Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary (2009)

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Summary The U.S. Department of Defense (DOD) vision for providing health care to the military and their families, spelled out in the Roadmap for Medical Transformation, is based on three “pillars”—high-quality health care delivery, in-house medical education, and research (MHS, 2006). DOD recognizes, however, that transformational advancements in the quality and productivity of the Military Health System (MHS) may require tools and techniques developed as part of operational systems engineering (OSE), a family of disciplines that includes indus- trial engineering, operations research, human factors engineering, and financial engineering/risk analysis, as well as from computer science and engineering and the social and behavioral sciences. All of these engineer- ing and science disciplines are integrally involved in the design, analysis, and control of complex processes and systems. Many companies in engineering-intensive manufacturing and ser- vice industries have also contributed to the development of OSE tools and methods as a result of their experiences with them in improving the performance of their own companies. The results of those applica- tions of OSE have led to a comprehensive understanding of the func- tion and dynamics of complex systems and insights into interactions between subsystems and processes in those industries. OSE tools can also support the rational, systematic management of the tensions and trade-offs between competing performance goals and priorities among stakeholders.  

 Systems Engineering to Improve Traumatic Brain Injury CARE Building a Better Delivery System: A New Engineering/Health Care Partnership, a 2005 report by the National Academy of Engineering (NAE) and Institute of Medicine (IOM) of the National Academies, documented that the health care sector as a whole has been relatively slow to embrace OSE tools and techniques. These tools and techniques could help untangle the complexities and lead to a deeper understand- ing of the dynamics of health care systems and subsystems and could be designed to optimize system performance to meet specific quality goals (e.g., safety, patient-centeredness, timeliness) and, at the same time, improve prediction, measurement, and management to meet other performance goals (e.g., cost, access, productivity). OSE, which combines science and mathematics to improve the op- eration of systems, has greatly benefited other enterprises by describing, analyzing, planning, designing, and integrating systems with complex interactions among people, processes, materials, equipment, and facili- ties using deterministic and probabilistic mathematics (called stochastic processes). The ultimate goal of OSE is to integrate all elements in the operations of a system to improve its efficiency and effectiveness. The idea of applying the tools, techniques, and concepts of OSE to health care has been a topic of discussion for some years, and health care systems and care providers in some areas have adopted them successfully. In epidemiology, for example, OSE tools have been used to evaluate intervention strategies, disease-control programs, screening programs, and health-promotion and disease-prevention programs, and to predict the incidence, prevalence, and mortality rates of diseases. OSE con- cepts have also been used to design health care systems, estimate future r ­ esource needs, optimize the allocation of resources, and optimize capac- ity, plan facilities, and design emergency services in health care systems. In medical decision making, OSE techniques have been used to plan and implement appointment systems to reduce waiting time for both outpatients and inpatients, optimize staff levels and scheduling, conduct inventories, plan material requirements, optimize supply chains, forecast demand, plan auxiliary services, and evaluate medical technologies. In 2007, the U.S. Army Medical Research and Materiel Command (USAMRMC) asked NAE and IOM to conduct a series of workshops to gather information and provide guidance to MHS on using OSE tools and technologies to improve the quality and productivity of health care delivery to the nation’s armed forces and other eligible beneficiaries of TRICARE (military/civilian health care interfaces). As a first step, 

summary  BOX S-1 Department of Defense Definition of Traumatic Brain Injury Traumatic brain injury (TBI) is a traumatically induced structural injury and/or physiological disruption of brain function as a result of an exter- nal force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: (1) Any period of loss, or a decreased level, of consciousness. (2) Any loss of memory for events immediately before or after the ­injury. (3) Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.). (4) Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient. (5) Intracranial lesion. Source: DOD, 2007. U ­ SAMRMC asked that a workshop be held to identify promising areas for near-, medium-, and long-term applications of OSE tools and infor- mation technologies for modeling, analyzing, designing, and improving the care and management of patients with traumatic brain injury (TBI) throughout the military health care continuum—from battlefield to field hospital to U.S.-based military health care facilities to TRICARE net- works and U.S. Department of Veterans Affairs (VA) facilities (Box S-1). The expecta­tion is that the application of OSE tools and techniques to TBI care will improve the delivery of care at both the tactical and strate- gic levels. OSE tools could also be used to improve tracking and navigating of patients through critical transition points, such as from a health care organization in one military service to a facility in another, or to the VA or a civilian health care facility. Transition points, or handoffs, also o ­ ccur when patients are moved from acute TBI care in a hospital to more chronic long-term management in a community clinic, or when 

