information Exchange: Persistent Challenges and New Strategies." (n.d.): 288-94. Web. Sept. 2014.
⦁ Wager, Karen A., Frances Wickham Lee, and John P. Glaser. Health Care Information Systems: A Practical Approach for Health Care Management. 2nd ed. San Francisco: Jossey-Bass, 2009. Print.
⦁ Wiseman, Nancy D., and Kim Painter. Koffsky. Could It Be Autism?: A Parent's Guide to the First Signs and next Steps. New York: Broadway, 2006. Print.
