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5
Medical Record Keeping
An Institute of Medicine committee studying the health consequences of the
Persian Gulf War noted that "the single most troublesome problem encountered
in attempts to conduct epidemiologic studies of illnesses among Persian Gulf
war veterans has been the inability to retrieve information on medical care
events such as hospitalizations, outpatient visits, and diagnosis and treatment
from DoD and VA medical records in a uniform and systematic manner"
(Institute of Medicine, 1996a, p. 128~. The committee went on to state that "cur-
rent systems are fragmented, disorganized, incomplete, and therefore poorly
suited to support epidemiologic and health outcomes studies" (p. 128~. As a re-
sult, the number one recommendation from the committee was to have the U.S.
Department of Defense (DoD) and the U.S. Department of Veterans Affairs
(VA) work together to develop a "single, uniform, continuous, and retrievable
electronic medical record for each service person" (p. 10~. They envisioned that
the record should include all relevant health items, allow linkage to exposure
and other data sets, and have the capability to incorporate relevant medical data
from other institutions with appropriate confidentiality protections.
The Presidential Advisory Committee on Gulf War Veterans' Illnesses
(1996b) directed the National Science and Technology Council (NSTC) to de-
velop an interagency plan to address health preparedness for and readjustment of
veterans and families after future conflicts and peacekeeping missions. NSTC
recommended that DoD "implement a fully integrated computer-based patient
record available across the entire spectrum of health care delivery over the life-
time of the patient" (National Science and Technology Council, 1998, p. 23~.
The goal was to "ensure the accuracy, timeliness, security, and retrievability of
information that must be entered into records or automated systems that docu-
ment personnel history for active, National Guard, and reserve service members
and veterans" (p. 23~.
72
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MEDICAL RECORD KEEPING
73
In accordance with its charge, the study team reviewed DoD's approach to
medical record keeping and provides recommendations to enhance the capability
of information systems to support the health of deployed U.S. troops. As part of
the review process, the study team held three workshops that covered various
aspects of DoD's approach to medical record keeping. The study team also so-
licited advice from additional experts on medical information systems, Edward
Hammond and Clement McDonald, who participated in DoD briefings and the
review. The study team and other experts consider the computer-based patient
record (CPR) essential for DoD to meet the health care needs of service mem-
bers before, during, and after deployments (Institute of Medicine, 1997~. Addi-
tional information systems are necessary to support population-based surveil-
lance beyond medical record surveillance, such as for laboratory-based
surveillance, reportable conditions, and disease non-battle injury (DNBI) re-
porting (Chapter 4~. This chapter summarizes the study team's observations,
findings, and recommendations.
While this study and report focused on the global needs for effective
automation of military medical records, information is available elsewhere pro-
viding more detail about the current medical record keeping practices of the
military services. A recent report provides information about specific medical
record keeping practices during the Gulf War, how policies and practices have
been modified to respond to identified problems, and plans for the future (Office
of the Special Assistant to the Deputy Secretary of Defense for Gulf War Ill-
nesses, 1999~.
INFORMATION NEEDS OF THE MILITARY HEALTH SYSTEM
As the largest health care system in the world, the military health system
has an extraordinary need to acquire, manage, analyze, and retain health infor-
mation on recruits, active-duty personnel, reservists, and veterans. While care of
the individual service member should be its first priority, the record-keeping
system in the military health system must meet several needs simultaneously to
fulfill the needs of Force Health Protection:
1. provide access to an individual's health data anytime and anywhere that
. .
care IS reqUlreC i,
2. support record keeping for the administration of preventive health services,
3. facilitate real-time medical surveillance of deployed forces and timely
medical surveillance of the total force,
4. provide comprehensive databases that support outcomes studies and epi-
demiological studies, and
5. maintain longitudinal health records of service members beginning with
recruitment and extending past the time of discharge from the military.
Each of these requirements is briefly elaborated upon below.
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74 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
Individual Care
Informed decision making requires access to comprehensive data on pa-
tients at the time that care is delivered. The mobile nature of military personnel,
including deployments abroad, makes use of CPRs the only practical option.
Because service members may be deployed to locations where access to the
CPR may be problematic, other methods of providing necessary health informa-
tion at the point of care must also be considered. It is unlikely, however, that
large amounts of data are required outside of a medical treatment facility. For
specific situations, such as medical evacuation, portable storage devices may be
useful.
Preventive Care
i
Although preventive care is part of care to individuals, its universal appli-
cation to members of the force (e.g., mass immunizations) and the need to track
compliance with guidelines warrant special attention. Service members need
immunizations to protect them from hazards associated with special deploy-
ments. These include immunizations against respiratory diseases prevalent in
training camps, against natural disease hazards during deployments, and against
biological warfare agents. CPR systems perform well when used to identify
service members who are eligible for a specific preventive medicine service,
remind health professionals to perform the service, and track members' health
statuses (McDonald, 1976; McDonald et al., 1984, 1992; Shea et al., 1996; Tang
et al., 1999~. Reminder and tracking functions should be incorporated into the
CPR to ensure the greatest possible integration of preventive medicine practices
with routine care.
