A comic saying attributed to Yogi Berra states: "When you come to the fork in the road, take it." In contrast to the early CPR system adopters, most health care institutions are standing at the fork, trying to decide whether or not to begin implementing a CPR system. Those who have made the decision to invest in a CPR system are grappling with the complicated issue of how to do so. Many organizations implement the CPR system in some, but not all areas. Others implement a partial system and depend on a combination of paper and electronic documentation. All adopters of CPR systems must address how to integrate the components of the CPR and how to integrate the CPR with other institutional information systems. The challenge of implementing such an expansive, robust system is daunting, but the option of continuing to manage the clinical and administrative data of an IDS on paper is increasingly becoming a nonviable alternative.

Recent Activity to Advance CPRs in the United States

Against the backdrop of technical and nontechnical changes, interest in and incentives to develop CPR systems have increased.

The National Library of Medicine (NLM) has been at the forefront in stimulating research on the effective use of CPR systems and networked access to shared data (Lindberg, 1995). NLM conducts intramural research that is directly applicable to technological and infrastructural needs of CPR system development and effectively uses its extramural research grants and contracts to apply the results of academic research to health care. Through its High-Performance Computing and Communications contracts, NLM has been a leader in facilitating the use of information technology by health care professionals of rural, urban, community, and statewide networks around the country. NLM's extensive work on the Unified Medical Language System (UMLS) has been a major contribution in the medical terminology arena. NLM and the Agency for Health Care Policy Research (AHCPR) are sponsoring a large-scale vocabulary test to assess the "extent to which a combination of existing health-related classifications and vocabularies covers vocabulary needed in information systems supporting health care, public health, and health services research" (Humphreys et al., 1996). NLM is further extending the reach of shared computer-based patient data and systems through its telemedicine program.

Due to AHCPR's role in developing scientifically based clinical guidelines, it has long recognized the importance of standard data definitions and capturing clinical data in structured form. AHCPR has also played an active role in facilitating standards development. Widespread use of CPR systems would not only facilitate the collection of aggregate data in support of guidelines development, but also make effective the dissemination and use of clinical guidelines in clinical practice.

In addition to the efforts undertaken by NLM and AHCPR, other federal



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