clinical outcomes associated with alternative treatment options and care processes; identification of best practices; and evaluation of the effects of different methods of financing, organizing, and delivering services.

Both private- and public-sector groups have identified the need to move forward expeditiously with the automation of clinical information. In 1991, the IOM issued a report concluding that computer-based patient records are an “essential technology” for health care and that electronic records should be the standard for medical and all other records related to health care. In that same year, the U.S. General Accounting Office issued a report stating that automated medical records offer great potential to improve patient care, increase efficiency, and reduce costs, and calling for the development of standards to ensure uniform electronic recording and transmission of medical information. A 1993 report of the U.S. General Accounting Office called for leadership and the acceleration of efforts to develop standards. In 1997, a revised edition of the 1991 IOM report noted the strides that had been made in the power and capacity of personal computers and other computer-based technologies, the remarkable growth of the Internet for research and some health applications, the increasing level of computer literacy among health professionals and the public, and the linkage of organizations and individuals in local and regional networks that were beginning to tackle the development of population databases.

Some health care organizations have made important advances, but overall progress has been slow. In a few large systems—most notably the health systems of the Department of Veterans Health Affairs—integrated electronic records systems have been implemented. There are also examples of robust, well-integrated hospital-based information systems (National Research Council, 2000), such as Intermountain Health Care (in Salt Lake City, Utah), but they are few and notable for their rarity. Many other organizations have automated major portions of clinical information systems—laboratory data, order entry, and the like—and others are on their way to becoming paperless in the next few years (McDonald et al., 1997; Warden and Lawrence, 2000).

There are numerous barriers to the automation of clinical information. The remainder of this section addresses four of these barriers: privacy concerns, the need for standards, financial requirements, and human factors issues.

Privacy Concerns and the Need for Standards

Two of the greatest impediments to the widespread automation of clinical information are the absence of national policies pertaining to privacy, security, and confidentiality and the lack of standards for the coding and exchange of clinical information (e.g., definitions and nomenclature, patient identifiers, and electronic transfer) (Dwyer, 1999; Kleinke, 1998; McDonald, 1998; U.S. Department of Commerce, 1994). Indeed, the issues of protecting privacy and data standardization are closely interrelated. In 1998, for example, plans of the De-



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