point-of-care data to create delivery-based evidence and make further steps in transforming clinical practice. These data present the opportunity to develop data useful for studies needed to complement and fill gaps in randomized controlled trial (RCT) findings. In the next paper, Alexander M. Walker from Worldwide Health Information Science Consultants and the Harvard School of Public Health discusses approaches to the development, application, and shared distribution of information from large administrative databases in clinical effectiveness research. He describes augmented databases that include laboratory and consumer data and discusses approaches to creating an infrastructure for medical record review, implementing methods for automated and quasi-automated examination of masses of data, developing “rapid-cycle” analyses to circumvent the delays of claims processing and adjudication, and opening new initiatives for collaborative sharing of data that respect patients’ and institutions’ legitimate needs for privacy and confidentiality. In the context of the ongoing debate about the relative value of observational data (e.g., as provided by registries) versus RCTs, Alan J. Moskowitz from Columbia University argues that registries provide data that are important complements to randomized trials (including efficacy and so-called pragmatic randomized trials) and to analyses of large administrative datasets. In fact, Moskowitz asserts, registries can assess “real-world” health and economic outcomes to help guide decision making on policies for patient care.

Complicated research questions increasingly need current information derived from a variety of sources. One promising source is distributed research models, which provide multi-user access to enormous stores of highly useful data. Several models are currently being developed. Speaking on that topic was Richard Platt, from Harvard Pilgrim Health Care and Harvard Medical School, who reports on several complex efforts to design and implement distributed research models that derive large stores of useful data from a variety of sources for multiple users.

THE ELECTRONIC HEALTH RECORD AND CARE REENGINEERING: PERFORMANCE IMPROVEMENT REDEFINED

Ronald A. Paulus, M.D., M.B.A.; Walter F. Stewart, Ph.D., M.P.H.; Albert Bothe, Jr., M.D.; Seth Frazier, M.B.A.; Nirav R. Shah, M.D., M.P.H.; and Mark J. Selna, M.D.; Geisinger

Introduction

The U.S. healthcare system has struggled with numerous, seemingly intractable problems including fragmented, uncoordinated, and highly variable care that results in safety risks and waste; consumer dissatis-



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