From Hospital Information Systems to Health Information Systems

K. A. Kuhn; D. A. Giuse

doi:10.1055/s-0038-1634170

Methods of Information in Medicine, Inhaltsverzeichnis

Methods Inf Med 2001; 40(04): 275-287
DOI: 10.1055/s-0038-1634170

Original Article

Schattauer GmbH

From Hospital Information Systems to Health Information Systems

Problems, Challenges, Perspectives

K. A. Kuhn

¹Institute of Medical Informatics, Philipps-University Marburg, Germany

,

D. A. Giuse

²Informatics Center, Vanderbilt University Medical Center, Nashville, TN, USA

› Institutsangaben

Abstract

Summary

Objectives: Hospital information systems are evolving towards health information systems. This article aims at identifying both proven benefits and critical issues, and at discussing problems and possible solutions.

Methods: Reports on HIS successes and failures were analyzed, and core challenges were identified. These challenges are discussed against state of the art solutions.

Results: In spite of demonstrated benefits, there are more severe problems than reports on successes suggest. Among today’s core problems are integration, human-computer interaction, socio-technical issues, and support of processes.

Conclusions: Significant efforts of all parties involved in the health care process are needed to improve, implement, and evaluate the concepts described.

Keywords

Hospital Information Systems - Information Systems

Volltext

Referenzen

References
1 Hammond WE. Hospital Information Systems: a review in perspective. In: van Bemmel JH, McCray AT. (eds). Yearbook of Medical Informatics ’94. Stuttgart, NewYork: Schattauer; 1994: 95-102.
2 Bakker A, Hammond E, Ball M. Summary report of observations, conclusions and recommendations. Int J Biomed Comput 1995; 39: 11-5.
3 Bakker AR. Setting the scene for the IMIA Working Group 10 working conference expanding HIS: fading boundaries. Int J Biomed Comput 1995; 39: 3-7.
4 Dick RS, Steen EB. (eds). The Computer-Based Patient Record:An Essential Technology for Health Care. Institute of Medicine, Committee on Improving the Patient Record, Washington: National Academy Press; 1991
5 Marietti C. Will the real CPR/EMR/EHR please stand up?. Healthc Inform 1998; 15: 76-81.
6 Federal Standard 1037C: glossary of telecommunication terms. U.S. Department of Commerce, Institute for Telecommunication Sciences, Boulder, CO; 1996. http://www.its.bldrdoc.gov/fs-1037/ last access 17 Apr 2001. Updated version: American National Standard for Telecommunications Telecom Glossary 2000 http://www.its.bldrdoc.gov/projects/telecomglossary2000 , last access 17 Apr 2001
7 Winter A, Haux R. A three-level graph-based model for the management of hospital information systems. Methods Inf Med 1995; 34: 378-96.
8 Safran C, Sands DZ, Rind DM. Online medical records: a decade of experience. Methods Inf Med 1999; 38: 308-12.
9 Kaihara S. Realisation of the computerised patient record; relevance and unsolved problems. Int J Med Inf 1998; 49: 1-8.
10 Fischer W. Use of PCSs for acute inpatient treatment in Europe and some other countries. Zentrum für Informatik und wirtschaftliche Medizin, Wolfertswil Switzerland: 1998. http://www.fischer-zim.ch/notes-en/PCSin-Europe-9810.htm last access 17 Apr 2001.
11 Teich JM. Clinical information systems for integrated healthcare networks. In: Chute CG. (ed). Proc AMIA Symp. 1998: 19.
12 Iakovidis I. Towards personal health record: current situation, obstacles and trends in implementation of electronic healthcare record in Europe. Int J Med Inf 1998; 52: 105-15.
13 Wang C, Ohe K. A CORBA-based object framework with patient identification translation and dynamic linking. Methods for exchanging patient data. Method Inform Med 1999; 38: 56-65.
