A Technological Approach to
Enhancing Patient Safety
Kathleen Covert Kimmel, RN, MHA, CHE
Joyce Sensmeier, MS, RN, BC, CPHIMS
Despite having unparalleled technology and resources, the US
healthcare system has room for improvement. Impressive
advancements in medical knowledge have accelerated at a
mind-boggling rate, but knowledge and information
distribution are ineffective and not readily available to the
majority of providers. Innovative surgical procedures using
advanced technology diagnostic equipment offer a
sophisticated understanding of a patient's condition, but
information distribution and communication is hampered by
the manual, paper-based patient charts in most hospitals. The
multiple people, departments, and processes that are an
integral component of effective and efficient patient-centered
care are typically lacking. Handwritten medication orders are
error prone. Indeed, deciphering handwriting is frequently a
challenge for those processing orders. Medications with
similar names, but different action classes, effects, and dose
ranges further complicate the medication management
process.
The good news is that there are technologies available to
rectify these challenges. Decision support systems offer the
latest recommended clinical knowledge to assist clinicians as
they evaluate, diagnose, and treat patients. Integrated,
enterprise-level electronic medical records offer real-time
access to clinical notes, procedures, test data, vital signs,
allergies, medication history, and other medical information
to the entire gamut of caregivers. Computerized physician
KEYWORDS
Patient-Centered Care
Electronic Medical Record
Bar Code Technology
Computerized Physician Order Entry
Hand-held and Wireless Devices
Clinical Decision Support Systems
The Institute of Medicine
Clinical Workflow Processes
The Leapfrog Group
Adverse Drug Events
order entry (CPOE), combined with sophisticated alerts, can
detect potential negative drug interaction dosage
irregularities, conflicts with other medical problems, etc., and
can greatly reduce errors.
Computerization in the clinical setting has focused on single-
purpose applications. The proliferation of computerized
clinical applications created an awkward collection of
systems wherein pieces of patient data were stored in a
variety of silos. As technology advancements occurred, new
systems were often stacked on top of the old. Although this
was originally intended to preserve familiar work processes,
adding layers of functionality to already cumbersome and
isolated legacy systems was similar to building a house of
sticks — under the weight of additional layers the system
began to crumble and collapse. The work processes related to
these systems became burdensome and enhanced the potential
for errors.
It is time for hospitals to take stock of their technology and
applications and evaluate clinical workflow. If technology is
applied to an inefficient manual process, it will retain its
inefficiencies when automated. Technology, combined with
clinical process transformation, holds the most promise for
improvement.
Given the expense of an electronic medical record system,
which includes physician order entry, medication
administration records, and decision support systems, funding
from the hospital supplemented by the federal government is
needed. The events of September 11, 2001, and the
subsequent threats of bioterrorism, have placed a spotlight on
the inability of our nation's local healthcare delivery model to
rapidly move patient-specific and organism/treatment-related
Healthcare Information and Management Systems Society ©2002
 A Technological Approach to Enhancing Patient Safety
data between and among hospitals and private physician
practices. Just as the government built the national highway
system after World War II because the existing road system
was inadequate to move large numbers of troops rapidly
across the country, the government needs to create a national
health information infrastructure as a medical communication
highway to protect its citizens.
DESCRIPTION OF THE ISSUE
Processes to detect and reduce medical errors in hospitals and
healthcare systems have been hampered by the lack of
integrated technology and decision support applications. So,
for many years, the extent of medical errors was unknown.
Uncovering the degree of the problem was fueled by the
medical error-related death of Boston Globe health columnist
Betsy Lehman in 1994. Her death triggered a landslide of
government hearings, meetings, and reports. Lehman, who
was being treated for breast cancer at Boston's Dana Farber
Cancer Institute, mistakenly received the cumulative dose of
the cancer drug Cisplatin, instead of the daily dose for four
days. The overdose caused heart failure. Post-event findings
and analysis culminated in the release of the Institute of
Medicine's (IOM) first report.1 In November 1999, the
Committee on the Quality of Care in America produced a
report titled "To Err is Human: Building a Safer Health
System." This report shocked the nation by exposing a quality
crisis, stating that between 44,000 and 98,000 hospital deaths
each year are related to preventable medical errors.
The report concluded that:
• the extent of harm that results from medical errors is
great;
• errors result from system failures, not people failures;
• achieving acceptable levels of patient safety will require
major systems changes; and
• a concerted national effort is needed to improve patient
safety.
The IOM report recommendations set a 50 percent reduction
in medical errors as a goal within five years, which could be
achieved by:
• creating a Center for Patient Safety;
• mandating a reporting system for medical errors;
• encouraging voluntary reporting;
• providing greater legal protection for data collected for
patient safety and quality improvement purposes;
• promoting performance standards (people and
organizations) that emphasize safety; and
• emphasizing safe use of drugs through the FDA.
2 Healthcare Information and Management Systems Society ©2002
In March 2001, the Committee on the Quality of Care in
America produced a second report, "Crossing the Quality
Chasm: A New Health System for the 21st Century." This
report presents a call for action to improve the US healthcare
delivery system.2
The Public Sector's Response to the First IOM Report
Although there continues to be great debate about the actual
number of errors, this report galvanized strong reaction from
both the private and public sector. Within two weeks after the
release of the first IOM report, the US Congress began a
series of hearings. President Clinton ordered a government-
wide feasibility study, which was followed in February 2000
by a presidential mandate to implement the IOM
recommendations—specifically to reduce medical errors by
50 percent in the next five years. The President's mandate
requires all 6,000 hospitals participating in the Medicare
program to implement patient-safety initiatives, including
medications and safety-oriented approaches.3 A Medicare
Patient Advisory Commission report suggested that the
Centers for Medicare and Medicaid Services (CMS), formerly
known as HCFA, consider providing financial incentives to
hospitals that adopt CPOE systems.4 The Agency for
Healthcare Research and Quality (AHRQ) received $50
million to fund error-reduction research, including
information-related strategies. The AHRQ produced a report,
"Making Healthcare Safer: A Critical Analysis of Patient
Safety Practices" in July 2001, which represented a first effort
to approach the field of patient safety through the lens of
evidence-based medicine.5
State governments have also responded to the IOM report.
For example, the State of California passed a bill mandating
that all non-rural hospitals implement CPOE by 2005.6
In the almost two years since the first report, the government
has continued to address the problem. In May 2001, Senators
Bob Graham (D-Fla.) and Olympia Snowe (R-Maine)
introduced legislation to provide grants to hospitals and
nursing facilities to implement technology that reduces
medication errors. The Medication Errors Reduction Act of
2001 calls for nearly $1 billion in grants during the next 10
years, with $93 million available to hospitals and $4.5 million
to skilled-nursing facilities each year. Under the bill,
individual hospitals will be eligible for grants of up to
$750,000, with grants for nursing facilities capped at
$200,000.
 A Technological Approach to Enhancing Patient Safety
The Fiscal Year '02 Appropriations Bill includes a 10 percent
increase in funding for the Department of Health and Human
Services, with $55 million set aside for AHRQ to determine
ways to reduce medical errors. Additionally, $15 million has
been appropriated for rural hospitals and designated for
medical errors reduction and systems improvement to comply
with provisions of the Health Insurance Portability and
Accountability Act.7
The Food and Drug Administration (FDA) is implementing
changes for the labeling of existing drugs, as well as testing
