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IMPLEMENTATION AND EVALUATION 89 wishes to set forth several principles for structuring and managing the review process based on earlier IOM reports on utilization management (1989) and quality assurance (1990). 1. Consistent with the recommendations of the IOM report on private-sector utilization management, review criteria should be public with respect to their content and their development process. (This does not require that software and other administrative tools be public.) 2. When criteria are used to assess quality of care, deny payment for specific services, or take similar steps, an appeals process needs to be provided. This process must be clearly described to patients and practitioners and be free from unreasonable complexity, delay, or other barriers. 3. Review organizations should make their review activities as manageable and nonintrusive as possible for both patients and practitioners. These organizations are one contributor to the growing "hassle factor" in medical care. 4. Insofar as possible, review organizations should provide constructive information and feedback to physicians aimed at improving practice rather than punishing missteps. The Forum will need to work with provider groups, HCFA, the PROs, and other organizations to encourage careful development and application of review criteria and other practice evaluation tools. These are not simple or unimportant tasks. Other Organizations Organizations involved with medical informatics and education clearly have a role to play in the dissemination and administration of practice guidelines. Many researchers, practitioners, and institutions are now involved in developing prototype expert systems and other computer support for information retrieval, decisionmaking, and monitoring (Shortliffe, 1987; Greenes and Shortliffe, 1990; Williamson et al., 1989). The relative utility of different approaches, for example, comprehensive nationwide systems (such as PDQ) versus institution- or service- specific systems, should be evaluated. Intended users of information systems may not, in fact, find them useful. The widespread use of information and decision support systems will, however, probably require extensive involvement of commercial enterprises with the capital and expertise to develop, market, and maintain generally usable software, consulting services, and so forth. AHCPR may want to give early consideration to its stance on such commercial developments as they pertain to the guidelines emerging from expert panels.