14 Board of Directors of the American Medical Informatics Association.. Standards for medical identifiers, codes, and messages needed to create an efficient computer-stored medical record. J Am Med Inform Assoc 1994; 1: 1-7.
15 The eleventh annual HIMSS leadership survey sponsored by IBM.. Healthcare Information and Management Systems Society. Chicago, IL: 2000. http://www.himss.org/survey/2000/survey2000.html last access 11 Sep 2000.
16 Ball MJ, Peterson H, Douglas JV. The computerized patient record: a global view. MD Comput 1999; 16: 40-6.
17 Tuttle MS. Information technology outside health care: what does it matter to us?. J Am Med Inform Assoc 1999; 6: 354-60.
18 Overhage JM. Computer-based patient records. In: van Bemmel JH, McCray AT. (eds). Yearbook of Medical Informatics ’97. Stuttgart, NewYork: Schattauer; 1997: 183-5.
19 Amatayakul M. HIPAA is heating up. MD Comput 2000; 17: 15-7.
20 Ebidia A, Mulder C, Tripp B, Morgan MW. Getting data out of the electronic patient record: critical steps in building a data warehouse for decision support. In: Lorenzi NM. (ed). Proc AMIA Symp Proc AMIA Symp. 1999: 745.
21 Nadkarni PM, Brandt C, Frawley S, Sayward FG, Einbinder R, Zelterman D, Schacter L, Miller PL. Managing attribute-value clinical trials data using the ACT/DB client-server database system. J Am Med Inform Assoc 1998; 5: 139-51.
22 Lee IN, Liao SC, Embrechts M. Data mining techniques applied to medical information. Med Inform Internet Med 2000; 25: 81-102.
23 Haruki Y, Ogushi Y, Okada Y, Kimura M, Kumamoto I, Sekita Y. Status and perspective of hospital information systems in Japan. Method Inform Med 1999; 38: 200-6.
24 Hanmer L, Ibrahim AS, Kadio A, Korpela M, Mouillet E. (eds). Spec issue on health informatics on the african continent (HELINA ’96). Method Inform Med 1997; 36: 61-162.
25 Hannan T, McGhee S, Kidd M. (eds). Spec issue on the second Asia Pacific Assoc for Med Inform and fifth Nat’l Health Inf Soc of Australia joint conf. Int J Med Inf 1999; 55: 1-86.
26 Amado Espinosa L. HIS priorities in developing countries. Int J Biomed Comput 1995; 39: 175-8.
27 Yacubsohn V. Hospitals without boundaries: HIS and primary healthcare in developing countries. Int J Biomed Comput 1995; 39: 169-73.
28 van der Lei J, Moorman PW, Musen MA. (eds). Spec issue on electronic patient records in medical practice. Method Inform Med 1999; 38: 287-361.
29 Yoshihara H. Development of the electronic health record in Japan. Int J Med Inf 1998; 49: 53-8.
30 Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-6.
31 Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991; 324: 377-84.
32 Bates DW, O’Neil AC, Boyle D, Teich J, Chertow GM, Komaroff AL, Brennan TA. Potential identifiability and preventability of adverse events using information systems. J Am Med Inform Assoc. 1994; 1: 404-11.
33 Leape LL. A systems analysis approach to medical error. J Eval Clin Pract 1997; 3: 213-22.
34 Kohn LT, Corrigan JM, Donaldson MS. (eds). To err is human: building a safer health system. Institute of Medicine, Committee on Quality of Health Care in America, Washington: National Academy Press; 2000
35 Stead WW, Haynes RB, Fuller S, Friedman CP, Travis LE, Beck JR, Fenichel CH, Chandrasekaran B, Buchanan BG, Abola EE. et al. Designing medical informatics research and library-resource projects to increase what is learned. J Am Med Inform Assoc 1994; 1: 28-33.
36 Tierney WM, Overhage JM, McDonald CJ. Demonstrating the effects of an IAIMS on health care quality and cost. J Am Med Inform Assoc 1997; 4 2 Suppl S41-6.
37 Stead WW, Bird WP, Califf RM, Elchlepp JG, Hammond WE, Kinney TR. The IAIMS at Duke University Medical Center: transition from model testing to implementation. MD Comput 1993; 10: 225-30.
