transfers, laboratory orders and reports, charges, and other activities. Most vendors of computer systems support this standard, which is also widely used internationally.

Radiology has been particularly active in standards development, dating back to the early 1980s. The American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) have cooperated to produce initial standards for exchanging digital radiological images and then to revise them in the face of changing technologies and user needs (ACR, 1994; OTA, 1995). The original standards emphasized connections between digital imaging equipment (e.g., a CT scanner) and display units and involved both hardware and software specifications. More recent work has focused on improving network communications capabilities and reducing hardware requirements. The major product as been the Digital Imaging and Communication in Medicine (DICOM) standard, which is now in its third version. A new working group has been considering whether and how to broaden the scope of DICOM by including other disciplines (e.g., cardiology, pathology) and other kinds of health information (ACR/NEMA, 1995).

Managing the Old and the New

A major issue for managers remains the rapid obsolescence—or at least succession—of hardware and software. Progress in information technologies often seems to comes in 18-to-36-month cycles that bring significant increases in processing speeds, storage capacity, or other technical dimensions. The advances that make systems faster, better, cheaper, more flexible, or convenient can be simultaneously satisfying and aggravating.

For example, as organizations move toward an integrated electronic patient record, they may not find it affordable or practical to replace all their older information systems for pharmacy, radiology, pathology, and other services. Thus, they often must develop innovative methods for connecting old, so-called "legacy" systems to new systems until it becomes possible to replace the old ones. In an increasingly competitive, cost-dominated environment, decisions about how much (and how) to invest in information technologies are both difficult and critical.

If the old systems have been abandoned by their manufacturers



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