It is probably not feasible to store all material on-line. It is difficult to say where the boundary between historical and recent data should be. It could be time based but equally it could be file size based. If an E.H.R. was introduced any down time would be disastrous if widespread and ideally would need to be kept localised. The number and size of these databases can be debated.
Access is a major issue.
On the one hand the consumer needs to be protected but on the other there are circumstances, particularly emergency situations, where the needs of the clinician should over-ride consent. If the system had a very strict audit trail of those accessing the data, and this was available to the consumer, and very heavy penalties were imposed for breaches, then consumers might feel more comfortable. In relation to the list of possible identifying mechanisms listed in the paper, not every-one has a drivers licence, swipe cards and PINs get lost or abused and therefore would introduce and administrative nightmare and the high technology suggestions are neither robust nor cost effective at the moment. Unless all health care providers are involved you again get into a situation where multiple systems are running in parallel creating an extremely inefficient environment. Given previous experience with the implementation of products at a State level, the enormity of this project should not be underestimated.