new drugs before they hit the market.8 Mix-ups with look-
alike or sound-alike drug names are a major source of
medication-caused injuries and death. It is hoped that using a
combination of eye-catching changes, including a mix of
upper- and lower-case as well as different colored letters, will
get the attention of pharmacists. In addition, FDA workers
will begin testing groups of volunteer physicians, nurses, and
pharmacists about potential confusion of new drug names
before the drugs hit the market.
The Private Sector Response to the First IOM Report
In addition to government agencies, the private sector has
also responded to the first IOM report. The Leapfrog Group,
a coalition of many of the nation's leading companies
sponsored by the Business Roundtable, seeks to create
meaningful, marketplace incentives to encourage the
healthcare sector to adopt systemic quality improvement
processes. The employer marketplace is responding to
Leapfrog's message. In fact, the Leapfrog Group, joined
recently by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), has grown from an
original membership of 60 purchasers to more than 90 and
now represents 25 million beneficiaries.
The Leapfrog Group has identified three initial patient safety
standards as the focus for consumer education and
information and hospital recognition and reward:
• reduce medication prescribing errors using CPOE;
• refer patients undergoing certain high-risk procedures to
high volume hospitals); and
• staff ICUs with intensivists (i.e., physicians certified in
critical care medicine).
Originally Leapfrog focused on encouraging providers to
voluntarily adopt their recommendations. In June 2001,
Leapfrog began taking action by using its economic clout to
influence provider acceptance of the three recommendations.
Approximately 900 hospitals in seven targeted markets
3 Healthcare Information and Management Systems Society ©2002
around the country (Atlanta, California, Eastern Tennessee,
Michigan, Minnesota, Seattle, and St. Louis), are being asked
how they process medication orders, staff their ICUs, and
how many open heart surgeries they perform each year. The
information will be available to millions of hospital-seeking
beneficiaries via the Leapfrog Web site.9
The Leapfrog Group and First Consulting Group have
released two new reports on CPOE. The first report is a guide
to help hospitals assess the effectiveness of their CPOE
systems in intercepting erroneous medication orders. The
second report provides starter-set information for hospital
decision makers to help them organize their CPOE effort and
launch the search for an appropriate CPOE solution.10
Leapfrog's report card-like summary of a hospital's IT
infrastructure is expected to help spark action by many
providers. Financial analysts are anticipating a profound
impact to healthcare IT spending as employers begin to shift
market share toward providers who adopt Leapfrog's patient
safety standards.11
The Leapfrog Group's efforts to impose economic sanctions
to drive compliance are coming to fruition. In fact, by year-
end 2001, General Motors was to have rewritten all of their
payer contracts to require them to include patient safety
requirements within their hospital provider contracts.12 This
action puts the onus of responsibility of obtaining provider
compliance with the health plans. Recently, a major health
plan began attempting to encourage compliance by presenting
financial rewards to providers who meet the safety standards.
Three Fortune 500 companies joined Empire Blue Cross to
recognize and reward hospitals that achieve the Leapfrog
safety standards. As of January 1, 2002, hospitals in Empire
Blue Cross and Blue Shield's networks receive a four-percent
bonus for meeting two quality standards — CPOE and ICU
staffing with intensivists. Hospitals that meet this standard
beginning in 2003 willreceive a three-percent bonus, and
those that wait until 2004 will receive a two-percent bonus.13
The Second IOM Report: Crossing the Quality Chasm
The second IOM report decries a medical system where
physician groups, hospitals, and other organizations "operate
as silos, often providing care without the benefit of complete
information about the patient's condition, medical history,
services provided in other settings, or medications prescribed
by other physicians."14 Harking back to their first report, this
report again addresses patient safety problems, stating that the
cause is a system that "relies on outmoded systems of work."
 A Technological Approach to Enhancing Patient Safety
The solution for safer, high-quality care is to "redesign
systems of care, including the use of information technology
to support clinical and administrative processes.”
Recommendations on Restructuring the US Healthcare
System
The report includes 13 recommendations for restructuring the
US healthcare system. While some recommendations pertain
to quality of care, others discuss funding for monitoring and
tracking existing solutions for quality of care. Also included
are recommendations for mutual efforts between payers and
providers to work toward a care system where patients and
providers cooperate, collaborate, and share information that is
current and evidence-based. Additionally, because 40 percent
of all care is directed toward chronically ill patients, there are
recommendations to identify at least 15 of the most prevalent
chronic diseases and to develop strategies for improving
quality of care for each.
The report also requests the AHRQ to facilitate further
thinking by convening workshops designed to promote
guidelines in specific topic areas. These areas include
redesigning care practices, using information technologies to
improve access to clinical information, supporting clinical
decision making in an electronic environment, and
coordinating care across patient conditions, services, and
settings over time.
The Centers for Disease Control and Prevention (CDC)
recently announced a collaborative effort with the E-Health
Initiative to develop a much needed information technology
infrastructure to combat bioterrorism. The initiative joins the
CDC with a consortium of healthcare IT vendors and
organizations that will link legacy IT systems in hospitals,
pharmacies, and labs with the CDC National Electronic
Disease Surveillance System (NEDSS). This effort is an
important first step in facilitating the capture of critical data
at the point of initial contact and transmitting disease
surveillance information to the government.15
DISCUSSION/ANALYSIS
Medical Error Statistics
The IOM's first report not only highlighted the number of
deaths in hospitals due to medical errors, it also estimated the
costs generated by those errors. National healthcare costs
attributable to those deaths were estimated to be $8 billion
annually.16 How extensive are medical errors? The National
Committee on Vital and Health Statistics (NCVHS) reports
4 Healthcare Information and Management Systems Society ©2002
the following statistics:
• One in 25 hospital admissions results in an injured
patient.
• Three percent of adverse effects cause permanent
disabling injury; of these, one in seven leads to a patient
death.
• Preventable medical errors account for 12 to 15 percent
of hospital costs.
• About 23,000 hospital patients die each year from
injuries linked to medication use.
• 80 percent of nurses calculate dosages incorrectly 10
percent of the time, and 40 percent of nurses make
mistakes more than 30 percent of the time.
• Approximately 180,000 unnecessary deaths and 1.3
million injuries occur from medical treatment in the
United States.17
Besides the IOM and the NCVHS, The Advisory Board
Company in Washington, D.C., is another source for
information on medical errors. The Advisory Board divides
adverse effects into several categories. Each category is listed
along with the number of times they occur per 1,000 hospital
visits:
• 65 incidents are due to adverse drug events;
• 60 incidents are due to nosocomial (hospital-acquired)
infections;
• 51 incidents are due to procedural complications; and
• 15 incidents are due to falls.
Adverse drug events (ADEs) top the list in frequency of
occurrences. ADEs have a wide range of causes and careful
measurement is a complex process.18 The second and third
categories, nosocomial infections and procedural
complications, may be related to provider training or
experience and hospitals' infection control policies and
procedures. The final category, falls, is usually related to
unstable patients, including elderly patients, and can be traced
to policies and procedures.
The average cost of an ADE is $4,700 per admission. When
ADEs, which account for more than 25 percent of all adverse
hospital incidents, are studied, the following results are
found:
• 56 percent are attributed to physicians;
• 34 percent are attributed to nurses;
• six percent are attributed to unit secretaries; and
• four percent are attributed to pharmacy staff.19
ADEs, the largest single category of medical errors, can be
 A Technological Approach to Enhancing Patient Safety

