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Empowering personal health records (PHRs) provides basic human right, awareness, and intention for health promotion. As health care delivery changes toward patient-centered services, PHRs become an indispensable platform for consumers and providers. Recently, the government introduced “My health bank,” a Web-based electronic medical records (EMRs) repository for consumers. However, it is not yet a PHR. To date, we do not have a platform that can let patients manage their own PHR.
This study creates a vision of a value-added platform for personal health data analysis and manages their health record based on the contents of the "My health bank." This study aimed to examine consumer expectation regarding PHR, using the importance-performance analysis. The purpose of this study was to explore consumer perception regarding this type of a platform: it would try to identify the key success factors and important aspects by using the importance-performance analysis, and give some suggestions for future development based on it.
This is a cross-sectional study conducted in Taiwan. Web-based invitation to participate in this study was distributed through Facebook. Respondents were asked to watch an introductory movie regarding PHR before filling in the questionnaire. The questionnaire was focused on 2 aspects, including (1) system functions, and (2) system design and security and privacy. The questionnaire would employ 12 and 7 questions respectively. The questionnaire was designed following 5-points Likert scale ranging from 1 (“disagree strongly”) to 5 (“Agree strongly”). Afterwards, the questionnaire data was sorted using IBM SPSS Statistics 21 for descriptive statistics and the importance-performance analysis.
This research received 350 valid questionnaires. Most respondents were female (219 of 350 participants, 62.6%), 21-30 years old (238 of 350 participants, 68.0%), with a university degree (228 of 350 participants, 65.1%). They were still students (195 out of 350 participants, 56.6%), with a monthly income of less than NT $30,000 (230 of 350 participants, 65.7%), and living in the North Taiwan (236 of 350 participants, 67.4%), with a good self-identified health status (171 of 350 participants, 48.9%). After performing the importance-performance analysis, we found the following: (1) instead of complex functions, people just want to have a platform that can let them integrate and manage their medical visit, health examination, and life behavior records; (2) they do not care whether their PHR is shared with others; and (3) most of the participants think the system security design is not important, but they also do not feel satisfied with the current security design.
Overall, the issues receiving the most user attention were the system functions, circulation, integrity, ease of use, and continuity of the PHRs, data security, and privacy protection.
A personal health record (PHR) is an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards, and that can be drawn from multiple sources while being managed, shared, and controlled by the individual [
PHR is that part of the electronic medical records (EMRs) or Electronic Health Records (EHR) that an individual “owns” and controls. In Taiwan, hospitals adopted EMR in 2004. It was related with the introduction of a basic format of EMR. In 2007, the National Health Informatics Project (NHIP) was promoted to implement the infrastructure of health information by the government to prepare the EMR exchange, and encourage hospitals to use EMR. In 2008, clinical document architecture (CDA) was adopted by the government to create 108 basic formats of EMR. The government of Taiwan also provided incentives to hospitals that adopted EMR. Until 2015, 406 hospitals (90% of Taiwan’s hospitals) already earned rewards and could exchange EMR with each other.
The research on PHR has increased. In the past, EMRs were stored in a large database; different medical service providers in the hospital could access the medical records in the database, but transfer between different hospitals was a problem. Thus, the implementation of PHRs allowed patients to achieve the integration of their PHRs and medical records [
Some studies listed the benefits of using PHR, including reducing health care costs, improving personal health outcomes, and improving the experience of care for patients and their families [
The current mechanism of medical record exchange in an EMR exchange center plays a role of a personal EMR platform. Through the Exchange Center, a medical record previously created in any hospital can be accessed from another hospital to reduce duplicate examinations, accelerate diagnosis and treatment, and reduce the medical resource burden. The medication record in the EMR is very conducive to decision-making by doctors to avoid drug allergies and other medical disputes. The importance of a personal EMR platform to a medical institution and its members is like the importance of the clients’ information to an enterprise, which is the basis for providing good service.
Although EMR is already being used well, the medical records are still owned by hospitals; people cannot own and manage their health care record. Therefore, the Ministry of Health and Welfare introduced the concept of “My health bank” in 2015 to let patients own their PHR. In the last three years, this initiative permitted people to download the integrated medical record from the Internet, which includes outpatient and hospital records, diagnosis, drug use records, cost, laboratory test and health examination report, allergies, and so on. It lets people view and manage their health care record at any time and from any place. However, “My health bank” still has some problems. The information it includes is a general report with no detailed content; it doesn’t have medical images, the content is still not standardized, and people can not add their own data regarding diet, exercise, nutrition records, or the health examination report from another examination center.
