a significant challenge for clinical system architects (Mandell, 1987; Benda, 1989). Experience demonstrates that providing a fee for data entry does have a positive impact. For example, the New England Deaconess Hospital found in an initial test in 1989 that paying $5 to physicians to input their own discharge summaries directly resulted in a 40 percent participation rate. Without escalating payment, 54 percent of the discharge summaries (in some months, as many as 70 percent) were entered into the system directly by physicians during the first six months of 1990 (Zibrak et al., 1990).

Technological Barriers

Several technological barriers still must be overcome before robust CPR systems can be fully realized, although no great technological breakthroughs are needed. The human interface—the place where man and machine meet—remains a major challenge (despite such advances as the graphical user interface and voice inputting) and is closely tied to system performance. As we move further into the 1990s, the major technological barriers to widespread implementation of the CPR include problems with text processing, the lack of appropriate confidentiality or security measures, and inadequate health data-exchange standards.

The Human Interface and System Performance

The lack of sufficiently powerful computing systems at an affordable price has been a major barrier to providing clinicians with an adequate human interface. Now, however, affordable state-of-the-art computer systems have been introduced, which are likely to resolve this problem. Slack (1989) argues that users of clinical systems require a response time of less than a second. Providing a simple-to-use, or nearly intuitive, human interface means dedicating a significant proportion of the computer's resources to that function, which reduces their availability for crucial clinical functions. As a result, clinical system architects in the past have generally been inclined to emphasize clinical function and performance at the expense of the human interface.

The most natural way for humans to communicate is through speech, and a great deal of computer science research has focused for decades on voice-recognition capabilities. Recently introduced, commercially viable systems address this problem in ways that are becoming acceptable to some in the health care sector, but currently available, affordable voice-recognition systems support only a portion of the health care requirements.

Three primary criteria must be met to enable widespread, effective use of such systems. First, the ability to accept and process continuous speech, that is, speaking without pausing between each individual word, is crucial.

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