D Military and Civilian Trauma Care in the Context of a Continuously Learning Health System¹

The Institute of Medicine (IOM) has categorized the characteristics of a continuously learning health system into four major groups: (1) science and informatics (real-time access to knowledge, digital capture of the care experience); (2) patient–clinician partnerships (engaged, empowered patients); (3) incentives (incentives aligned for value, full transparency); and (4) continuous learning culture (leadership-instilled culture of learning, supportive system competencies) (IOM, 2013). Benefits resulting from these characteristics include improvement of clinical decision making, improvement of health care safety and quality, real-time generation and application of knowledge for health care improvement, health care anchored in patient needs, teamwork and collaboration in support of continuous learning as a core aim, systems analysis and information development, and the creation of feedback loops for system and performance improvement. Table D-1 denotes to what degree these characteristics have been integrated into current trauma care systems, with specific comparison of the military versus civilian systems. Although pockets of excellence can be identified,

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¹ The analysis in this appendix was excerpted from a report commissioned by the National Academies of Sciences, Engineering, and Medicine Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector, written by Elliott R. Haut, Johns Hopkins University School of Medicine and the Johns Hopkins Bloomberg School of Public Health; N. Clay Mann, University of Utah School of Medicine; and COL (ret) Russ S. Kotwal, Uniformed Services University of the Health Sciences and Texas A&M Health Science Center. The paper in its entirety is available on the study website at nationalacademies. org/TraumaCare.

TABLE D-1 Characteristics of a Continuously Learning Health System: Military Versus Civilian Trauma Systems

STATUS

1 Functional

2 Progressing

3 No Progress

BARRIERS TO IMPLEMENTATION

A Absent (No Barriers)

B Budgetary (Lack of Priority and/or Financial Restraints)

C Confidentiality (Policy, Regulations, and Concerns for Patient Privacy, and/or Operational Security)

D Decision Making (Lack of Leadership, Decision Making, Mandate, Policy, and/or Culture)

NOTES: Notable for both military and civilian systems is that on each characteristic of a learning health system, no entity of care is currently functional and without barriers (“1A”), 100 percent have a decision making barrier (“D”), 56 percent have a confidentiality barrier (“C”), and 55 percent have a budgetary barrier (“B”).

AE = aeromedical evacuation; CASEVAC = casualty evacuation; CCATT = critical care air transport team; CIV = civilian; EMT = emergency medical technician; FST = forward surgical team; ICU = intensive care unit; MEDEVAC = medical evacuation; MIL = military; N/A = not applicable; VA = U.S. Department of Veterans Affairs.

both systems have characteristics that can be improved and barriers to be removed, particularly in the realm of decision making and leadership. Notable for both systems is that on each characteristic of a learning health system, no entity of care is currently functional and without barriers (“1A”); all have a decision-making barrier (“D”); 56 percent have a confidentiality barrier (“C”); and 55 percent have a budgetary barrier (“B”).

In the area of science and informatics, the barrier is not technology. The advanced interconnectivity of computers and mobile devices (e.g., iPhones) is remarkable. In fact, many people have better, more seamless transitions (i.e., cloud-based sharing of files, contacts, photos, etc.) in their personal lives than in the health care information technology world. Robust systems exist for both real-time data access and digital capture of health care, which have been implemented successfully by some. However, the use of technology has yet to be maximized and globally integrated into trauma system practices.

Specifically, on the civilian side, the National Emergency Medical Services Information System project ensures the standardization and exportability of out-of-hospital patient care information among all health care systems in U.S. states. Nevertheless, existing health information exchanges have few federal or state incentives to integrate emergency medical services (EMS) data into electronic health records. Some EMS agencies have Global Positioning System (GPS)-enabled tablet computers in the back of ambulances capturing time-stamped vital signs and procedures. However, when EMS providers arrive at a trauma center, they cannot download the computer-generated documentation directly into the hospital electronic medical record or trauma registry. They may need to print their data to be scanned into a nonsearchable medical record days later, only to be reabstracted by hand by a trauma registrar, losing data fidelity and not giving the trauma team immediate access to the information. Similarly, the nearly ubiquitous use of the National Trauma Data Standard in acute care hospital-based trauma registries and adoption of Trauma Quality Improvement Program performance measures and monitoring greatly enhance standardization of care decisions and benchmarking of performance metrics. However, the interoperability of these products with other phases of care and health care exchanges remains limited.