Another part of prevention is to "do no harm." Adverse drug reactions cause
significant morbidity in hospitals (Bates et al., 1995; Leape et al., 1995; Classen et
al., 1991; Lazarou et al., 1998~. Adverse events also occur in the ambulatory care
setting, including the military ambulatory care setting. Computer-based decision
support associated with physician order entry can effectively reduce the incidence
and costs of adverse drug interactions (Classen et al., 1 99 1; Evans et al., 1 993; Lee
et al., 1996; Shiffman et al., 1999~. Military CPR systems should include auto-
mated decision support to detect potential drug allergies and drug-drug interac-
tions as well as other decision support functions (Johnston et al., 1994~.
Medical Surveillance
In addition to providing data to support immediate care of individuals, the
military health system must support ongoing medical surveillance of the military
force to ensure maximal preparedness for the military mission and to detect
health threats promptly. Useful information for surveillance will come not only
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MEDICAL RECORD KEEPING
75
from individual medical records, but also from sources such as mandatory re-
portable conditions, aggregate DNBI data, and laboratory databases. Conse-
quently, the ability to consolidate data from all regions in the world must exist
and must be available in a timely manner. To analyze aggregate data, common
representation of data is required. At a minimum, common data definitions and
common data models must exist for all relevant health items to be consolidated.
Also, since the interpretation of data depends on how data are gathered, the use
of common applications to acquire data increases the consistency of data col-
lected at different locations.
The operational utility of surveillance data to commanders (particularly in
theaters of operation where the risk of chemical or biological agents is high)
depends on both the accuracy of the data and the timeliness with which com-
manders can access and interpret aggregate data. Real-time linkages between
medical units and upper echelons of command are needed so that surveillance
data can be used to detect and immediately respond to health threats.
Correct interpretation of real-time surveillance data during an engagement
and epidemiological studies of war-related illnesses after a deployment also de-
pend on accurate documentation of exposures. Data systems containing detailed
records of duty locations and environmental exposures, such as those discussed
by one of the companion reports to this one, Strategies to Protect the Health of
Deployed U.S. Forces: Detecting, Characterizing, and Documenting Exposures
(National Research Council l999b), must be interfaced with the CPR so that
links between exposures and illnesses can be studied and adverse health effects
can be treated or prevented.
Databases for Epidemiologic Studies
it is crucial that health information collected from individuals be gathered in
a manner that permits asking epidemiologic questions about deployed popula-
tions. Two unmet requirements after past deployments have been the need to
conduct good epidemiologic studies of the effects of putative deployment expo-
sures and the need for information to assess the long-term health status of de-
ployed individuals. Meeting these needs requires record-keeping systems that
can link personnel information, location information, individual exposure infor-
mation, and health outcome information.
Longitudinal Record Keeping
Manifestations of the health effects of war are often delayed and are some-
times prolonged. Consequently, information-gathering activities should continue
for years, perhaps indefinitely, after discharge from the military, as discussed in
Chapter 4. For discharged service members who later receive their health care
from VA, ongoing follow-up requires interfaces between VA and DoD health
information systems. For service members and reservists who receive care from
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76 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
civilian health care providers, mechanisms for the capture of essential health
data from the Recruit Assessment Program (RAP) and Health Evaluation and
Assessment Review (HEAR) instruments are necessary.
Defining, understanding, treating, and preventing illnesses that follow de-
ployment of U.S. troops require diligent and comprehensive record keeping. The
following section examines some of the major information systems activities
under way and planned in DoD.
MAJOR INFORMATION SYSTEMS ACTIVITIES
To gain an understanding of the ongoing information systems activities in
support of Force Health Protection, the study team heard briefings on several
projects including the Composite Health Care System (CHCS), the Government
CPR (GCPR) project, the Preventive Health Care Application (PHCA), the Per-
sonal Information Carrier (PIC), and various survey instruments. Observations
for each project area are summarized below.
Composite Health Care System
The CHCS is a clinical information system project that began in the early
1980s. The scope of clinical information stored in CHCS is currently limited to
ancillary data such as laboratory results and pharmacy data. CHCS is deployed
at 86 medical treatment facilities worldwide, and each CHCS stores data in a
local database. Unfortunately, data from the local databases cannot be linked to
construct a consolidated database. The lack of data integration also makes it
difficult to provide a continuous record for service members. The study team
heard several examples of the difficulties in accessing information from dispa-
rate CHCSs. For example, when a service member changes duty stations or is
deployed, data stored in one CHCS cannot be transferred to the CHCS at another
location. Laboratory data critical to effective medical surveillance can be trans-
ferred to another facility only by electronic mail because laboratory results are
stored in local CHCS databases. The CHCS hardware and software were de-
scribed as "difficult and expensive to operate and maintain, and the system has
an architecture that does not readily provide expansion of capabilities to meet
current and future military health system mission needs" (U.S. Department of
Defense, 1998a). Because of the limitations of CHCS, a second phase of CHCS
(CHCS II) was initiated in 1997, and the original program was named CHCS I.
The CHCS II program includes development of a CPR, immunization track-
ing, health risk assessment, pre- and postdeployment health status tracking, and
security services. CHCS II has been planned as a "system of systems" (U.S. De-
partment of Defense, 1 999c). A "best-of-breed" approach (an approach that identi-
fies applications that serve specific tasks and interfaces them to a central system)
has been adopted as the strategy for information systems in the military health
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MEDICAL RECORD KEEPING
77
system. Although this strategy takes advantage of multiple niche products, it pres-
ents a significant challenge to data integration because the different products do
not share a common data model or database (Hammond, 1999; McDonald, 1999~.
