are developed at different institutions, the ability to share these databases will become important. Anticipating this need, the Center for Medical Informatics at the Columbia Presbyterian Medical Center has been exploring and testing the development of the Arden syntax for medical logic modules (Hripcsak et al., 1990). The Arden syntax is designed to facilitate the sharing of medical knowledge and is especially well suited for the transfer of medical knowledge bases among disparate medical decision support systems.

Clinical data derived from operational CPR systems will contribute significantly to the body of medical knowledge used by future medical decision support systems. Indeed, it is highly probable that CPR systems may realize their full impact only when used in conjunction with medical decision support systems. Similarly, medical decision support systems are likely to mature only when medical knowledge can be readily transferred between systems. Therefore, indirectly, the Arden syntax may be crucial to the rate of CPR system deployment.

Clinician Interaction and Resistance

Perhaps the single greatest challenge that has consistently confronted every clinical system developer is to engage clinicians in direct data entry. Clinical systems have used many different strategies to solve this problem; they range from eliminating the need for clinician input to mandating direct data entry by clinicians.

The LDS Hospital in Salt Lake City, Utah, is a good example of an innovative approach to circumvent resistance to clinician data entry. As discussed earlier in this chapter, the hospital's HELP system directly captures clinical data (from the laboratory, intensive care units, and other departments) virtually without human intervention wherever possible; it uses specially designed data-capture devices attached to conventional medical instruments that convert analog to digital information. Today, most vendors of such medical instruments and devices provide computer-ready output capabilities as standard equipment or as options.

Other systems require data to be typed by clinicians or by some intermediary. Yet the bulk of the patient record is still unstructured text, such as the patient history, the discharge summary, and physical examination findings; this text must be entered into the clinical system either by dictation, which must be transcribed in some timely manner, or by automated speech-recognition systems. Another alternative is for the information to be typed manually into the system. Many system developers have attempted to use typed input, but this approach has generally failed because busy clinicians reject it. The next section discusses possible technical support to overcome clinician resistance to interacting with CPR systems.

Finding appropriate mechanisms to encourage direct clinician input remains



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