Some electronic medical records allow storage of images (i.e., photographs of traumatic wounds, operative procedures). Yet many have not been enabled because of lack of leadership understanding of the importance of these visual data and greater priority of concerns about possible regulatory and Health Insurance Portability and Accountability Act violations. Privacy concerns have been raised, especially as leaked photos of high-profile cases have appeared on social media sites. Yet the informal workarounds used (e.g., residents taking photos and text messaging or emailing attending physicians) likely put confidentiality more at risk than if

leaders would acknowledge that this occurs and enable a more controlled approach to optimizing image sharing. Some studies of specific integrated computerized clinical decision support tools have shown that they dramatically improve care, but they have been used only sporadically.

On the military side, there are real concerns about operational security as technology can provide friendly force location, troop composition, and other detailed information to enemy forces or others who would do harm. Although secure systems have been developed and are in use, interfacing classified and unclassified data systems requires leaders who realize that performance improvement must be accomplished regardless of the classification and where data reside. Unclassified data residing on classified systems can be transferred to unclassified systems if appropriate measures and approval are obtained. Although classified data residing on classified systems cannot be transferred to unclassified systems, unclassified data on unclassified systems can be transferred to classified systems for integrated analysis with classified data. Although active mission details and information on trauma training programs and personal protective equipment must be safeguarded so as not to provide enemy forces with friendly force vulnerabilities, these data can still be analyzed and published on classified systems in near real time for performance improvement and to inform leaders. Additionally, when some unclassified data are being aggregated, these data can become classified and should then be transferred to classified systems.

Patient–clinician partnerships are critical to ensure that care remains focused on the factors that patients value. The concept of patient-centered care is not new, but it is receiving more attention, especially with the creation of the Patient-Centered Outcomes Research Institute. In some areas of trauma care, patients are routinely and heavily engaged and drive decision making. For example, patient advocacy groups have been instrumental in improving long-term care for trauma patients with spinal cord injury, traumatic brain injury, and amputations. These groups, many of which focus on military injuries, raise awareness and funds while helping give patients a voice to let their preferences be known. Collaborative projects between researchers and patient stakeholders provide usable data, allowing patients to make informed decisions about their medical care. For example, amputation decisions may be informed by prospective observational studies that have shown differences in long-term functional outcomes when comparing amputation versus limb salvage for patients with severe lower extremity trauma in both the civilian (Bosse et al., 2002) and military (Doukas et al., 2013) settings. Yet in other areas, patients are less empowered to change trauma care delivery, and decisions are made with little to no patient input.

The major barrier to improved patient-centered care falls under the category of decision making. The issue is not one of mandate or policy; it is primarily a lack of leadership from medical professionals, who are often

hesitant to change culture. Newer ideas, such as including family members in multidisciplinary rounds and engaging them to help with care (e.g., range-of-motion exercises, bathing) of intensive care unit (ICU) patients, are still uncomfortable for some physicians and nurses. However, early feedback suggests that families and patients end up with a better experience overall as a result of these practices and may have improved outcomes (Wyskiel et al., 2015a,b).

Incentives, especially those that are financial, are often not aligned to encourage continuous improvement within a learning health system. Although some changes in the forms of value-based purchasing and pay for performance are slowly occurring, the classic fee-for-service model is still the norm in much of the private sector. A major difference between trauma care in the civilian and military sectors is that the military basically has a single-payer system, covering all aspects of care for its covered population. This should, in theory, help align financial incentives across the continuum of care. However, an extremely large budget coupled with little financial accountability may also drive military health care spending, rather than pushing it to reduce waste and reward high-value care. Accordingly, barriers to progress in this area are somewhat financial, but are also driven by culture and lack of leadership. The aim of the Choosing Wisely campaign is to cut back on unnecessary medical testing and procedures (Morden et al., 2014), but the campaign’s reception has been somewhat lukewarm as individual physicians often do not want their practice of the art of medicine to be dictated to them from external sources.

In a continuous learning culture, active monitoring of the quality and safety of health care is a major focus. The importance of data use in quality improvement work is discussed later, but must be mentioned here as there are numerous barriers to allowing this to occur in a useful manner. From a budgetary standpoint, financial incentives in this regard have been sorely lacking. Most hospitals expend considerably more resources on and have many more data analysts assigned to financial issues (e.g., supply chain, staffing) versus quality-of-care improvement initiatives, indicating their true prioritization. Some issues of confidentiality exist, especially when attempting to learn from individual patient harm. On the civilian side, hospital lawyers and risk management departments frequently fear financial and/or reputational losses and therefore do not allow examples of harm to be shared so others can learn and prevent errors from occurring again. To some degree, the military has been effective in overcoming this barrier by establishing and maintaining a Joint Trauma System weekly worldwide trauma teleconference that connects the entire continuum of the trauma system in order to critically review trauma care delivery for best practices as well as for performance improvement opportunities.