immediately influenced by information technology. CPOE a demonstrable return on investment. The good news for
and bar code medication administration are two proven hospitals is that positive return-on-investment data related to
technology-supported work processes that can reduce medical some of these technologies already exists. An early study at
errors in three of the categories listed above.20 an academic medical center estimated that CPOE generated
savings of $5 to $10 million annually on a $500 million
While technology is a critical component to patient safety budget.25 A more recent study presented at the 2001 Annual
management, it should also be a part of an organization-wide HIMSS Conference and Exhibition provides evidence from
strategy that includes workflow process redesign. Decreasing Montefiore Medical Center, a 1,100-bed academic health
the number of ADEs requires the combination of clinical system, of tremendous savings for CPOE and medication
workflow transformation along with selective implementation administration record — roughly $6 million annually. This
of technology. Systems can be integrated and processes figure combines the time savings for nurses, unit secretaries,
automated without solving the problem. Traditional and pharmacists.26
workflows must be re-evaluated to harness technology and
assist in information capture, flow, analysis, transmission, and Table 1 uses data from the 2001 Hospitals & Health
trending. Networks third annual survey. The results indicate that the
"most wired" hospitals, namely hospitals that have embraced
CONCLUSIONS/RECOMMENDATIONS/POSITION technology solutions, have better control of expenses, higher
STATEMENT
Table 1. Return on Investment Data Substantiates the Value of
Investing in Technology 27
The Role of Technology
A common theme throughout the IOM reports is the critical Attribute Technologically Other Hospitals
Advanced Hospitals
role information technology plays in reducing medical errors.
In his statement before the subcommittee on Labor, Health Average length of stay 3.24 days 3.73 days
and Human Services, and Education of the Senate Committee Highest AA credit rating 35% 15%
on Appropriations, Dennis O'Leary, president of the Joint
FTEs per occupied bed 3.3 3.8
Commission on Accreditation of Healthcare Organizations
Paid hours per 90.3 113.9
(JCAHO), stated, "Medical error reduction is fundamentally
adjusted discharge
an information problem. The solution to reducing the number
Net patient revenue $423,780 $164, 241
of medical errors resides in developing mechanisms for per discharge per discharge
collecting, analyzing, and applying existing information. If
Expenses per adjusted $3,995 $4,511
we are going to make significant strides in enhancing patient facility discharge
safety, we must think in terms of the information we need to
Annual increase in 0.6% 2.8%
obtain, create, and disseminate."21 The Healthcare expenses
Information and Management Systems Society (HIMSS) is
advocating for the use of information technology including productivity, and more efficient utilization management than
point-of-care, unit-of-use bar coding to reduce medical errors their peers.28 According to a report from Cerner Corporation,
and improve productivity.22 Evidence of the impact of Samaritan Regional Medical Center saved $3 million
technology is demonstrated by the Veterans Health annually and avoided 36 deaths by using a computerized data
Administration, which has seen a system-wide 75 percent repository that was populated with medication rules.29 A 1998
reduction in medication errors since implementing bar code study by the Gartner Group estimated a positive return on
medication administration software.23 The American Medical investment for ambulatory computer-based patient records.
Informatics Association also contends that errors can be This report produced a formula for calculating the amount of
prevented by computer systems that provide electronic patient savings per year/per physician by multiplying $41,400 per
records, physician order entry, practice standards, medical year/per practitioner to calculate the savings in an ambulatory
vocabularies, and computerized decision support.24 environment.30

