The development and implementation of electronic health records (EHR) have occurred slowly in the United States. To date- these approaches have- for the most part- followed four developmental tracks: (a) Enhancement of immunization registries and linkage with other health records to produce Child Health Profiles (CHP)- (b) Regional Health Information Organization (RHIO) demonstration projects to link together patient medical records- (c) Insurance company projects linked to ICD-9 codes and patient records for cost-benefit assessments- and (d) Consortia of EHR developers collaborating to model systems requirements and standards for data linkage. Until recently- these separate efforts have been conducted in the very silos that they had intended to eliminate- and there is still considerable debate concerning health professionals access to as well as commitment to using EHR if these systems are provided. This paper will describe these four developmental tracks- patient rights and the legal environment for EHR- international comparisons- and future projections for EHR expansion across health networks in the United States.