The most critical and ubiquitous barrier to a learning health system

in both the military and civilian sectors relates to decision making. The trauma systems of both sectors lack the leadership necessary to promote and maximize learning from failures and mistakes, and push for changes in practice in order to prevent recurrences of errors. In the military, leaders are often comfortable promoting good news stories such as “highest combat casualty survival rate in history”; however, these same leaders are often reluctant to take it to the next level and be relentlessly dissatisfied with any degree of preventable morbidity and mortality. Additionally, as medical leaders do not own prehospital assets, and as nonmedical leaders who own prehospital assets are not held accountable for medical efforts, there is no true ownership of prehospital preventable morbidity and mortality, which is where most combat deaths occur (Butler et al., 2015; Eastridge et al., 2012; Kotwal et al., 2013; Mabry, 2015). There remains a pervasive cultural barrier to learning from mistakes in civilian medicine. In particular, a clearly defined hierarchy both within physician ranks (student, intern, resident, fellow, attending) and among professionals (medics, nurses, physician assistants, physicians) limits safety improvement in real time, as not all health care professionals feel comfortable speaking up, even when egregious errors are about to be made. The military hierarchy of rank exacerbates and complicates this concern.

Although the military and civilian levels of care do not always have direct analogues, the overall general structure of prehospital, in-hospital, and postdischarge care is similar. The nuances remain different at every level, but where similarities exist, there can be opportunities to share best practices and learn from one another. One major difference is the proportion of patients who undergo interhospital transfer. In combat theaters, the vast majority of injured military patients do not remain at the initial treating facility. Most undergo at least one and, more frequently, two interhospital transfers, often across thousands of miles and multiple continents. To achieve this medical transportation, the military has multiple modes of transport as well as various types of medical providers, depending on where the evacuation is occurring. In the prehospital realm of a combat zone, where personnel and transportation assets are subject to hazardous conditions, medical capabilities for casualty evacuation and medical evacuation have traditionally been more limited. However, recent data from the Afghanistan conflict have shown that increased medical capabilities on prehospital transport platforms, similar to the practice in the civilian sector, can improve morbidity and mortality on the battlefield (Kotwal et al., 2016; Mabry et al., 2012; Morrison et al., 2013). Rapid interfacility aeromedical transport out of a combat zone, with robust critical care air transport team en route capability (ICU physician, ICU nurse, and respiratory therapist), has proven effective (Ingalls et al., 2014). Additionally, interfacility transport between Role 4 hospitals (Outside Contiguous United States [OCONUS]

to Contiguous United States [CONUS] or CONUS to CONUS) has proven beneficial from the standpoint of patient–clinician partnerships as family members have been afforded the opportunity to travel as attendants with their injured family members. Annex 4-1 at the end of Chapter 4 provides an example case of an injured military service member to illustrate the multiple transports as well as highlight the opportunity for better data use along the continuum of care.

In the civilian sector, the majority of injured patients remain at the first hospital to which they arrive. Some patients are transferred from the initial treating center for medical necessity (i.e., higher level of care and/or specialized services) or for social reasons to be closer to home/family if they were injured in a different state or region.

Differences also exist between the military and civilian trauma care systems in most other categories. One key difference is in the immediate first response to an injured patient. In the military setting, all personnel have received some degree of basic trauma training and tools (e.g., tourniquets, pressure dressings) to begin self- or buddy care. In the civilian sector, only a minority of the public truly understand initial trauma care, and rarely are they provided such tools. Emerging from the military’s tactical combat casualty care guidelines, the 2015 “Stop the Bleed” campaign (http://www.dhs.gov/stopthebleed) recently began to address this concern. For trained prehospital providers, the military education system is focused primarily on traumatic injury care, environmental injury prevention and care, and care for common minor illnesses. In the civilian realm, emergency medical technicians and paramedics receive broader training that encompasses all aspects of care (e.g., cardiac arrest, obstetrical emergencies). While the equipment, personnel, staffing, and medical care available at the final destination hospital are comparable, there are likely dramatic differences in resources between military and civilian initial hospital care. A basic non-trauma center emergency department may likely have more physical capabilities (e.g., x-ray, computerized tomography (CT) scan) than a forward surgical team (FST) operating in a tent; however, it may lack immediate surgical response training as provided by the military. Arriving at an FST in a combat zone versus a small rural nontrauma hospital may prove advantageous for a casualty if the FST has been seeing patients routinely; however, this may not be the case if it has been a while since the FST has seen and treated a casualty.

While Table D-1 illustrates barriers with respect to characteristics of a continuously learning health system for both the military and civilian trauma systems, Box D-1 highlights specific military trauma system gaps or barriers in data collection, distribution, and use whose resolution could improve trauma care and patient outcomes.

REFERENCES