Economic Justification for Information Systems Technology Technology is rapidly progressing. Electronic medical records
Given the significant capital restraints now burdening with decision support at the time of order entry are improving
healthcare organizations, purchasing this technology requires each year in their features, functions, and capabilities. These
5 Healthcare Information and Management Systems Society ©2002
 A Technological Approach to Enhancing Patient Safety

systems are justifying themselves in saving lives and money.
Accessibility to mobile computing devices at the point of care
is evolving. Wireless computing devices enable physicians,
other ordering clinicians, and nurses to enter patient data at
the patient bedside. Use of bar coding in combination with
decision support assures that patients are receiving the correct
medication or treatment. Utilizing CPOE, physicians are able
to review up-to-date patient test results and other pertinent
data prior to writing orders, as well as receive decision
support while processing them.
Now is the time for a call to action for all healthcare
stakeholders. Health plans need to provide the ordering
physician with information on disease state management,
efficacy of various drugs, and treatments at various stages of
the clinical condition. The reference laboratory must supply
results that offer guidance in the interpretation of the test and
support the physician in selecting additional tests or proper
treatment. A four-way cooperative alignment between the
ordering physician and the three major purveyors of
information — the health plan, the reference laboratory, and
pharmaceutical companies — is required. This can only be
achieved when this information is available through decision
support capabilities at the time of order entry. Orders may be
entered using a hand-held device, wireless tablet, laptop, or
desktop PC. Orders and results need to be immediately
available to the physician, as well as to the entire treatment
team at the hospital. This patient care team also needs to
include the patient. Patients must be informed decision
makers and active participants in their care. When all
healthcare stakeholders recognize their responsibility and
work together to address the patient safety issues, healthcare
in this nation and all over the world will be vastly improved.