 Systems Engineering to Improve Traumatic Brain Injury CARE there is a changeover in caregivers from one shift to another. Minimizing c ­ onfusion, delays, and/or variations in the quality of care during hand- offs is a key area in which OSE techniques may be helpful. During the planning phase of the workshop, a steering committee of experts in TBI, military and veterans health care delivery, and OSE, supported by NAE and IOM professional staff, compiled a list of issues raised by stakeholders in the MHS community related to the care of mild, moderate, and severe TBI cases. From that list, they identified is- sues that could potentially benefit from OSE approaches and categorized them into five major challenge areas for TBI care: (A) the development of new TBI knowledge (B) the detection and screening of TBI conditions (C) communication and coordination for TBI care (D) measuring and forecasting the demand for TBI care (E) the capacity, organization, and resource allocations of the TBI care system The committee then condensed the major stakeholder issues in each of these categories into two or three issues for OSE analysis, that is, analytical challenges that could be met through the application of OSE approaches and that could lead to improvements in the delivery of TBI care. This workshop summary synthesizes the results of a two-day NAE/ IOM invitation-only workshop held in Washington, D.C., June 11–12, 2008. The introduction (Chapter 1) reviews the potential of OSE for improving the quality of health care and places the challenge of TBI care in the context of the broader issues of the quality of, and cost chal- lenges to MHS health care. Chapters 2 through 5 provide individually authored summaries of the workshop presentations and discussions. These ­included background on the medical aspects of TBI and major clinical and logistical challenges in TBI care, as well as examples illustrat- ing relevant applications of OSE tools and methods, and a case study of a shift by a major unit in an academic health system from expert-based medical practice to expert-managed system-supported practice. Chapter 6 includes the charges to the five working groups that  The level of severity is classically defined at the time of injury using measures of the state of consciousness (the Glasgow Coma Scale), the duration of the loss of consciousness, and post-traumatic amnesia. 

summary  were asked to address the five major challenge areas for TBI care and describes the results of their deliberations. It includes suggestions for 10 illustrative “analysis plans,” that is, designs for potential OSE studies, analyses, and applications that could answer important questions raised by TBI stakeholders and help improve the performance of the TBI care delivery system. The suggestions for analysis plans were developed by the working groups to illustrate potential applications of OSE tools and methods to specific TBI care challenges. However, the working groups are not Academy-appointed committees, and the summaries reflect the views of the individuals who participated in each group discussion—and not necessarily the views of the institution or the workshop planning committee. The suggestions for OSE studies and projects should not be construed as consensus recommendations of the working groups, the workshop participants as a whole, or the National Academies. SUMMARY OF suggestions for ANALYSIS PLANS by THE WORKING GROUPs Figure S-1 captures the challenges raised during the TBI workshop from the perspective of OSE. As the figure shows, before OSE methods can be brought to bear, OSE practitioners must have a preliminary understanding of the relationships between blast and concussive inju- ries and TBIs. Working Group A was asked to address this issue, the development of TBI knowledge. To this end, the group developed an analysis plan for using diagnostic and screening tools to establish pre- and post-event baselines, as well as conducting basic research on blast and concussive effects. The current MHS TBI care delivery system must be better specified and understood for OSE tools and methods to be effective. The complex military health care delivery system includes facilities, logistical support, and personnel in the MHS, VA, and civilian health care systems, as well as the families of soldiers suffering from TBI and the soldiers themselves. One of the basic challenges associated with the delivery of care is patient tracking and case management. Working Group C participants suggested an approach to the devel- opment of an information system for tracking, monitoring, and cueing care delivery for all TBI patients. The approach focuses on the integra- tion and augmentation of existing databases and a communications 

 Real World Model World Improved understanding of effects Identify blast effects on Develop model Assess value brain function (A) for diagnosis of prevention (B) (D) Diagnostic Improved Changes in methods screening prevalence Structure TBI information Improved Evaluate screening Estimate current and system and methodology Prevalence for coordinated care diagnostic processes future prevalence (C) processes (B) (D) Improved screening processes Patient stream Burden of disease Disease history of patient stream Information on Model episode of care Develop database on natural history Develop disease model and allocation of civilian events Impacts on scarce resources (A) (A) disease history (E) Information on effects of treatment Improved treatment processes and associated resource requirements FIGURE S-1 Interrelationships among suggestions for analysis plans developed by participants in Working Groups A through E. Figure S-1.eps landscape 

