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Increasing amounts of medical knowledge, clinical data, and patient expectations have created a fertile environment for developing and using clinical practice guidelines. Electronic medical records have provided an opportunity to invoke guidelines during the everyday practice of clinical medicine to improve health care quality and control costs. In this paper, efforts to incorporate complex guidelines [those for heart failure from the Agency for Health Care Policy and Research (AHCPR)] into [...]

There is an urgent need to capture and record data related to clinical outcomes, but there are many barriers. The range of problems includes lack of agreement on conceptualization of the term "outcome," inadequate measures of outcomes, and inadequate information systems to capture and manipulate data that would reflect outcomes. This article focuses on information system requirements to capture, store, and utilize clinical outcome data. For greatest accuracy, outcome data [...]

Health care delivery systems and organizations around the world are undergoing reorganization and reengineering. Rational decision making about such activities must be based on information. Much of the presently available data is inadequate for this task, and therefore needs to be transformed. One such experience in the province of Alberta, Canada, is discussed. The development of a comprehensive information strategy, the need to apply information management principles, the organizational implications [...]

From my viewpoint as a patient, 1. Medical knowledge has expanded to the point that individuals cannot adequately improve quality without the assistance of computer programs. 2. The medical profession must concentrate on why and how computer program projects must be used, not on why they cannot be used. 3. The successful application of computer programs to clinical medicine is dependent mainly on the efforts of individual institutions and people [...]

Develop a model for structured and encoded representation of medical information that supports human review, decision support applications, ad hoc queries, statistical analysis, and natural-language processing.

Develop a continuous-speech interface that allows flexible input of clinical findings into a medical diagnostic application.

To investigate the issues raised in applying a preliminary version of the GALEN compositional concept reference (CORE) model to a series of radiographic reports, and to demonstrate that the same underlying concept model could be used in conjunction with both a detailed, fine-grained model of medical records based on that used in the PEN&PAD project and with other more conventional medical-record models.

Develop standard terms and codes for recording nursing care information in patient records to permit relevant data to be abstracted into a shared database for effectiveness research.

The introduction by the Health Care Financing Administration, in 1993, of separate conversion factors for "medical" and "surgical" services to be used in calculating Medicare charges would ordinarily necessitate the use of year-specific software source code. By designing the system to utilize macro-substitution of the year in the names of Current Procedural Terminology for Physicians Code databases, database fields, and system variables, it is possible to calculate Medicare charges without [...]

To evaluate the potential ability of computerized information systems (ISs) to identify and prevent adverse events in medical patients.