References
1
Committee on Quality of Health Care in America, Institute of Medicine, To Err is Human, National Academy Press, 2000.
2
Committee on Quality of Health Care in America, Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century,
National Academy Press, 2001.
3
The White House Office of the Press Secretary, Press Briefing by Senior Administrative Officials on President's Initiative to Reduce Medical
Errors, February 22, 2000. www.pub.whitehouse.gov
4
Medicare Payment Advisory Commission. Report to Congress: Selected Medical Issues, June 1999.
5
Shojannia KG, Duncan BF, McDonald KM, Wachter RM. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. AHRQ
Publication 01-E058, July 20, 2001.
6
California Senate Bill No. 1875. Chapter 816, Statutes of 2000.
7
Healthcare Information and Management Systems Society. 2001 Congressional Review. Advocacy Dispatch, January 18, 2001.
www.himss.org/about/advocacy.asp.
8
Daily Dose E-Mail. FDA implementing changes with new labels. Modern Healthcare, January 2, 2002.
9
Lovern E. Minding hospitals' business: Purchasing coalition pushes hospitals to improve patient safety through process measures, but industry says
standards are too expensive. Modern Healthcare. May 28, 2001.
10
Kilbridge P, Welebob E, Classen D. Overview of the Leapfrog Group Evaluation Tool for Computerized Physician Order Entry. Leapfrog Group
and First Consulting Group, 2001.
11
Falci RG, Steward RT, Weinberger A. An Update on the Leapfrog Movement: A Macro Catalyst is Maturing into a Fundamental Change Agent.
Bear Stearns Equity Research White Paper, September 6, 2001.
12
Ibid.
13
Media Release Three fortune 500 companies join Empire Blue Cross and Blue Shield to recognize and reward hospitals that achieve Leapfrog
safety standards. Empire BCBS, October 19, 2001.
14
Ibid.
15
Healthcare Information and Management Systems Society. CDC's ongoing push to create a national bioterrorism early warning system. HIMSS
NewsBreak, December 24, 2001.
16
Beers JB, Berger MA. Medical Errors: Sources and solutions. Proceedings of 2001 Annual HIMSS Conference and Exhibition, session 17, 2001.
17
National Committee on Vital and Health Statistics. Testimony, June 23-24, 1999.
18
Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, Vander Vliet M, and Seger DL.
Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Journal of the American Medical
Association. 1998; 280:1311-1316.
19
Clinical Initiatives Center Prescription for Change, Best Practices for Medication Management, Washington, D.C., The Advisory Board Company,
(202) 672-5290.
20
Beers JB, Berger MA. Medical Errors: Sources and solutions. Proceedings of 2001 Annual HIMSS Conference and Exhibition, Session 17, 2001.
21
O'Leary D. Statement of the Joint Commission on Accreditation of Healthcare Organizations before the U.S. Senate and the Subcommittee on
Labor, Health and Human Services and Education of the Senate Committee on Appropriations, February 22, 2001.
www.jcaho.org/govt/oleary_02220.html.
22
Simpson N. Advocacy White Paper: Bar Coding for Patient Safety. Healthcare Information and Management Systems Society, December 2001.
http://www.himss.org/advocacy/about/advocacy.asp