The best-of-breed approach tends to favor growth of independent, task-specific
applications without sufficient consideration of the overall integration strategy.
The need for data integration must be proactively interjected into the process of
defining, specifying, and prioritizing information requirements. To the extent pos-
sible, the needs of all three services should be considered concurrently to maxi-
mize reuse of data and software programs. Attempts to combine data gathered
from different applications into a single database are fraught with difficulty and
often are not possible. Development and maintenance of interfaces to multiple
systems requires substantial effort and must be updated every time any one pro-
gram is updated. To work at all, there must be a well-articulated and precisely
defined technical architecture that spans all branches of the military. Similarly, a
common approach to data standards by all who need data (e.g., caregivers, epide-
miologists, and preventive medicine professionals) should be adopted. Otherwise,
the same or similar data will be collected multiple times instead of being collected
once and reused (Hammond, 1999; McDonald, 1999~.
A consistent theme observed throughout the briefings was a mutual lack of
awareness and coordination among the various project participants involved
with information-gathering activities and systems. In general, each need for data
has been addressed by a separate data-gathering activity at the individual service
level. It was common to find that each branch of the military had its own proc-
esses and programs for the gathering of data. Effective central oversight author-
ity common to all three services to ensure that independent efforts are coordi-
nated or, better yet, consolidated into a single activity that serves the needs of all
three services was not apparent. The study team received very few details about
the implementation plans and milestones for many of the important medical rec-
ord-keeping projects including CHCS II, the final common pathway for infor-
mation systems projects. Although the intent is that all applications be integrated
into CHCS II, the study team heard no concrete technical plans for the integra-
tion. In addition, it is not clear that CHCS II data from different regions will be
consolidated. According to one briefing, CHCS I data will not be integrated with
CHCS II data (L. Ray, 1998~. Compromising the ability to share data among
applications would undermine the vision of creating a uniform CPR for all
service members and would prolong the state of data fragmentation described in
previous studies.
In addition to developing technical plans for data integration, organizational
plans need to be developed to standardize policies and practices relating to
medical record keeping. The study team heard of differences in policies between
the services regarding whether certain information should be recorded and of
differences in the forms used to record information. In short, whether and how
medical information was recorded varied on the basis of the type of data in-
volved (e.g., outpatient care, inpatient care, immunizations, or investigational
drug use), the location of the service member (e.g., garrison, deployed, and lo
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78 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
cation of deployment), and the branch of service. Policies, procedures, and
practices should be standardized so that consistent and comprehensive data can
be stored in the CPR throughout the military enterprise.
A new program, the Theater Medical Information Program, is planned to be
a f~eld-deployable system that will link information databases. It is planned to
"support mission-critical information and data from across the areas of medical
command and control, patient movement, medical logistics, health care delivery,
and manpower, personnel, training, and resources" (U.S. Department of De-
fense, 1998b, p. 4~. CHCS II is anticipated to be only one of many systems or
modules that it links and integrates (U.S. Department of Defense, 1998c). Al-
though CHCS II is scheduled to begin worldwide deployment in 2000 (U.S.
Department of Defense, l999f), many of its features and characteristics are still
under development, and it is likely to be several years before it is ready to pro-
vide the functions described above. The Theater Medical Information Program
is fully funded through 2004.
Since CHCS II will be a key component used by the Theater Medical Infor-
mation Program for the care of the service member during a deployment, it is vital
that the two systems work together well to meet the needs of deployment. CHCS
II must be developed and implemented with a priority for the readiness mission.
A separate area of concern for the study team was the medical record-
keeping needs of the reserve component. As described in Chapter 8, members of
the reserves do not receive their health care from the military health system but
from civilian providers through their employers' insurance or paid for by them-
selves. Thus medical records for reserve forces are not readily available to the
military system. Because reservists increasingly constitute a significant portion
of deployed forces, ensuring that health care providers have adequate informa-
tion to care for reservists during deployments and that epidemiologists have suf-
f~cient population data for this group should be a high priority. The reserves are
at increased risk of adverse health consequences (Iowa Persian Gulf Study
Group, 1997), perhaps because of the episodic nature of their participation in the
military. Consequently, the health information management needs of the reserve
component should be explicitly addressed in the information systems strategy.
Currently, they are not.
One means to acquire health status information from reserve members
would be through annually administering the HEAR survey to members of the
reserves, as recommended in Chapter 4, and through administering the RAP
instrument to all recruits as currently planned by DoD and recommended in
Chapter 4. It is important that data be captured electronically and be retrievable
as part of a computerized patient record for reserve members. While such a CPR
for reservists would not be as complete as that for those who are active-duty
service members, it should provide information useful during deployments and
for surveillance.
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MEDICAL RECORD KEEPING
Government Computer-Based Patient Record Project
79
As part of his commitment to resolving the health information management
issues that impeded study of Gulf War illnesses, the President directed DoD and
VA to work together to ensure that service members' health information can be
passed seamlessly from the military health system to VA (White House, 1997~.