We still do not have a platform that can let patient manage their own PHR. This study creates a vision of a value-added platform for personal health data analysis and management of health records on the basis of the contents of the "My health bank"; patients can retrieve their health records and medical records through the personal EMR platform to manage their own health conditions. The availability of medical records can contribute to the transparency of the medical records and facilitate immediate access to the medical contents, thereby allowing discussions of disease conditions with the patients’ relatives and friends and related medical personnel. Thus, the ownership of the medical record is reverted to the patient.
The National Committee on Vital and Health Statistics found that a critical success factor for PHRs is the provision of software tools that help patients manage their own health conditions [
This research gives a vision of the electronic PHR management platform and uses importance-performance analysis (IPA) to identify the important factors from patients' perspectives. The purpose of this study was to explore consumer perception regarding this kind of platform, and try to both identify the key success factors and important aspects using importance-performance analysis, and give some suggestions for future development based on the findings.
In this study, we used a cross-sectional study design. We let the participants watch a Web-based video on the vision of personal EMR platform. After the video introduction, we asked them to fill a structured questionnaire on the Internet (created by Google Form) for quantization of their acceptance and importance of the personal EMR platform’s functions and security.
In this study, we developed a Web-based video simulation describing the scenario of the personal EMR platform's operation, as shown in
After viewing the video, the participants were asked to fill out a Web-based questionnaire in Google Form regarding the importance and satisfaction of the performance of the personal EMR platform.
Scenario of personal electronic medical record platform.
In order to explore their impact on public acceptance of the personal EMR platform and its importance, this study utilized a questionnaire on importance-performance analysis [
We modified this questionnaire into 2 main constructs including (1) system functions and (2) system design and security and privacy, with 12 and 7 questions, respectively. The questionnaire was designed following 5-point Likert scale with the scale ranging from 1 (“disagree strongly”) to 5 (“Agree strongly”).
Before the study, this study invited 4 experts to do expert validity and was pretested by 30 patients. No major problems emerged during this pretest. As showed in
Questionnaire design and reliability analysis.
Aspect | Definition | Questions | Cronbach alpha |
System functions | People’s opinion of satisfaction and importance of personal EMRa platform’s system function | 12 | .936 |
System design and security | People’s opinion of satisfaction and importance of personal EMR platform’s system design and security | 7 | .917 |
aEMR: electronic medical record.
This study used random sampling of the Internet users. We put the video on the YouTube platform from 31st March 2014 to 9th April and publicized it through email and Facebook. After participants finished watching this video, they were asked to fill the questionnaire (Web-based questionnaire in Google sheet format).
The sample size was calculated by using the Magnani [
This study used Excel (Microsoft) and SPSS (IBM Corp) as statistic tools for analysis. We used descriptive statistics to calculate the mean, standard deviation, median, frequency distribution, and percentage statistics to ascertain the data distribution in system functions, and system design and security. The objective was to examine the relationship between characteristics of participants, as well as all of the aspects above, and set 0.05 as the significance level; if
We also performed IPA to measure the participants’ attitudes toward the personal EMR platform’s functions. We calculated the mean of every factor in “system functions” and “system design and security” aspects, and we put them in a quadrant diagram.
This research gathered 350 valid questionnaires. As shown in
Characteristics of respondents.
