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and/or expensive interactions between the two might occur. In a tightly integrated system, as compared to disparate and separate Internet-based systems, such interactions might be minimized. This situation suggests that a near-term challenge will be to ensure quality control and coordination among the many different Internet-born clinical transactions and to develop robust medical decision-support tools that can serve a wide range of institutions and patient populations.

18. In a survey of 153 chief information officers conducted by the College of Health Information Management Executives in 1998, 80 percent said they use HL7 and 13.5 percent planned to implement it in the future.

19. All claims data in this paragraph derive from research conducted for Faulkner & Gray's 2000 Health Data Directory, as cited in Goedert (1999).

20. For additional information on these efforts, see Rybowski and Rubin (1998) and Affiliated Health Information Networks of New England (1999).

21. Further information on HCFA's pilot program can be obtained from either <http://www.wedi.org> or <http://www.afecht.org>.

22. For example, the U.S. Public Health Service released a report in 1995 describing the potential applications of the Internet in public health and identifying technical challenges to be addressed (U.S. Public Health Service, 1995). In 1997, the New York Academy of Medicine and the National Library of Medicine cosponsored a symposium on public health informatics that called for improved structures and assessment mechanisms for public health information (Lasker, 1998). Slide presentations of several symposium speakers are available at <http://www.nlm.nih.gov/nichsr/nyam/nyam.html>. The Department of Health and Human Services' document Healthy People 2010 (U.S. Department of Health and Human Services, 1998) includes a section on objectives for improving the public health infrastructure. They include widespread access to the Internet and real-time, on-site access to public health data for public health workers and individuals. Section 14, objectives 5 and 6, is the most relevant example.

23. Participating organizations include the National Network of Libraries of Medicine, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, the Association of State and Territorial Health Officials, and the National Association of County and City Health Officials.

24. Reports from physicians' offices and hospitals also tend to be reported on paper.

25. Jac Davies, Washington State Department of Health, presentation to the study committee, February 11, 1999, Seattle, Washington.

26. The traditional public health functions are surveillance, case identification, treatment, prevention, research, guidelines, education and feedback.

27. President Clinton's proposal for this program would also create a network of regional labs to provide rapid analysis and identification of select biological agents.

28. The Health Alert Network is part of a larger antibioterrorism effort that received $158 million in FY99. Another $72 million was proposed for FY2000, which would raise the total to $230 million.

29. This information is derived from "Health Alert Network Architectural Standards," supplement to the Centers for Disease Control and Prevention Program Announcement No. 99051.

30. The Association of American Medical Colleges reports that total enrollment in full-time undergraduate medical programs in the United States was 66,900 in the 1997-1998 academic year. There were 99,099 residents being trained in clinical settings (primarily teaching hospitals). According to the quinquennial survey, approximately 242,000 students were enrolled in all health sciences programs during the 1996-1997 academic year.

31. The SHINE project at Stanford Medical Center is experimenting with providing CMEcontinue



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