In 1998, the GCPR project was established to accomplish this goal. The GCPR
project is a cooperative venture involving the DoD, the Veterans Health Ad-
ministration, and the Indian Health Service to facilitate seamless exchange of
patient data among government health information systems. The effort is to be
standards based and is to include input from and cooperation with private-sector
standards-setting organizations. The study team applauds and supports the goals
of the GCPR project. Their intention to work with and build on existing work of
health care standards organizations (e.g., ML-7) is excellent. The early focus on
building and refining reference models is well placed. However, the GCPR proj-
ect team may be underestimating the level of effort and time required to make
substantive progress in this area. For example, the Institute of Electrical and
Electronic Engineers' MEDIX standards group and HL-7 have been working on
the Reference Information Model (RIM) for over 12 years. It may be unrealistic
to expect that the GCPR project team can complete an information model, even
of a limited domain, in a matter of a year. The model of any one domain is inter-
related with the global, or overall model. Furthermore, their plan to draw on
available bodies of work, extend them to meet GCPR needs, and make those
extensions available to the international community (GCPR Framework Project,
l999c) is not part of the standards-development process. Such "extensions" per-
formed outside the context of the consensus-based standards process tend to
cause divergence from standardization, rather than to strengthen it.
Due to a delay in finalizing the contract with the prime contractor, the study
team did not receive any details of the proposed architecture, project plans, and
implementation approach during the workshop briefings. While the draft report
was being reviewed, the study team received two documents providing an over-
view of the technical architecture proposed by Litton/PRC for the GCPR Frame-
work, the basis for developing a "virtual" longitudinal patient record (GCPR
Framework Project, l999b,c). The overview document (GCPR Framework Proj-
ect, l999b) describes an architecture that relies on a proposed standard for distrib-
uted object services (CORBA Common Object Request Broker Architecture) to
identify the patient, locate the various repositories of patient information, translate
the meanings of data in heritage systems (existing systems of DoD, VA, and HIS)
into a common information model, and ensure system security. The project plans
to integrate heritage systems, commercial off-the-shelf systems, and government
off-the-shelf systems in a "best-of-breed" approach.
The GCPR team is committed to demonstrating the ability of their Frame-
work to: "~1) share patient data with no loss of meaning or usefulness, and (2) be
able to cooperate in the joint execution of tasks" (GCPR Framework Project,
l999b, p. 3~. It is important that the proof of concept prototype demonstrate the
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80 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
Framework's ability to meet these objectives. For example, using their chosen
domain of laboratory data, it would be useful to evaluate the Framework's abil-
ity to mediate the application of decision support rules stored in one system to
laboratory data that are combined from other heterogeneous data sources.
The study team and external advisors find the architecture described to be
reasonable conceptually, but are concerned about the feasibility, practicality,
cost, and maintainability of the approach. Within a limited domain (e.g., ex-
changing lab test results), it should be possible to develop a proof-of-concept
prototype as proposed by the GCPR project team. The challenge will be to as-
sess the scalability of both technical and non-technical aspects of the prototype
to a large health system the size of the DoD, VA, and IHS.
A key element of the proposed GCPR Framework is the virtual database, "a
single interface to a variety of distributed, heterogeneous data sources" (GCPR
Framework Project, l999b, p. 8~. While it is technically possible to wrap (that is,
translate a proprietary interface into a standard interface) heritage systems in a
CORBA environment, the ability to maintain the "meaning and usefulness" of
the data will prove quite challenging. Although a CORBA-wrapped object may
be able to communicate with other CORBA components and services, limita-
tions in the heritage system will persist. For example, if some context of data
(e.g., date/time stamp, authentication of the person entering data, medications
being taken by patient) were not stored in the heritage system, it will be impos-
sible to answer a query requiring such information. Another example where
wrapping heritage systems will not necessarily satisfy critical system require-
ments involves security. The documents mention encryption and digital certif~-
cates techniques to secure communication of data, but do not address the ad-
ministrative security features needed in each repository to protect identifiable
patient information. If a heritage system does not support role-based access or
does not record audit trails of all accesses and updates, applying a CORBA
wrapper will not raise the functional capabilities of the system to meet Health
Insurance Portability and Accountability Act (P.L. 104-191) requirements.
The GCPR documents do not describe how deficits in data collection will
be handled to achieve the goals of medical record keeping and medical surveil-
lance. For example, if some important information (e.g., exposure data) is not
captured in the heritage system, the feasibility of conducting recommended
medical surveillance activities will be limited. If the goal of the GCPR project is
merely to access existing data in legacy systems, a simpler Web-based approach
could be entertained. A key motivation for creating a computer-based patient
record is to efficiently capture comprehensive information about all service
members and to make relevant views of that information available to decision
makers. Consequently, accommodating the need for entering new data and rec-
onciling data elements among the various heritage systems should be addressed
in the architectural plans.
The information management component of the GCPR Framework acts to
synthesize "a virtual patient record . . . out of disparate records stored on differ-
ent systems in different locations" (GCPR Framework Project, l999b, p. 11~.
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MEDICAL RECORD KEEPING
81
The GCPR project team proposes to accomplish this "by unifying the informa-
tion in these records in a common representation, by using a clinical lexicon to
standardize terminology and a Common Information Model to provide a shared
semantic base of understanding" (p. 11~. The study team has significant con-
cerns about the feasibility of this goal, since none of the needed standards cur-
rently exists or is likely to be developed in the next few years. No acknowledg-
ment is made of the costs of developing or maintaining such standards. It is also
not clear how changes made to the heritage systems will be incorporated into the
information model and how these would propagate to other systems that may
rely on the data from the source system.