Characteristics | n (%) | |||
Male | 131 (37.4) | |||
Female | 219 (62.6) | |||
<20 | 46 (13.1) | |||
21-30 | 238 (68.0) | |||
31-40 | 56 (16.0) | |||
>40 | 10 (2.9) | |||
High school degree | 8 (2.3) | |||
University degree | 228 (65.1) | |||
Institute or above | 114 (32.6) | |||
Students | 195 (55.7) | |||
Services | 61 (17.4) | |||
Manufacturing | 29 (8.3) | |||
Financial industry | 7 (2.0) | |||
Military and police education | 47 (13.4) | |||
Unemployed | 11 (3.1) | |||
<30,000 | 230 (65.7) | |||
30,001~50,000 | 94 (26.9) | |||
50,001~70,000 | 21 (6.0) | |||
>70,001 | 5 (1.5) | |||
Northern Taiwan | 236 (67.4) | |||
Central Taiwan | 49 (14.0) | |||
Southern Taiwan | 55 (15.7) | |||
Eastern Taiwan | 7 (2.0) | |||
offshore islands | 3 (0.9) | |||
Excellent | 28 (8.0) | |||
Good | 171 (48.9) | |||
Normal | 132 (37.7) | |||
Poor | 19 (5.4) |
The Importance-performance Analysis (IPA) framework was introduced by Martilla and James [
In this study, the questionnaire was divided into “system functions” and “system design and security,” the two aspects that evaluate the relationship between importance and satisfaction of performance. We focused on the key area for improvement in the second quadrant of the IPA to identify the services showing high importance and low satisfaction of performance to determine the improvement priorities. This analysis is expected to provide direction for future enhancement and implementation of the personal EMR platform as a reference for government agencies and system developers.
In the system function part, as shown in
Satisfaction of performance and importance with the order of every question in system function part (order 1: most important or satisfied, 12: least important or satisfied).
Question | Satisfaction of |
Order | Importance, |
Order | Quadrant | Chuchiming |
F1. Personal EMRa platform have detailed operating instructions | 3.42 (0.92) | 12 | 4.19 (0.78) | 7 | Ⅱ | 0.71 |
F2. Personal EMR platform lets patients integrate existing paper-based medical history | 3.66 (0.83) | 10 | 4.15 (0.73) | 9 | Ⅲ | 0.11 |
F3. Personal EMR platform lets patients access their own PHR from other hospitals to avoid duplication of examinations, tests, and medication | 3.89 (0.89) | 4 | 4.38 (0.69) | 1 | Ⅰ | 3.00 |
F4. Personal EMR platform lets patients integrate their own PHR data and provide continuous numerical statistics | 3.72 (0.88) | 8 | 4.20 (0.74) | 6 | Ⅱ | 0.33 |
F5. Personal EMR platform allow doctors to add more details on the medical records | 3.77 (0.92) | 7 | 4.22 (0.77) | 5 | Ⅰ | 0.40 |
F6. Personal EMR platform lets patients maintain and keep complete personal “health record” (such as disease history, medication history, and blood pressure) | 3.93 (0.88) | 3 | 4.31 (0.72) | 3 | Ⅰ | 0.00 |
F7. Personal EMR platform lets patients maintain and keep complete personal “health examination record” (such as blood test and urine test reports) | 3.95 (0.86) | 1 | 4.26 (0.72) | 4 | Ⅰ | −0.75 |
F8. Personal EMR platform lets patients maintain and keep complete personal “medical image” (such as X-ray and MRI) | 3.87 (0.86) | 5 | 4.19 (0.76) | 7 | Ⅰ | −0.29 |
F9. Personal EMR platform lets patients maintain and keep complete personal “endoscopic image” | 3.80 (0.89) | 6 | 4.14 (0.78) | 10 | Ⅳ | −0.40 |
F10. Personal EMR platform lets patients maintain and keep complete personal medical record (such as diagnosis and prescriptions) | 3.95 (0.86) | 1 | 4.34 (0.73) | 2 | Ⅰ | −0.50 |
F11. Personal EMR platform lets patients share their PHR with family (friends) to enable them understand their health condition | 3.53 (1.01) | 11 | 3.74 (1.02) | 12 | Ⅲ | −0.08 |
F12. Personal EMR platform lets patients share their medical records with another physician as a reference when diagnosis is carried out | 3.72 (0.91) | 8 | 4.08 (0.84) | 11 | Ⅲ | −0.27 |
aEMR: electronic medical record.
bindex developed by Dr Chuchiming. In this study, Chuchiming index>0 indicates items need concerted improvement (perceiving targets), Chuchiming index<0 indicates resources can be drawn from items (shifting resources), Chuchiming index=0 indicates items can fit people’s expectation (balancing items).
In
It also has 5 functions with below average satisfaction of performance, including “detailed personal EMR platform operating instructions” (F1), “integrating existing paper-based medical history” (F2), “sharing PHR with family or physician” (F11, F12), and “integrating their own PHR data and provide continuous numerical statistics” (F4).
