Clinical decision making is driven by information in the form of patient data and clinical knowledge. Currently prevalent systems used to store and retrieve this information have high failure rates, which can be traced to well-established system constraints. The authors use an industrial process model of clinical decision making to expose the role of these constraints in increasing variability in the delivery of relevant clinical knowledge and patient data to decision-making clinicians. When combined with nonmodifiable human cognitive and memory constraints, this variability in information delivery is largely responsible for the high variability of decision outcomes. The model also highlights the supply characteristics of information, a view that supports the application of industrial inventory management concepts to clinical decision support. Finally, the clinical decision support literature is examined from a process-improvement perspective with a focus on decision process components related to information retrieval. Considerable knowledge gaps exist related to clinical decision support process measurement and improvement.

Donald A.B. Lindberg M.D. arrived as Director, U.S. National Library of Medicine (NLM) in late 1984 with the intention of implementing a physician-friendly interface to MEDLINE, a prime example of his interest in making NLM information services more directly useful in medical care. By early 1986, NLM’s Grateful Med, an inexpensive PC search interface to MEDLINE useful for health professionals, had joined the group of end-user systems for searching MEDLINE that emerged in the 1980s. This chapter recounts Grateful Med’s rapid iterative development and the subsequent campaign to bring it to attention of health professionals. It emphasizes Lindberg’s role, the challenges faced by those introducing and using the interface in a pre-Internet world, and some longer-term effects of the effort to expand health professionals’ use of MEDLINE during the decade from 1986 to 1996.

Information technology, medical knowledge, and medical practice are on a collision course. The consequences of the impact will change the way physicians work, the way medical knowledge is processed, packaged, and distributed, and the way patients obtain medical care and information. Today's educators need to design an information technology curriculum to prepare students for this emerging world of practice. Computer labs, based on today's complex and unreliable desktop systems, are not the answer. What is needed by students who entered medical school in 1997-98 is an informatics curriculum that is based on the real-world requirements of 2003 and beyond. The authors draw upon academic studies and their own clinical and industry experiences to outline some predictable elements of what lies ahead. Their predictions--ubiquitous, simple network computing and "power tools" for managing medical knowledge--have implications for how schools cover such educational topics as patient confidentiality, systems thinking and error management, and knowledge resource evaluation.

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