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IMPLEMENTATION AND EVALUATION 87 these reasons, early and formal involvement of the PRO community in the guidelines development process seems highly desirable. The development of computer-based expert systems may also include feedback provisions. More important, the use of such systems is likely to enhance the reliability and validity of clinical decisionmaking. Application and Administration of Guidelines Administering practice guidelines refers to the practical activities required for users to apply the guidelines in making specific decisions about appropriate health care for particular patients or classes of patients. As noted earlier, it is unrealistic to expect the developers of guidelines to anticipate all the contingencies that different users of guidelines will routinely face. Some adaptation is an inevitable and frequently desirable feature of guidelines application. The primary individual appliers of practice guidelines are, in the short run, likely to be physicians, nurses, or other clinicians whose services come within the scope of a particular set of guidelines. The greater the role of the patient in making a health care decision, the more the patient will be a primary individual user of guidelines. The primary organizational appliers of practice guidelines will be health care providers including hospitals, nursing homes, group practices, and public clinics. The primary users of medical review criteria, standards of quality, and performance measures should be, first, health care providers in their internal review and monitoring programs and, second, external quality review programs, health benefit plans, and claims payers. Placing health care providers first as users of these instruments reinforces the call of the recent IOM report on quality assurance for Medicare (1990) for increased emphasis on professional self-review, outcomes assessment, and information feedback. OBRA 89 holds AHCPR and its Forum accountable for administering a government program, not for administering guidelines in a health care setting. The Forum and other government agencies may, however, support the application of guidelines at the practice level by funding the development of computer-based medical decision systems and similar activities. HCFA and its contractors are likely to administer medical review criteria for such purposes as preprocedure review, quality assurance, and claims administration for Medicare. Other agencies of the federal government, such as the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service, presumably can have a more direct role in using guidelines, performance measures, medical review criteria, and standards of quality in