The original time line presented to the study team called for operation of a
proof-of-concept laboratory version of a virtual patient database (linking data
from heritage systems) by September 1999, and for operation of a full pilot sys-
tem by February 2000, followed by testing at a live site. More recent time lines
call for the prototype phase to finish by February 2000, the pilot tests to finish
by March 2001, and enterprisewide implementation by August 2002 (GCPR
Framework Project, l999d). Given the people and organizational challenges
associated with standards development and the technical complexity of the proj-
ect, the study team is concerned that the project will not meet its goals according
to the proposed time lines.
Health Assessment Instruments
To gather health information from all service members, a number of survey
instruments have been or are being developed. The study team was briefed about
plans to automate several of the health assessment instruments that were de-
scribed in Chapter 4. The study team's summarized observations are below.
Preventive Health Care Application
PHCA includes two modules: software to capture data from the Health
Evaluation and Assessment Review (HEAR) survey and an immunization tracking
module (ITM) (U.S. Department of Defense, l999e). Deployment of PHCA with
HEAR began in the spring of 1999; ITM entered beta testing in February 1999.
Both applications draw on data stored in the local, stand-alone PHCA database.
PHCA receives demographic data from CHCS I through a one-way interface. Data
stored in the local PHCA database cannot be uploaded to CHCS I.
The study team attended separate demonstrations (different vendors were
involved) of HEAR and ITM. The computer-based implementation of the
HEAR survey was a verbatim translation of the paper-based survey form. Al-
though there are many opportunities to streamline the data-collection process
when the paper-based survey is converted to a computer-based format, the pro
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82 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
gram did not take substantial advantage of that capability beyond incorporating
skips to appropriate questions.
The second component of PHCA is ITM. The ITM software is divided into
several modules, most of which communicate with each other through batch
processes. Multiple vendors are involved. The ITM program downloads demo-
graphic information (which originates from CHCS) from the local PHCA. It
downloads vaccine supply data from a separate vaccine inventory program
through a batch interface. During mass immunizations, a stand-alone program
called Mass Immunization (MI) is used on a laptop computer to track immuni-
zations. MI downloads demographic data from ITM. Once immunization data
are entered into MI, they are uploaded to ITM and are subsequently uploaded to
the Defense Eligibility Enrollment Reporting System (DEEPS). The study team
was struck by the use of several different software programs, many written by
different vendors, to document the administration of a vaccine. PHCA has not
been used during the ongoing mass anthrax immunization program because it
was not yet fully developed at the start of the immunizations. Instead, each
service adapted a different service-specif~c system to track anthrax immuniza-
tions before uploading the information into DEERS. DEERS itself is primarily
an administrative system; its use for medical records was an expedient made
necessary because the medical records systems were not adequate.
The study team was particularly concerned that PHCA data from HEAR
and ITM were stored in a local database at the medical treatment facility. Con-
sequently, medical surveillance data gathered through the HEAR survey resides
locally. If an individual transfers to another duty station, HEAR data would have
to be transferred by filling out a paper form (DD Form 2766) and hand entered
into the PHCA system at the new station. The stand-alone nature of PHCA sub-
stantially limits its utility as a repository of patient information and as a medical
surveillance tool. It is planned that PHCA will be able to upload data for transfer
when CHCS II is implemented, although concrete plans have not yet been de-
f~ned (ACS Government Solutions Group, 1999~.
Pre- and Postdeployment Questionnaires
The current pre- and postdeployment health assessment questionnaires
(which can be found in Appendix J) are intended to be administered immedi-
ately before and after a deployment, respectively. The questionnaires consist of
scannable forms, and the data are stored at the U.S. Army Center for Health
Promotion and Preventive Medicine. These data are not yet linked to HEAR
data or to other health data. It was not clear that the data have been used in any
decision making to date.
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MEDICAL RECORD KEEPING
Recruit Assessment Program
83
A new questionnaire that is planned to be administered as the Recruit As-
sessment Program is being developed to collect baseline data on all U.S. military
recruits. The intent is to collect data on a scannable form. Since the program is
still entering a pilot stage, no decision has yet been made regarding the computer
program into which the data will be entered or how much of the data-collection
activity will be coordinated with the HEAR survey program or the pre- and
postdeployment questionnaire activities.
Overall, the study team was concerned about the lack of coordination
among the various data-gathering projects in the different services. Although
most of the survey developers expected data from their surveys to be entered
into a computer, each survey typically uses its own dedicated software program.
Epidemiology researchers and preventive medicine professionals were not ade-
quately consulted in the development of many of the survey instruments. Under-
standing the requirements of both the primary and the secondary users of data at
the outset would improve the chances of designing a common survey instrument
that serves multiple purposes. Minimizing the number of surveys administered
and their frequency of administration is highly desirable, considering the logisti-
cal challenges associated with the collection of accurate data from troops being
deployed. The ability to analyze aggregate data from multiple sites is critically
dependent on the compatibility of the applications used to gather data and the
database definitions used to store the data. One approach to ensuring comparable
data is to use a common software application to gather the data. Another ap-
proach is to ensure that the multiple applications used comply with data stan-
dards so that the data can be integrated easily. Without establishing shared data
standards ahead of time, data obtained through different software programs can-
not be combined easily.
