system/database management, (2) administrative management, and (3) clinical management. System/database management software consists of software tools that have been constructed by the VA for the support, development, and maintenance of the DHCP. Administrative management software supports all normal hospital administrative tasks, including scheduling. Clinical management software supports clinical information provision in the laboratory, pharmacy, and other departments. It includes a complete surgery module and also partially supports medicine, cardiology, and oncology. The VA is recognized for its use of state-of-the-art technologies in selected radiology departments (Dayhoff et al., 1990).

To advance the clinical aspects of the DHCP, the VA has launched the Clinical Record Project. Clinical record development is under way at several sites and includes modules to support order entry/results reporting, a health summary, a problem index, allergies/adverse reactions, progress notes, crisis warnings, consults information, clinical observations, and clinical measurements. These and other clinical modules represent the VA's commitment to constructing its own state-of-the-art CPR system.

Department of Defense

The Department of Defense (DoD) has contracted for the deployment of a clinical information system at its hundreds of care facilities around the world (General Accounting Office [GAO], 1988, 1990). The system, known as the Composite Health Care System (CHCS), is currently being tested in multiple care facilities in the United States that serve a range of care settings. One example involves health maintenance organization-like settings in Hawaii where hospitals and associated care facilities and clinics are networked. As military personnel visit any of these facilities, the CHCS allows clinicians to gain immediate access to patient care data from previous patient encounters.

The CHCS is an excellent environment and opportunity to design, test, and evaluate certain desirable features of the ideal CPR system, and its potential in this regard may prove vital to accelerating the development of CPR systems generally. For example, the military has established a command structure that permits testing in a closed-loop environment. This means that, within limits, DoD can mandate particular clinician behaviors to evaluate various potentially beneficial methods of providing care and that the CHCS can measure the benefits, if any, that are derived. Currently, the CHCS represents the largest demonstration of actual clinician hands-on data entry to clinical systems: because military facility commanders can require clinicians to input data into the system, alternative input mechanisms may be evaluated. In addition, DoD is testing a prototype professional workstation to facilitate clinicians' interaction with the CHCS.

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