6 Healthcare Information and Management Systems Society ©2002

 A Technological Approach to Enhancing Patient Safety

23
Johnson CL, Carlson RA, Tucker CL, Willette C. Using BCMA software to improve patient safety in Veterans Administration Medial Centers.
Journal of Healthcare Information Management. 2002; 16:1, 46-51.
24
Bates DW, Cohen M, Leape LL, Overhage JM., Shabot MM, Sheridan, T. Reducing the frequency of errors in medicine using information tech-
nology. Journal of the American Informatics Association, August 2001, 299-308.
25
Glaser J, Teich JM, Kumperman G. Impact of information events on medical care. Proceedings of the 1996 Annual HIMSS Conference and
Exhibition, 1996.
26
Manzo J, Taylor RG, Cusick D. Measuring medication related ROI an process improvement after implementing POE. HIMSS News, February
2001.
27
Solovy A. The big payback: 2001 survey shows a healthy return on investment for into tech. Hospitals & Health Networks, July 2001, 40-50.
28
lbid.
29
Dennings EH. Healthcare Management Consultants. Cerner Corporation, June 22, 2001.
30
Duncan M. A simplified financial ROI for an ambulatory CPR. Gartner Group, October 1998.

Author Biographies

Kathleen Covert Kimmel, RN, MHA, is a consultant with IBM's Global Services, Healthcare Industry. She has a BS in nursing from
the University of Massachusetts and an MHA from Duke University. She is a board-certified healthcare executive with the American
College of Healthcare Executives. She currently serves as chair of the HIMSS Outcomes special interest group.

Joyce Sensmeier, MS, RN, BC, is the Director of Professional Services at the Healthcare Information and Management Systems
Society (HIMSS). She is responsible for HIMSS advocacy efforts, certification, advancement, and the Integrating the Healthcare
Enterprise initiative. Sensmeier is also a faculty member at Loyola University Chicago.

©2002 Healthcare Information and Management Systems Society. All rights reserved. No part of this publication may be
reproduced, adapted, translated, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without the prior written permission of the publisher.

HIMSS, 230 East Ohio, Suite 500, Chicago, IL 60611

Tel: 312/664-4467 Email: publications@himss.org

7 Healthcare Information and Management Systems Society ©2002