Deployment Medical Surveillance System
In the absence of CPRs, medical surveillance is fragmented and not avail-
able in real time. The study team heard of some special efforts to improve cen-
tral reporting and surveillance during deployments. For example, the study team
was briefed on the collection of disease and non-battle injury (DNBI) medical
surveillance data from Bosnia and from Southwest Asia. In both theaters, diag-
noses assigned to outpatient encounters are recorded in the sick-call log by using
the 10th revision of the International Classification of Diseases. Twenty-f~ve
codes are used. These data are reported weekly to the Joint Task Force under the
Joint Task Force surgeon.
The data have several limitations. One of the biggest challenges is ensuring
that the encounter diagnoses are accurately abstracted from the progress notes.
In general, the task of filling out the classification sheets is assigned to a non
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84 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
clinician with no training in abstracting. Furthermore, the frequency with which
reports are submitted may not be sufficient to detect important outbreaks or sen-
tinel diseases. In addition, multiple diagnoses for individual subjects are coded
as separate events, which may distort the percentage calculations. These sur-
veillance data are stored on local servers and thus are not combined with other
data. Without a central strategy for collection, consolidation, and analysis of
field data, medical surveillance will continue to be fragmented and incomplete.
Another problem with incomplete data collection during deployments in-
volves inpatient data. Both policies and practices differ significantly among dif-
ferent deployments and among the different services in the military. For example,
inpatient data from Bosnia are sent to the Patient Accounting and Reporting Real-
Time Tracking System (PARRTS), a central patient reporting and tracking data-
base, whereas inpatient data from Southwest Asia are not because PARRTS is
not expected to be part of the planned Theater Medical Information Program now
under development. Furthermore, when a service member is treated in a host na-
tion facility or at a military health system-sponsored facility, data are not cap-
tured in the medical surveillance system. Although more deployment surveillance
data are being reported to central facilities now than during the Gulf War, collec-
tion, consolidation, and timely analysis of health data about U.S. troops are far
from complete and systematic efforts to correct this situation are lacking.
Although the Theater Medical Information Program is planned to carry out
the function of facilitating medical surveillance during deployments, it is likely
to use modifications of existing programs. Developers should take into account
the different demands of different deployment settings. Many of the problems
identified above are not problems related to technology alone but are problems
related to the training and equipment available to those carrying out necessarily
active data-collection roles. An important change will be the implementation of
systems that permit less active and time-intensive collection of data. If this
change is implemented, medical surveillance will then involve the active scru-
tiny and analysis of data collected passively.
Personal Information Carrier
The study team was briefed about the PIC, which is being developed to
store medical data in a form that service members could carry with them at all
times. The PIC, which was conceptualized as a "smart card" (a computer proc-
essing unit and memory embedded in a small device), would store an individ-
ual's medical status and history, including medical documents, x-rays, and vac-
cination records (National Science and Technology Council, 1998~. The study
team heard a number of different purposes described for the PIC. At times it was
described as the official complete medical record for each service member (U.S.
Department of Defense, 1997c). At other times it was described as an informa-
tion carrier to communicate information from the field to the central CPR (Page,
1999~. Most recently, it is planned to "serve as the abridged Electronic Theater
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MEDICAL RECORD KEEPING
85
Medical Record in settings where computer network connectivity is not avail-
able, providing in-theater health care providers with immediate access to accu-
rate clinical information" (U.S. Department of Defense, l999d, p. 1~. The in-
formation on the PIC is to be read by a proprietary access device. Data would be
transferred to a portable computer that would upload the PIC information to the
central CPR periodically whenever a network connection was available.
The descriptions of the PIC did not justify clearly the use of high-capacity
smart-card technology or adequately assess the feasibility of its use under ad-
verse conditions such as the battlefield. Smart-card technology such as that pro-
posed for the PIC has been proposed since the 1980s for possible application in
civilian health care. To date, there have been no significant uses of the technol-
ogy in any sizable installation. There are several reasons for the lack of success
so far: (1) data on the card are frequently out of date (e.g., laboratory test re-
sults); (2) each card technology requires proprietary card readers, which are not
widely available; (3) there is no predominant card technology; (4) there are no
data content or format standards for the storage of data on the card; (5) the costs
of the cards and the readers are significant; and (6) damage or loss of the card
may result in lost information. Most of these issues apply to use by the military
health system as well. Some additional requirements are unique to the military
(e.g., durability, readability, and size). Earlier feasibility studies of PIC devices
raised concerns about their tolerance of muddy conditions (U.S. Army Medical
Department, 1997~. Despite these limitations, however, there may be niche ap-
plications for PIC use in the military. One possible use would be to capture and
communicate medical histories and interventions about a service member un-
dergoing medical evacuation. For this use scenario, however, a PIC is needed
only for cases of medical evacuation, not as a personal medical record for all
service members. The logistical and financial implications of these two scenar-
ios are drastically different. Although testing of candidate PICs is under way, a
clear justification and use scenario is needed.
INFORMATION SYSTEMS ACQUISITION AND
DEVELOPMENT PROCESS
Recognizing the need to consolidate 80 to 90 legacy information technology
projects into a more manageable structure, in 1996 the military health system
designated each military service to be responsible as executive agent for a subset
of systems focused on a particular area of interest. The five areas of interest are
clinical, logistics, resources, executive information, and theater medical systems.