38 Marshall PD, Chin HL. The effects of an electronic medical record on patient care: clinician attitudes in a large HMO. In: Chute CG. (ed). Proc AMIA Symp Proc AMIA Symp. 1998: 150.
39 Hendrickson G, Anderson RK, Clayton PD, Cimino J, Hripcsak GM, Johnson SB, McCormack M, Sengupta S, Shea S, Sideli R. et al. The integrated academic information management system at Columbia-Presbyterian Medical Center. MD Comput 1992; 9: 35-42.
40 Stead WW, Borden R, Bourne J, Giuse D, Giuse N, Harris TR, Miller RA, Olsen AJ. The Vanderbilt University fast track to IAIMS: transition from planning to implementation. J Am Med Inform Assoc 1996; 3: 308-17.
41 Greenes RA, Pappalardo AN, Marble CW, Barnett GO. Design and implementation of a clinical data management system. Comput Biomed Res 1969; 2: 469-85.
42 Bakker AR, Leguit FA. Evolution of an integrated HIS in The Netherlands. Int J Med Inf 1999; 54: 209-24.
43 Borst F, Appel R, Baud R, Ligier Y, Scherrer JR. Happy birthday DIOGENE: a hospital information system born 20 years ago. Int J Med Inf 1999; 54: 157-67.
44 McDonald CJ, Overhage JM, Tierney WM, Dexter PR, Martin DK, Suico JG, Zafar A, Schadow G, Blevins L, Glazener T, Meeks-Johnson J, Lemmon L, Warvel J, Porterfield B, Warvel J, Cassidy P, Lindbergh D, Belsito A, Tucker M, Williams B, Wodniak C. The Regenstrief Medical Record System: a quarter century experience. Int J Med Inf 1999; 54: 225-53.
45 Tierney WM, Miller ME, Overhage JM, McDonald CJ. Physician inpatient order writing on microcomputer workstations. Effects on resource utilization. JAMA 1993; 269: 379-83.
46 McDonald CJ. The barriers to electronic medical record systems and how to overcome them. J Am Med Inform Assoc 1997; 4: 213-21.
47 Digital Imaging and Communications in Medicine (DICOM).. NEMA PS 3.1 – PS 3.12. National Electrical Manufacturers Association; Rosslyn, VA: 1992. 1993, 1995, 1997, 1998.
48 Kuzmak PM, Dayhoff RE. The VA’s use of DICOM to integrate image data seamlessly into the online patient record. In: Lorenzi NM. (ed). Proc AMIA Symp Proc AMIA Symp. 1999: 92.
49 Teich JM, Glaser JP, Beckley RF, Aranow M, Bates DW, Kuperman GJ, Ward ME, Spurr CD. The Brigham integrated computing system (BICS): advanced clinical systems in an academic hospital environment. Int J Med Inf 1999; 54: 197-208.
50 Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, Vander Vliet M, Seger DL. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998; 280: 1311-6.
51 Slack WV, Bleich HL. The CCC system in two teaching hospitals: a progress report. Int J Med Inf 1999; 54: 183-96.
52 Gardner RM, Pryor TA, Warner HR. The HELP hospital information system: update 1998. Int J Med Inf 1999; 54: 169-82.
53 Classen DC, Pestotnik SL, Evans RS, Burke JP. Computerized surveillance of adverse drug events in hospital patients. JAMA 1991; Nov 27 266 2847 51.
54 Haug PJ, Gardner RM, Tate KE, Evans RS, East TD, Kuperman G, Pryor TA, Huff SM, Warner HR. Decision support in medicine: examples from the HELP system. Comput Biomed Res 1994; 27: 396-418.
55 Bleich HL, Slack WV. Designing a hospital information system: a comparison of interfaced and integrated systems. MD Comput 1992; 9: 293-6.
56 Karson TH. Visual integration. A new technology for the thinking physician. MD Comput 2000; 17: 38-40.
57 HL7 technical committee Clinical Context Object Workgroup (CCOW). Health Level Seven, Inc.; Ann Arbor, MI.: www.hl7.org/special/Committees/ccow_sigvi.htm last access 17 Apr 2001
58 Leading IT companies by revenue.. Healthc Inform. 2000 17: 58-76.
59 Dorenfest SI. The decade of the ’90s: poor use of IT investment contributes to the growing healthcare crisis. Healthc Inform 2000; 17: 64-7.
