By extension, the use of patient records that are linkable requires coordination among the institutions that are likely to contribute to or use such records. Thus, autonomy within and among provider institutions must be addressed when planning and implementing CPR systems.

Disaggregation of care (i.e., the delivery of medical care by many small providers who operate independently of and in competition with one another) has significant implications for the adoption of a coordinative, systemwide technology. Such technology is often subject to nonadditive benefits—that is, the benefits of collaboration among multiple providers outweigh the benefits of individual adoption. As a result, providers have fewer incentives to acquire such technology (NAS, 1979).

The reimbursement policies that are applied to providers influence their willingness and ability to acquire CPR technology. For instance, under cost-based reimbursement schemes, providers have more incentive to acquire technologies that are reimbursable than technologies that are not reimbursable. In contrast, prospective payment systems create incentives for institutions to reduce costs—and thus to acquire potentially cost-reducing technologies such as CPR systems. Under current reimbursement policies, any potential acquisition of new technology must contribute to the improvement of a provider's financial status or at least be budget neutral. It should also substantially improve patient care processes, for example, by providing clinical decision support or by giving complete record access to authorized personnel.

Leadership

Given the fragmented environment of the U.S. health care system, it is not surprising that at present no one organization or agency is leading the effort to establish the necessary infrastructure for national implementation of CPRs and CPR systems. National and regional organizations may be knowledgeable about the issues, but they are not consistently soliciting information from or educating their members about CPRs. Thus, despite the many aspects of CPRs that are in need of coordination, no organization has the operational responsibility and funds to establish programs and projects to set the direction for the health care industry. Overcoming this problem could be the key requirement for progress, and the committee devoted considerable attention to discussing and formulating its primary recommendation in this area (see Chapter 5).

User Behavior, Education, and Training

Users are more likely to accept a technology if several conditions are met: they have a stake in the system; they can use it at minimum cost; the



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