In February 1999, the five business areas, as well as information technology
infrastructure and customer support, were consolidated under a single Program
Executive Officer (PEO), who is responsible for all acquisition tasks necessary
to support approved functional requirements (Tibbets, 1999a).
Functional requirements are developed by the Functional Integration Work-
group, consisting of clinicians, resource managers, logisticians, and health care
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86 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
administrators who are senior officers below the general or flag rank. The in-
formation requirements are reviewed by the military health system Program
Review Board, consisting of the medical chief information officers of the Army,
Navy, Air Force, and the military health system, as well as representatives of the
medical comptrollers of the Army, Navy, and Air Force. The information re-
quirements are sent to the Theater Functional Steering Committee for approval,
and then are approved and funded by the Information Management Proponent
Committee (Tibbets, l999b).
Once the information technology projects are prioritized and funded, the
approved projects are sent to the PEO for implementation (U.S. Department of
Defense, l999b). The PEO has full life-cycle responsibility for the approved
projects, including development or procurement, worldwide deployment, and
operation of the systems. Work is outsourced to industry through competitively
awarded contracts. In time, the PEO plans to migrate the military health system
to an information technology architecture that consists of multiple software ap-
plications running in a single worldwide network computing environment, pro-
viding for progressively greater degrees of information interoperability, data
center consolidation, and remote management of information technology assets
from data center to desktop (Tibbets, 1999a).
While the study team notes that the previous process for prioritizing, fund-
ing, and procuring information technology seemed to encourage selection of
individual systems to address individual needs, it is not yet clear how well the
new system will work to encourage development of an architecture to accom-
modate the diverse needs. The study team urges continued emphasis on broad-
based input to the development of functional requirements, and external input as
feasible throughout the process.
CONFIDENTIALITY OF HEALTH INFORMATION
Given the mandatory nature of health data collection in the military, including
the collection of sensitive information (e.g., human immunodeficiency virus in-
fection status and mental health status), stringent regulations, policies, and proce-
dures are necessary to maintain system security and to protect the confidential
health information of all service members and their dependents. Included in the
legislative mandates of the Health Insurance Portability and Accountability Act of
1996 (P.L. 104-191) are provisions governing system security and the confidenti-
ality of patient data (Health Insurance Portability and Accountability Act of 1996,
1996~. When they become law, the military will have to comply with them in the
same manner that civilian providers do. The Secretary of Health and Human
Services released the Notice of Proposed Rule Making for security regulations in
August 1998, drawing heavily on the recommendations of the Institute of Medi-
cine study of current security practices (National Research Council, 1997~. Final
regulations are expected by the end of 1999.
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SUMMARY
There are many challenges to the development, implementation, and main-
tenance of a health information system to serve the diverse needs of the military.
It is not surprising that there are separate activities in each of the services. In
some cases these are driven by immediate needs, and in other cases they arise
out of a lack of awareness of existing solutions or projects under way elsewhere
in the military. To meet the health needs of U.S. forces deployed abroad, how-
ever, a unified CPR system that supports the readiness mission is essential. At
the core of a unified record is a common data model and common data content
definitions that facilitate integration of data from distributed sites and systems.
Interfacing of the data from heritage systems will continue to pose substantial
barriers to conducting medical surveillance and epidemiological studies of the
health of and illnesses suffered by deployed troops. Data integration should be
the goal from the beginning. Acquisition and development plans should begin
with a clearly articulated technical architecture, a common data model, and
common data standards.
The process of developing an integrated CPR for the military health care
system is complex, yet it is essential to ensure military readiness and a healthy
force. It involves tremendous expenditures of money and resources and requires
extensive expertise. With so much at stake, the study team recommends that an
external advisory board participate in the effort by providing ongoing review
and advice regarding the military health information systems strategy. Com-
posed of members of academia, industry, and other governmental organizations
such as the National Library of Medicine, this group would provide synergy and
potential leverage between the military and civilian health information system
sectors. The study team believes that this partnership will increase the likelihood
of success for the overall endeavor.
The study team recommends that a comprehensive review of the military
health information systems strategy be undertaken to enumerate the information
needs; define an expedient process for the development of an enterprisewide
technical architecture, common data model, and common data standards; iden-
tify critical dependencies; establish realistic time lines; assess the adequacy of
resources; and perform a realistic risk assessment with contingency plans. A
truly integrated CPR accessible for medical care, medical surveillance, and epi-
demiological research is absolutely essential to the health and readiness of U.S.
troops deployed abroad. A thoughtful review of the current strategy will increase
the chance of success.
FINDINGS AND RECOMMENDATIONS
Finding 5-1: Medical information system development and acquisition within
the U.S. Department of Defense have been piecemeal. There is no clear effective
central authority to ensure that data from all software systems can be consoli
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8 8 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES
dated to serve the needs of those involved with individual care and medical sur-
veillance.
Recommendation 5-1: Clarify leadership authority and accountability for
establishment of an integrated approach to the development, implementa-
tion, and evaluation of information system applications across the military
services. Establish a top-level technical oversight committee responsible for
approving all architectural decisions and ensuring that all application com-
ponent selections meet architecture and data standards requirements.
Finding 5-2: Several current and proposed information systems address task-
specif~c information needs at a local level without sufficient consideration of the
overall integration strategy and the need for a common architecture. Thus, mul-
tiple overlapping projects address similar information requirements.
