Clinical Informatics is not a spectator sport," noted Dr. Randy Miller, Professor of Biomedical Informatics at Vanderbilt University, many years ago. The essence of that quote is borne out in the description of the Computerized Physician Order Entry (CPOE) project at Toronto's University Health Network in this journal. It is also borne out in the experience of developing and deploying North America's most widely utilized electronic medical record, the Veterans Health Administration's (VHA) Computerized Patient Record System (CPRS). The most critical elements of CPRS's success have not been technical advances; rather, the involvement of field-based participants - physicians, nurses, pharmacists and other medical centre support staff - has been the key. In fact, the origins of CPRS were not even supported by the national VHA structure of the late 1970s when the computerization effort started. As recounted in the book Computerizing Large Integrated Health Networks by Dr. Robert Kolodner (current VHA Chief Health Informatics Officer), an "underground railroad" of clinical users in VA promulgated the development of a clinical information system along with critical programming staff. This user-driven system evolved into CPRS over a period of nearly 20 years.

Why is it so critical that front-line clinicians become intimately involved in the implementation of a computerized patient record system? The answers are manifold, but they can be divided into a few key areas. First, "implementation" of a provider order entry system is not an event. There are no ribbons to cut at a CPOE ceremony because implementation is never "done." Rather, it is an iterative process. The workflow of one group of healthcare providers will be different from another, and each will fit differently into the pathways that the software has created. The software will then have to be readjusted. As the providers adapt to the software, their own workflow will change, and new modifications to the software will again be necessary.

In VHA, CPRS is currently in Version 26, after its original testing and distribution in 1997. It is a nationally programmed application, with one new substantial version every four to six months, each of which needs to be tested, validated and then deployed across more than 160 medical centres and 600 outpatient clinics, with new training and support resources involved at each step. Having clinical champions heavily involved is crucial to the success of this process.

Second, computers are ruthless enforcers of rules - that's their real power in impacting clinical care - but they don't care what the rules are. In healthcare, practice patterns have evolved to such a point that no one person actually knows what all the rules are, at least not enough to guide programmers. They just know what they do. Front-line clinicians need to meet, discuss, bribe, cajole and then come to a consensus on what the rules are. Our experience has been that rules frequently have to be created in situations where we didn't know we needed any. Not only is clinical informatics not a spectator sport, it is a contact sport!

Third, healthcare really is different from other industries. Complex decision-making, non-linear workflow, shared responsibilities, extreme time-sensitivity of information flow and recognition of previously unrecognized patterns define medical care in the 21st century. Programmers and other technical staff have much to learn from clinicians. By and large, programmers enjoy it and can deliver better products and systems when clinicians can work with them to demonstrate what it is they really need to accomplish to take good care of other human beings.

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