and seldom contain patient record data other than, for example, laboratory results, drug prescriptions, or diagnostic codes. Some systems store patient data, but none of them fully replaces the paper-based patient record. Many existing systems are not connected or are only loosely interconnected in networks. CPRs are being developed as part of a hospitalwide network (Degoulet et al., 1991; Van Mulligen et al., 1994; Scherrer et al., 1995) or as stand-alone or interconnected applications, such as in primary care (Westerhof et al., 1987; Branger et al., 1992; van der Lei et al., 1993). Increasingly, systems are being interconnected by electronic data interchange.

The field of hospital information systems in Europe consists, on the one hand, of mainly homemade systems (e.g., Bakker, 1984; Scherrer et al., 1995) sometimes supporting a group of hospitals and, on the other, of systems offered by industry, mainly of U.S. origin. A wide variety of information systems are operational on different platforms. Information systems in Europe reflect the differences in health care organizations which arise from the different historical developments, legislation, education, and languages among European countries. Therefore, systems developed in one European country are rarely installed in another country. This is also why the European hospital information system industry, with few exceptions, is virtually absent from the global market.

The differences in health care structures of different European countries might pose less of a problem for patient-centered approaches, such as CPRs. In all countries, patient care itself is quite similar. Europe has succeeded early at its attempts at CPR development and has since made considerable progress in the use of CPRs, especially in the primary care setting (van der Lei et al., 1991a; Millman et al., 1995). On the basis of these successes, several collaborative projects were started in health care; these were financially subsidized in part by the European Union (EU, 1994). Three developments related to CPRs in Europe deserve attention: the use of CPRs in the primary care setting, in hospitals, and for shared care (i.e., collaboration between care providers). In addition, in the area of standardization in health care, the European Union plays a pivotal role on a global scale as well (De Moor, 1993).

Network technology and communication (in Europe the latter is called telematics) are now prominent developments in information technology and have a large impact on health care (Branger et al., 1992; EU, 1994). By using standard communication networks and standard software (De Moor, 1993), data interchange between the four levels of health care delivery (i.e., the region, the institution, the clinical department or outpatient clinic, and the individual physician, nurse, or patient) is more efficient. A fully operational exchange of patient data between systems, with proper authorization, is one of the present challenges in European health care.

The data in CPRs are not begging to be used for electronic data exchange, research, and shared care. The use of CPRs for purposes other than direct patient care has been associated with several problems (van der Lei et al., 1991a; Vlug

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