It means a paperless process or sharing with others is not seen as important functions by the participants. They just want to have a platform that can let them maintain and keep complete personal records and basic medical images.
After conducting the Analysis of Variance (ANOVA) test, we didn’t find any significant difference between the various age groups, annual income groups, and health status groups, meaning that the results described above are consistent in every group.
In the system design and security part, as shown in
Satisfaction of performance and importance with their order of every question in system design and security part (order 1: most important or satisfied, 7: least important or satisfied).
Question | Satisfaction of |
Order | Importance, |
Order | Quadrant | Chuchiming |
S1. The interface should be simple and easy to understand | 3.82 (0.91) | 3 | 4.28 (0.76) | 4 | Ⅳ | −0.25 |
S2. Personal EMRa platform lets patients access their own PHRb quickly | 3.91 (0.86) | 1 | 4.25 (0.71) | 7 | Ⅳ | −0.86 |
S3. Personal EMR platform lets patients login by multiple methods such as citizen digital certificate, id, and password. | 3.87 (0.92) | 2 | 4.39 (0.86) | 1 | Ⅰ | 1.00 |
S4. Personal EMR platform lets patients access their own PHR under a secure environment | 3.78 (0.96) | 4 | 4.34 (0.76) | 2 | Ⅱ | 1.00 |
S5. Personal EMR platform lets patients login by id and password | 3.73 (0.85) | 7 | 4.27 (0.82) | 5 | Ⅲ | 0.40 |
S6. Personal EMR platform lets patients login by “Citizen Digital Certificate” | 3.76 (0.95) | 6 | 4.26 (0.80) | 6 | Ⅲ | 0.00 |
S7. Personal EMR platform lets patients set access rights for every physician, family, or friend. | 3.78 (0.92) | 5 | 4.29 (0.76) | 3 | Ⅲ | 0.67 |
aEMR: electronic medical record.
bPHR: personal health record.
cindex developed by Dr Chuchiming. In this study, Chuchiming index>0 indicates items need concentrated improving (perceiving targets), Chuchiming index<0 indicates resources can be drawn from items (shifting resources), Chuchiming index=0 indicates items can fit people’s expectation (balancing items).
In
After conducting the ANOVA test, we found some differences in system design and security part in terms of the importance attributed to system design and security part, as shown in
Differences found in analysis of importance and satisfaction of performance between every demographic class in system design and security part by analysis of variance (ANOVA) test.
Attitude | Category | N | Mean (SD) | |||
Importance | ||||||
<20 | 46 | 4.034 (0.657) | 2.586 | .05 | ||
21-30 | 238 | 4.315 (0.637) | ||||
31-40 | 56 | 4.258 (0.616) | ||||
>40 | 10 | 4.371 (0.629) | ||||
High school | 8 | 4.161(0.442) | 0.504 | .60 | ||
University degree | 228 | 4.251(0.640) | ||||
Institute or above | 114 | 4.316(0.656) | ||||
Students | 195 | 4.315(0.624) | 0.734 | .60 | ||
Services | 61 | 4.253(0.661) | ||||
Manufacturing | 29 | 4.118(0.615) | ||||
Financial industry | 7 | 4.122(0.550) | ||||
Military and police education | 47 | 0.204(0.720) | ||||
Unemployed | 11 | 4.351(0.611) | ||||
<30,000 | 230 | 4.276(0.634) | 0.270 | .76 | ||
30,001~50,000 | 94 | 4.280(0.615) | ||||
50,001~70,000 | 26 | 4.181(0.727) | ||||
Northern Taiwan | 236 | 4.308(0.636) | 1.510 | .20 | ||
Central Taiwan | 49 | 4.262(0.629) | ||||
Southern Taiwan | 55 | 4.171(0.648) | ||||
Eastern Taiwan | 7 | 3.796(0.552) | ||||
offshore islands | 3 | 4.333(1.033) | ||||
Poor | 19 | 4..180(0.789) | 0.349 | .79 | ||
Normal | 132 | 4.260(0.664) | ||||
Good | 171 | 4.272(0.615) | ||||
Excellent | 28 | 4.367(0.594) | ||||