60 Ash JS, Gorman PN, Hersh WR. Physician order entry in U.S. hospitals. In: Chute CG. (ed). Proc AMIA Symp Proc AMIA Symp. 1998: 235.
61 Stead WW, Lorenzi NM. Health informatics: linking investment to value. J Am Med Inform Assoc 1999; 6: 341-8.
62 Berg M. Patient care information systems and health care work: a sociotechnical approach. Int J Med Inf 1999; 55: 87-101.
63 Anderson JG, Aydin CE. Evaluating the impact of health care information systems. Int J Technol Assess Health Care 1997; 13: 380-93.
64 Anderson JG. Clearing the way for physicians’ use of clinical information systems. Commun ACM 1997; 40: 83-90.
65 Tonnesen AS, LeMaistre A, Tucker D. Electronic medical record implementation barriers encountered during implementation. In: Lorenzi NM. (ed). Proc AMIA Symp Proc AMIA Symp. 1999: 624.
66 Crossing the quality chasm: a new health system for the 21st century. Committee on Quality of Health Care in America, Institute of Medicine. National Academy Press; Washington DC: 2001
67 Lenz R, Kuhn KA. Intranet meets hospital information systems – the solution to the integration problem?. In print: Method Inform Med 2001
68 Leguit FA. Interfacing integration. In: Bakker AR, Ehlers CT, Bryant JR, Hammond WE. (eds). Proc IMIA Working Conference on Hospital Information Systems: Scope-Design-Architecture. Amsterdam: North-Holland; 1992: 141-8.
69 Sittig DF, Kuperman GJ, Teich JM. WWW-based interfaces to clinical information systems: the state of the art. In: Cimino JJ. (ed). Proc AMIA Annu Fall Symp Proc AMIA Annu Fall Symp. 1996: 694.
70 Hripcsak G, Cimino JJ, Sengupta S. WebCIS: large scale deployment of a Web-based clinical information system. In: Lorenzi NM. (ed). Proc AMIA Symp Proc AMIA Symp. 1999: 804.
71 Wang K, van Wingerde FJ, Bradshaw K, Szolovits P, Kohane I. A Java-based multi-institutional medical information retrieval system. In: Masys DR. (ed). Proc AMIA Annu Fall Symp Proc AMIA Annu Fall Symp. 1997: 538.
72 Kohane IS, van Wingerde FJ, Fackler JC, Cimino C, Kilbridge P, Murphy S, Chueh H, Rind D, Safran C, Barnett O, Szolovits P. Sharing electronic medical records across multiple heterogeneous and competing institutions. In: Cimino JJ. (ed). Proc AMIA Annu Fall Symp Proc AMIA Annu Fall Symp. 1996: 608.
73 Nadkarni PM, Brandt CM, Marenco L. Web EAV: automatic metadata-driven generation of web interfaces to entity-attribute-value databases. J Am Med Inform Assoc 2000; 7: 343-56.
74 Stalidis G, Prentza A, Vlachos IN, Anogianakis G, Maglavera S, Koutsouris D. Intranet Health Clinic: web-based medical support services employing XML. In: Hasman A, Blobel B, Dudeck J, Engelbrecht R, Gell G, Prokosch HU. (eds) Proc MIE2000 and GMDS2000, Stud Health Technol Inform 2000; 77: 1112-6.
75 Wegner P. Interoperability. ACM Comput Surv 1996; 28: 285-7.
76 Musen MA. Domain ontologies in software engineering: use of Protege with the EON architecture. Method Inform Med 1998; 37: 540-50.
77 Stead WW, Miller RA, Musen MA, Hersh WR. Integration and beyond: linking information from disparate sources and into workflow. J Am Med Inform Assoc 2000; 7: 135-45.
78 Falasconi S, Lanzola G, Stefanelli M. Ontology and terminology servers in agent-based health-care information systems. Method Inform Med 1997; 36: 30-43.
79 Bouguettaya A, Benatallah B, Elmagarmid A. Interconnecting heterogeneous information systems. Boston: Kluwer Academic Publishers; 1998
80 Degoulet P, Sauquet D, Jaulent MC, Zapletal E, Lavril M. Rationale and design considerations for a semantic mediator in health information systems. Method Inform Med 1998; 37: 518-26.
81 Spahni S, Scherrer JR, Sauquet D, Sottile PA. Towards specialised middleware for health-care information systems. Int J Med Inf 1999; 53: 193-201.