summary  system that would provide access to, and the dissemination of, informa- tion to appropriate users. The architecture of the resulting system would be compatible with the military care delivery system. During the workshop discussions, it was noted that data are also available from outside the military in the form of records of concussive and other closed-head injuries and TBI cases in the civilian world. These data could contribute to a more detailed understanding of the medical course of TBIs and the effectiveness of alternative treatments. Working Group A participants suggested an approach for integrating civilian and military data for use in the military environment. The other blocks in Figure S-1 constitute typical, interrelated tasks that have been addressed by OSE techniques and methodologies in other contexts. The development of a quantitative disease model is essential to evaluating the long-term demand for care, strategies for treatment, and the design (and costs) of a high-quality, efficient care delivery system. Working Group A participants developed an approach that would model the course of TBI cases using a finite state-space sto- chastic process in which patients transition from one state to another as a function of additional (non-TBI) trauma, treatment, the long-term impacts of trauma, and co-morbidities that impact the state definition and occupancy times in any given state. The group also developed a plan for using a survey methodology integrated with data mining to define states, estimate transition probabilities, and determine the distributions of occupancy times. Parameters in the quantitative disease model include diagnosis and screening characteristics, state definitions, and state transitions. Working Group B participants outlined the development of a series of models to quantitatively describe and evaluate current practices and to then optimize the screening process based on an analysis of data obtained from data mining and a survey. The group noted that Markov decision theory, Bayesian networks, influence diagrams, and simulations would be viable approaches to evaluating and designing TBI diagnostic and screening processes. For MHS to assess its capacity to treat TBI, it must be able to understand and predict the “demand” on the system. Working Group D participants observed that estimating demand is extremely difficult, complicated by the many instances of TBI, especially mild TBI (mTBI), that are not reported promptly in theater or are unrecognized in post- deployment interviews. Group D participants observed that historical 

 Systems Engineering to Improve Traumatic Brain Injury CARE data could be analyzed as a basis for making statistical estimates of the number of mTBI cases in the current population of military personnel who have served or are serving in Iraq and Afghanistan. The group then outlined a methodology for forecasting future mTBI cases, taking into account conditions in the military theater, threats, and role-based expo- sures. The group also addressed the challenge of assessing the value of TBI prevention efforts, enlisting methods of estimating which specific investments in prevention strategies might yield reductions in TBI inci- dence, as well as cost savings to the health care system and reduction in the burden on soldiers and their families. Given a quantitative disease model and an understanding of the ef- fectiveness, availability, and costs of various treatments, it is possible to design and evaluate care delivery from the perspective of individual pa- tients, a patient population, and the entire health care enterprise. Work- ing Group E participants designed an approach to the development of an enterprise-level health care delivery model that would address, quan- titatively, a broad spectrum of TBI treatment capacity, organizational, and resource allocation issues that would support decisions on policy and the design of the health care enterprise. The suggestions for analysis plans developed by the five working groups indicate how OSE methods and tools could contribute to meet- ing the challenges of delivering effective, efficient, high-quality TBI care and management. Particular quantitative methods and models could provide insights into the design of diagnostic and screening processes, the delivery of care, the sizing of facilities, and the design of the overall health care delivery complex to meet current and future demands. As shown in Figure S-1, the challenges addressed by the OSE analysis plans are interrelated with the outputs of the plans. Each plan could poten- tially provide inputs to the development of one or more of the other plans. Collectively, the plans address many of the issues initially raised by TBI stakeholders. The suggestions and assumptions of the working groups revealed several common interdependencies that are important to the develop- ment and application of OSE methods and tools to TBI care. These dependencies cut across the five focus areas: • an assumption that sufficient, reliable data are available for the development of initial versions of all of the approaches outlined by the working groups and that additional reliable data could be 

summary  generated to improve and refine these approaches and provide more comprehensive, precise support to meet MHS needs in providing TBI care • the value of standardized, detailed coding to improve the accuracy of records of TBI symptoms, injuries, and, possibly, treatments • the importance of data sharing and interoperability of databases relevant to TBI diagnosis, treatment, measurement, and prediction • the need for extensive, detailed maps of care paths and processes and associated information, patient, provider, and material flows for TBI care The ideas and concepts introduced during the workshop may be helpful to DOD leaders working to refine and improve DOD’s system of health care delivery, both at the individual patient-provider level and at the enterprise level. Applications of OSE concepts, tools, and methods may potentially contribute to improvements in care, not only for TBI patients but for all patients receiving MHS health care. References DOD (U.S. Department of Defense). 2007. Traumatic Brain Injury: Definition and Reporting. Memorandum. HA Policy 07-030. Dated October 1, 2007. Available online at http://mhs. osd.mil/Content/docs/pdfs/policies/2007/07-030.pdf (accessed August 13, 2008). MHS (Military Health System). 2006. QDR Medical Roadmap Implementation. Military Health System Office of Transformation PPT Presentation, July 13, 2006. Available online at http://www.tricare.osd.mil/ocfo/_docs/071306_qdr_trans_infra.ppt#0 (accessed September 11, 2007). NAE/IOM (National Academy of Engineering/Institute of Medicine). 2005. Building a B ­ etter Delivery System: A New Engineering/Health Care Partnership, edited by P.P. Reid, W.D. Compton, J.H. Grossman, and G. Fanjiang. Washington, D.C.: The N ­ ational Academies Press.