Satisfaction of performance | ||||||
<20 | 46 | 3.637(0.739) | 1.533 | .20 | ||
21-30 | 238 | 3.867(0.773) | ||||
31-40 | 56 | 3.737(0.794) | ||||
>40 | 10 | 3.614(1.149) | ||||
High school | 8 | 3.821(0.457) | 1.097 | .34 | ||
University degree | 228 | 3.853(0.766) | ||||
Institute or above | 114 | 3.719(0.839) | ||||
Students | 195 | 3.834(0.762) | ||||
Services | 61 | 3.763(0.872) | ||||
Manufacturing | 29 | 3.828(0.732) | ||||
Financial industry | 7 | 3.918(0.605) | ||||
Military and police education | 47 | 3.699(0.869) | ||||
Unemployed | 11 | 3.948(0.652) | ||||
<30,000 | 230 | 3.822(0.763) | 4.074 | .02 | ||
30,001~50,000 | 94 | 3.888(0.786) | ||||
50,001~70,000 | 26 | 3.401(0.889 | ||||
Northern Taiwan | 236 | 3.810(0.733) | 0.962 | .43 | ||
Central Taiwan | 49 | 3.843(0.764) | ||||
Southern Taiwan | 55 | 3.813(0.765) | ||||
Eastern Taiwan | 7 | 3.306(0.871) | ||||
offshore islands | 3 | 4.238(0.719) | ||||
Poor | 19 | 3.143 (0.838) | 5.077 | .002 | ||
Normal | 132 | 3.874 (0.723) | ||||
Good | 171 | 3.825 (0.774) | ||||
Excellent | 28 | 3.852 (0.934) |
Differences found in analysis of importance and satisfaction with performance between every demographic class in system functions part by analysis of variance (ANOVA) test.
Attitude | Category | N | Mean (SD) | |||
Importance | ||||||
<20 | 46 | 3.984(0.677) | 2.406 | .07 | ||
21-30 | 238 | 4.209(0.588) | ||||
31-40 | 56 | 4.198(0.536) | ||||
>40 | 10 | 4.417(0.626) | ||||
High school | 8 | 4.208(0.396) | 1.204 | .30 | ||
University degree | 228 | 4.148(0.607) | ||||
Institute or above | 114 | 4.254(0.588) | ||||
Students | 195 | 4.233(0.594) | 1.565 | .17 | ||
Services | 61 | 4.111(0.636) | ||||
Manufacturing | 29 | 3.994(0.440) | ||||
Financial industry | 7 | 3.845(0.667) | ||||
Military and police education | 47 | 4.234(0.632) | ||||
Unemployed | 11 | 4.205(0.503) | ||||
<30,000 | 230 | 4.198(0.610) | 0.387 | .68 | ||
30,001~50,000 | 94 | 4.230(0.560) | ||||
50,001~70,000 | 26 | 4.154(0.635) | ||||
Northern Taiwan | 236 | 4.215(0.596) | 1.037 | .27 | ||
Central Taiwan | 49 | 4.197(0.528) | ||||
Southern Taiwan | 55 | 4.089(0.594) | ||||
Eastern Taiwan | 7 | 3.786(0.829) | ||||
offshore islands | 3 | 4.111(1.197) | ||||
Poor | 19 | 4.154(0.709) | 0.267 | .85 | ||
Normal | 132 | 4.152(0.605) | ||||
Good | 171 | 4.204(0.594) | ||||
Excellent | 28 | 4.232(0.521) | ||||
Satisfaction of performance | ||||||
<20 | 46 | 3.601(0.699) | 1.282 | .28 | ||
21-30 | 238 | 3.815(0.717) | ||||
31-40 | 56 | 3.702(0.757) | ||||
>40 | 10 | 3.725(1.069) | ||||
High school | 8 | 3.844(0.649) | 0.522 | .59 | ||
University degree | 228 | 3.792(0.713) | ||||
Institute or above | 114 | 3.710(0.780) | ||||
Students | 195 | 3.788(0.710) | 0.734 | .60 | ||
Services | 61 | 3.745(0.820) | ||||
Manufacturing | 29 | 3.690(0.600) | ||||
Financial industry | 7 | 3.738(0.598) | ||||
Military and police education | 47 | 3.722(0.845) | ||||
Unemployed | 11 | 3.924(0.619) | ||||
<30,000 | 230 | 3.747(0.702) | 4.366 | .01 | ||
30,001~50,000 | 94 | 3.904(0.754) | ||||
50,001~70,000 | 26 | 3.442(0.831) | ||||
Northern Taiwan | 236 | 3.757(0.765) | 0.526 | .72 | ||
Central Taiwan | 49 | 3.847(0.610) | ||||
Southern Taiwan | 55 | 3.759(0.679) | ||||
Eastern Taiwan | 7 | 3.476(0.830) | ||||
offshore islands | 3 | 4.208(1.018) | ||||
Poor | 19 | 4.180(0.789) | 0.349 | .79 | ||
Normal | 132 | 4.260(0.664) | ||||
Good | 171 | 4.272(0.615) | ||||
Excellent | 28 | 4.367(0.594) |
Quadrant diagram of the importance and performance of product establishment and functionality.