82 Ferrara FM. The standard ’Healthcare Information Systems Architecture’ and the DHE middleware. Int J Med Inf 1998; 52: 39-51.
83 Szyperski C. Component software: Beyond object oriented programming. Reading: Addison Wesley; 1998
84 1999 International workshop on component-based software engineering: Developing a handbook for component-based software engineering. Carnegie Mellon Software Engineering Institute.; http://www.sei.cmu.edu cbs/icse99/papers/index.html last access 07 May 2001
85 Object Management Group, Inc.,. Healthcare Domain Task Force: CORBAmed. www.omg.org/homepages/healthcare/Road-map/corbamed_roadmap.htm last access 17 Apr 2001
86 Object Management Group, Inc.. CORBAmed specifications. http://www.omg.orgtechnology/documents/formal/corbamed_specifications_availabl.htm last access 17 Apr 2001
87 Dolin RH, Rishel W, Biron PV, Spinosa J, Mattison JE. SGML and XML as interchange formats for HL7 messages. In: Chute CG. (ed). Proc AMIA Symp. 1998: 720.
88 Dolin RH, Alschuler L, Behlen F, Biron PV, Boyer S, Essin D, Harding L, Lincoln T, Mattison JE, Rishel W, Sokolowski R, Spinosa J, Williams JP. HL7 document patient record architecture: an XML document architecture based on a shared information model. In: Lorenzi NM. (ed). Proc AMIA Symp. 1999: 52.
89 Rishel W. HL7 with CORBA and OLE: software components for healthcare. In: Cimino JJ. (ed). Proc AMIA Annu Fall Symp. 1996: 95.
90 HL7 standards: HL7 Version 3 (draft). Health Level Seven, Inc.. Ann Arbor, MI.: www.hl7.org/library/standards.cfm last access 17 Apr 2001
91 Grimson W, Berry D, Grimson J, Stephens G, Felton E, Given P, O’Moore R. Federated healthcare record server – the Synapses paradigm. Int J Med Inf 1998; 52: 3-27.
92 Frandji B. Open architecture for health care systems: the European RICHE experience. In: Dudeck J, Blobel B, Lordieck W, Bürkle T. (eds) New technologies in hospital information systems, Stud Health Technol Inform 1997; 45: 11-23.
93 Scherrer JR, Spahni S. Healthcare information system architecture (HISA) and its middleware models. In: Lorenzi NM. (ed). Proc AMIA Symp. 1999: 935.
94 Synergy on the Extranet (SynEx).. GESI Gestione Sistemi per l’Informatica srl. Roma, Italy.: http://www.gesi.it/synex/suite.htm last access 17 Apr 2001
95 The SynEx Project. CHIME Centre for Health Informatics & Multiprofessional Education, University College. London: http:www.chime.ucl.ac.uk/HealthI/SynEx last access 17 Apr. 2001
96 Rector AL. Thesauri and formal classifications: terminologies for people and machines. Method Inform Med 1998; 37: 501-9.
97 Jung B, Grimson J. Synapses/SynEx goes XML. In: Kokol P, Zupan B, Stare J, Premik M, Engelbrecht R. (eds) Proc Medical Informatics Europe ’99, Stud Health Technol Inform 1999; 68: 906-11.
98 van Bemmel JH. Toward a virtual electronic patient record. MD Comput 1999; 16: 20-1.
99 Patterson R, Huff SM. The decline and fall of Esperanto: lessons for standards committees. J Am Med Inform Assoc 1999; 6: 444-6.
100 Poon AD, Fagan LM, Shortliffe EH. The PEN-Ivory project: exploring user-interface design for the selection of items from large controlled vocabularies of medicine. J Am Med Inform Assoc 1996; 3: 168-83.
101 Sittig DF, Kuperman GJ, Fiskio J. Evaluating physician satisfaction regarding user interactions with an electronic medical record system. In: Lorenzi NM. (ed). Proc AMIA Symp. 1999: 400.
102 Boralv E, Goransson B, Olsson E, Sandblad B. Usability and efficiency. The HELIOS approach to development of user interfaces. Comput Methods Programs Biomed 1994; 45 Suppl: S47-64.
103 Ammenwerth E, Buchauer A, Bludau B, Haux R. Mobile information and communication tools in the hospital. Int J Med Inf 2000; 57: 21-40.
