where proximity between the health care team members and the patient was the rule, the patient and care team in the outpatient setting meet more by appointment than by clinical demand. Relying on paper-based mail is inefficient and fallible. Clinicians need integrated communications support for effective functioning of the multidisciplinary outpatient health care team (Tang et al., 1996). A communications infrastructure that is linked to the shared patient record facilitates overall coordination of care and timely response to changing patient conditions.

Clinical Decision Support

Few, if any, commercial systems provide a high level of proactive decision support. Drug interaction checking and simple abnormal laboratory-test result alerts are available, but the richness of applying a broad range of knowledge to influence physicians' orders is still under development (Johnson, 1994).

Only when both patient data and clinical knowledge reside in the system in machine-understandable format can the system provide additional support to the clinician making decisions. For example, encoded medical knowledge about the meaning and significance of changing laboratory-test results would allow a system to provide alerts, an active function, in addition to the passive data retrieval function. Similarly, if the system could match the patient context with relevant clinical guidelines, it could present ordering options consistent with the appropriate guidelines. The clinician is responsible for the definitive decision, but the system can actively provide options and explanations that improve the clinician's efficiency and compliance with accepted guidelines of practice.

In summary, since the first edition, there has been a significant increase in development efforts on CPR systems. We remain optimistic that the remaining years of the decade-long challenge will deliver on the promises of computer-supported decision making.

At the Fork

In 1991, the Committee on Improving the Patient Record reported that the most advanced CPR systems were found in several academic medical centers or teaching hospitals affiliated with universities as well as in the Department of Veterans Affairs and the Department of Defense. Not surprisingly, today the most advanced CPR systems implemented in the United States can be found in the same places. Of the seven institutions that have been recognized as part of the Computer-based Patient Record Institute Davies CPR Recognition Program (described below), four are academic medical centers and one is the Department of Veterans Affairs. One of the distinguishing factors of institutions that have been recognized as having advanced CPRs is the clear organizational leadership and commitment to CPR system implementation that helped make their efforts successful (CPRI, 1995c, 1996c, 1997).



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