information infrastructures, with emphasis on developments in rural areas; and recommendations for addressing key issues and challenges specific to rural areas.

Over the past several decades, two important trends shaping health care delivery have accentuated the need for information and communications technology (ICT) as a key tool for supporting system improvement. First, there has been an exponential increase in medical knowledge. Sizable public and private investments in clinical research have led to a vastly expanded clinical knowledge base and many new drugs, medical devices, and other interventions, offering much potential to improve health and reduce pain and suffering. But translating new medical knowledge into practice has been difficult and slow (Balas et al., 1998).

It is no longer possible for an individual clinician, relying solely on the unaided human mind, to remain abreast of the expanding knowledge base and apply this knowledge appropriately to each patient (Becher and Chassin, 2001; Jerome et al., 2001). Computer-aided decision supports (e.g., reminders, prompts, and alerts) are needed to translate knowledge effectively into practice and safely utilize the many drugs and devices currently available.

Second, the life expectancy of the American public has been increasing (in part as a result of successes of the health care system), leading to an increased need for the management of chronic conditions (Anderson and Horvath, 2002; IOM, 2001a, 2003e; NCHC, 2002). About 40 percent of the American public have one or more chronic conditions, and approximately one-half of these individuals have two or more such conditions (Anderson and Horvath, 2002). Individuals with multiple chronic conditions see an average of six different clinicians per year and often receive care in multiple settings (e.g., hospital, rehabilitation facility, home health care provided in the community). Appropriate management of chronic conditions requires a high degree of communication among members of the care team and between clinicians and patients (as well as informal caregivers), and immediate access to complete patient records by all authorized users. Management of many chronic conditions also requires informed and engaged patients willing to modify health behaviors, monitor key health indicators, and implement complex medication and treatment regimens.

In the current health care delivery system, however, most critical patient information is recorded in handwritten medical records dispersed across various settings, including ambulatory practices, hospitals, nursing homes, and others. Clinical information does not travel with the patient, nor is it readily accessible by clinicians or the patient. Lacking computerized patient

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