104 Blackman J, Gorman P, Lohensohn R, Kraemer D, Svingen S. The usefulness of handheld computers in a surgical group practice. In: Lorenzi NM. (ed). Proc AMIA Symp. 1999: 686.
105 Monnich G, Wetter T. Requirements for speech recognition to support medical documentation. Method Inform Med 2000; Mar 39: 63-9.
106 Zafar A, Overhage JM, McDonald CJ. Continuous speech recognition for clinicians. J Am Med Inform Assoc. 1999; 6: 195-204.
107 Grasso MA, Ebert D, Finin T. Acceptance of a speech interface for biomedical data collection. In: Masys DR. (ed). Proc AMIA Annu Fall Symp. 1997: 739.
108 Chute CG, Baud RH, Cimino JJ, Patel VL, Rector AL. (eds). Spec issue on coding and language processing. Method Inform Med 1998; 37: 311-575.
109 Rector AL. Clinical terminology: why is it so hard?. Methods Inf Med 1999; 38: 239-52.
110 Rossi Mori A, Consorti F, Galeazzi E. Standards to support development of terminological systems for healthcare telematics. Methods Inf Med 1998; 37: 551-63.
111 The OpenGALEN project.. www.opengalen.org/technology/technology.html last access 17 Apr 2001
112 Cimino JJ, Clayton PD, Hripcsak G, Johnson SB. Knowledge-based approaches to the maintenance of a large controlled medical terminology. J Am Med Inform Assoc 1994; 1: 35-50.
113 van Ginneken AM, Stam H, van Mulligen EM, de Wilde M, van Mastrigt R, van Bemmel JH. ORCA: the versatile CPR. Methods Inf Med 1999; 38: 332-8.
114 Melles RB, Cooper III T, Peredy G. User interface preferences in a point-of-care data system. In: Chute CG. (ed). Proc AMIA Symp. 1998: 86.
115 Coiera E. When conversation is better than computation. J Am Med Inform Assoc 2000; 7: 277-86.
116 Kuhn K, Gaus W, Wechsler JG, Janowitz P, Tudyka J, Kratzer W, Swobodnik W, Ditschuneit H. Structured reporting of medical findings: evaluation of a system in gastroenterology. Method Inform Med 1992; 31: 268-74.
117 Wyatt CP. Clinical data systems, part 3: development and evaluation. The Lancet 1994; 344: 1682-1688.
118 Lorenzi NM, Riley RT. Managing change: an overview. J Am Med Inform Assoc 2000; 7: 116-24.
119 Lauer TW, Joshi K, Browdy T. Use of the equity implementation model to review clinical system implementation efforts: a case report. J Am Med Inform Assoc 2000; 7: 91-102.
120 Gremy F, Fessler JM, Bonnin M. Information systems evaluation and subjectivity. Int J Med Inf 1999; 56): 13-23.
121 Berg M. Medical work and the computer-based patient record: a sociological perspective. Method Inform Med 1998; 37: 294-301.
122 Friedman CP, Wyatt JC. Evaluation methods in medical informatics. New York: Springer; 1996
123 Teich JM, Spurr CD, Schmiz JL, O’Connell EM, Thomas D. Enhancement of clinician workflow with computer order entry. In: Gardner R. (ed). Proc Annu Symp Comput Appl Med Care. 1995: 459-63.
124 Jablonski S. Development and operation of workflow management applications in health care. In: Proc 13th Int’l Congress and Exhibition, CARS’99. 1999
125 Heinl P, Horn S, Jablonski S, Neeb J, Stein K, Teschke M. A comprehensive approach to flexibility in workflow management systems. In: Proc ACM Conference on Work Activities Coordination and Collaboration. 1999
126 Brigl B, Winter A. Strategic information management in hospitals – bibliographic review and discussion of the German situation. Informatik, Biometrie und Epidemiologie 2000; 31: 57-69.
127 Austin CJ, Trimm JM, Sobczak PM. Information systems and strategic management. Health Care Manage Rev 1995; 20 (Suppl. 03) 26-33 /34-42.
128 Friedman CP, Frisse ME, Musen MA, Slack WV, Stead WW. How should we organize to do informatics? Report of the ACMI Debate at the 1997 AMIA Fall Symposium. J Am Med Inform Assoc 1998; 5: 293-304.