ing a women's health issue that would not otherwise have been recognized. (Refer to Chapter 4 for a more thorough discussion of EPI.)

CLINICAL PRACTICE

Information Technology

VHA operates 172 hospitals, 132 nursing homes, 73 home health care programs, and more than 650 outpatient clinics. In 1998, these facilities, along with other contractual programs, served 3.4 million of 9.4 million individuals who qualified for care (Kizer, 1999). However, DVA has experienced dramatic changes in the past few years, eliminating more than half of its acute-care beds and, from 1994 to 1998, increasing by 43 percent the number of ambulatory-care visits per year (Kizer, 1999). Most importantly, the creation of VISNs resulted in a need to integrate clinical data on a VISN-wide basis.

The Computerized Patient Record System (CPRS) allows all individuals on the health care team to view demographic data, future appointments, advanced directives, medications, orders, and progress notes. The Clinical Information Resources Network (CIRN) serves as the means for transmitting those data across the VHA network. CIRN ensures that a patient's primary care provider can receive all data on that patient's care, no matter where it was originally delivered. CIRN presents an opportunity to monitor health care delivery patterns and to allow VHA to modify clinical guidelines on the basis of current physician practices (DVA, Veterans Health Administration, 1998).

Homelessness

VHA is the nation's largest direct provider of services to homeless people, providing health care to more than 80,000 homeless people each year (Robert Rosenheck, Director, Veterans Administration Northeast Program Evaluation Center, personal communication, August 1999). In fact, on any given day in 1996, homeless people accounted for 13.5 percent of all hospital admissions (Wilson and Kizer, 1997).

Homelessness presents a unique set of circumstances for the treatment of infectious diseases. Physician monitoring is limited to the patient's motivation to seek care, and living conditions are often sub-standard. Since these conditions often involve sharing congregate spaces with large numbers of individuals, the transmission of communicable diseases cannot easily be prevented.

However, care of homeless veterans could be improved by use of EPI to identify the most prevalent infections and comorbidities and devise effective prevention strategies. For example, EPI data showed that for fiscal year 1998, 8.1 percent of all patients with hepatitis virus infection were homeless (Kralovic et al., 1999). Since EPI can identify the emerging pathogens that affect homeless



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