Recommendation 5-2: Coordinate the evaluation of information needs for
maximum reuse of data elements, data-gathering instruments few., sur-
veys), and software systems across the military health system.
. Assess information requirements across the military enterprise in the
context of a global data model and a common architecture for the computer-
based patient record.
. Include primary and secondary data users (e.g., preventive medicine pro-
fessionals and epidemiologists) in the process of specifying, selecting, and de-
veloping data-gathering instruments and information systems.
. Analyze the logistical and work flow effects of data-gathering activities
as part of the specification and design process.
Finding 5-3: Medical record-keeping practices vary widely on the basis of the
type of data involved (e.g., outpatient care, inpatient care, and immunizations),
the location where medical service is provided (e.g., a garrison or a deployment
location), and the branch of service.
Recommendation 5-3: Develop standard enterprisewide policies and pro-
cedures for comprehensive medical record keeping that support the infor-
mation needs of those involved with individual care, medical surveillance,
and epidemiological studies.
Finding 5-4: There are many challenges to the development, implementation,
and maintenance of a health information system to serve the diverse needs of the
military. An assessment of the readiness of the information technology organi-
zation to meet the challenges according to the necessary time lines would alert
the leadership to areas that require additional resources, management attention,
or contingency planning. Ongoing external input could help to take into account
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benefits, costs, reliability, feasibility, cross-military ease of use, and the ability
to use such systems for subsequent individual and population health studies.
Recommendation 5-4: Conduct an independent risk assessment of the mili-
tary health information system strategy and implementation plan. Establish
an external advisory board that reports to the Secretary of Defense and that
is composed of members of academia, industry, and government organiza-
tions other than the Department of Defense and the Department of Veter-
ans Affairs to provide ongoing review and advice regarding the military
health information system's strategy and implementation.
Finding 5-5: The conceptual architecture proposed for the GCPR Framework
Project provides an open-systems architecture to interface heritage applications
with new applications. However, limitations of the heritage systems will impede
development of fully integrated records and functional decision support. The
study team is concerned about the feasibility, practicality, cost, and maintain-
ability of the approach when scaled beyond the limited proof-of-concept proto-
type that is planned. The GCPR team acknowledges that "the technical solution
being pursued in the GCPR Framework project has a moderate to high probabil-
ity of failure . . . " (GCPR Framework Project, 1999a, p. 21~.
Recommendation 5-5: To reduce the risks of the entire GCPR Framework
Project, the GCPR project team should ensure that the Phase I prototype is
sufficiently representative of the complexity expected for the total project.
The prototype should include evaluation of the following:
. Integration of data from heterogeneous sources while preserving the
meaning of the original data
. Implementation of decision rules stored in one system acting on data
from another system
. Entry of data in a new system and its reconciliation with data in heri-
tage systems
. Incorporation of existing standards in the prototype and identifica-
tion of gaps in available standards
. Measurement of performance characteristics of the virtual database
and estimation of the performance of a comprehensive system with all the
data components and middleware services in operation
. Estimation of the level of effort and costs of maintaining the middle-
ware services
Finding 5-6: The health information needs of reserve service members are not
being adequately addressed. Although there are challenges to gathering data on
reservists, no substantive initiative to acquire or link health data for this group
exists.
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90 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES
Recommendation 5-6: Develop methods to gather and analyze retrievable,
electronically stored health data on reservists. For example, ensure that
data from the Recruit Assessment Program and the Health Evaluation and
Assessment Review collected from reserves (as recommended in Chapter 4)
are captured as part of a computerized record permitting retrievability and
population-level analysis as well as the addition of new data from periods of
deployment or activation.
Finding 5-7: The need for high-capacity smart-card technology for a universal
personal information carrier is not clearly justified, and its fit with the remainder
of the information infrastructure for the military system is not clearly articulated.
Recommendation 5-7: Reexamine the information requirements for the
personal information carrier (PIC) and develop a justification for applying
the appropriate technology to satisfy the information requirements.
. Identify specific scenarios for the use of the PIC and the relevant military
population affected.
. Define the minimum data needed for the provision of care in the battle-
f~eld setting.
. Explore practical alternatives for the provision of access to necessary
emergency information at the point of care and estimate the infrastructural costs
associated with each option.
Finding 5-8: The military mission requires collection, storage, and communi-
cation of sensitive, individually identifiable health information for each service
member.
Recommendation 5-8: Make available to service members the regulations,
policies, and procedures regarding system security and protection of indi-
vidually identifiable health information for each service member.
. Comply with all system security regulations adopted by the Secretary of
Health and Human Services to the extent practical in the military.
. Develop confidentiality policies to comply with federal privacy legisla-
tion and regulations in accordance with the Health Insurance Portability and
Accountability Act of 1996 (PL 104-191~.
Finding 5-9: Funding of major projects is uneven. The Government Computer-
Based Patient Record project operates year by year, the Theater Medical Infor-
mation Program project is fully funded, and the second version of the Composite
Health Care System project is funded for deployment but not additional devel-
opment.
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91
Recommendat10n S-9: {rent the development of ~ Uptime computer-based
patient record far service members as ~ major ncquish10n, Huh ~ commen-
surnte level of h1gh-level responsibH1ty and nccountab1Hty. Clear koala
strntegles, 1mplementnt10n plans, milestones, and costs must be donned and
approved.
Representative terms from entire chapter:
medical record