Quadrant diagram of the importance and performance of the security of the system.
Liang’s [
This study focused on system functions and system design and security to identify the key functions of patients’ views by using IPA to determine which functions people think are important for them. The study can serve as a guide when this kind of platform is built in the future. We found people do not need overly complex functions; they just want a platform that lets them integrate and manage their medical visits, health examination, and life behavior record. However, viewing the Web-based medical image is not an important function for them, and they also do not care if their PHR is shared with others. Surprisingly, most of the participants think the system security design is not important. The importance of 5 of 7 questions in total is below average (4.29, 1: most not important, 5: most important); they only think “letting patients login by multiple methods, such as citizen digital certificate, id and password” and “letting patients access their own PHR under a secure environment” is important. Satisfaction in performance is also not high. The significance of only 3 of 7 questions is higher than average (3.8). We also found that the satisfaction regarding performance is of lower importance not only in system functions aspects but also in system design and security aspects. This means that although they think some of the system functions and system security design are not very important, they are not satisfied even when the system has these functions. However, although future personal EMR platform could have many system security designs, people may still not think these are enough to make sure the system is secure.
With increased acceptance of PHR, users increasingly believe that the use of a personalized EMR could help them understand their own medical records. Research on PHR became more popular in recent years; however, most of the research was focused on investigating the use of doctors and nurses’ satisfaction. Rarely were the patients’ views given consideration. Some studies have also pointed out that if the patients are satisfied with the use of information in this context, one could improve the feasibility of using PHR [
Compared with these studies, our results are similar; however, our study focused on system functions and system design and security. These questions are related to perceived usefulness, patient and health professional interaction, and management and interoperability aspects for perceived usefulness. Our research found participants pay more attention to how PHR can help them manage their health records, such as medical records, health examination records, and medical images, while also helping them avoid duplication of examinations, tests, and medication. For patient and health professional interactions, participants think PHR can let physicians add more details to the medical records; regarding management and interoperability, it was found in our study that detailed operating instructions, log in methods, and operation with secure methods are important for the participants, but the satisfaction with performance are below average.
Overall, the issues receiving the most user attention were the system functions, circulation, integrity, ease of use, continuity of the PHR, and data security and privacy protection. “My health bank” query service implemented by the government in recent years allows patients to check medical records (including the date of medical treatment, drug use, inspection report, and the doctor's advice) for 1 year through a personal certificate. Through this access, the integrity and continuity of PHRs can be achieved, but the propaganda for publicity still needs to be strengthened. In future, the government should provide functions and services that can meet the needs of the users, which will also enable the users to understand their own medical records, enhance understanding of the disease for the doctors, enhance the quality of EMR writing, reduce duplicated examinations, and develop holistic care.
The personal EMR platform concept proposed in this study is relatively new in Taiwan. Most people are not yet aware of this process. Therefore, their understanding of the personal EMR platform may be poor. In this study, the system was introduced by way of a video to ensure that the participants understood as much as possible before they began to fill out the Web-based questionnaire, which we expected to reduce possible errors. Although the accuracy and validity of the data were not validated due to the lack of sample representation and extrapolation of the results, this prospective study can act as a reference for future studies on the development of the domestic personal EMR platform.
This study was conducted only by a Web-based questionnaire survey. Most of the participants were people with high Internet usage, young, and the areas of residence were concentrated in the north, which could cause the findings to be generalized to the whole population. Therefore, if the results were to extend to other regions or remote areas, there may be a gap. We suggest that future researches could use diversification methods for the survey.
electronic medical records
Personal Health Records
None declared.