The Clinical Decision Support System (CDSS) at Columbia Presbyterian Medical Center (CPMC) at Columbia Univ. in New York City was begun in the mid 1980s resulting from a National Library of Medicines Integrated Academic Information Management System  (IAIMS) program grant to CPMC. A CDSS is necessarily dependent upon an Electronic Health Record environment in order to capture the patient care observations (such as demographics, encounters, measurements) that document patient care and this data structure was created and used in both ambulatory and resident settings of care within the CPMC enterprise. The technical approach is described by Jenders (Ref C2) who depicts how the clinical decision support structure and supporting vocabularies were developed. Particularly significant was the systematics of the terminology used in the Medical Logic Modules (MLMs) that were base upon the same formal logic process as those of the HELP system.