F. The Future

Driven by issues that surfaced during the Gulf War and that have lingered through subsequent deployments, the Department of Defense appears to be looking toward technology as the basis for meeting its medical recordkeeping challenges. The computer-based patient record (CPR) and the personal information carrier (PIC)—the envisioned cornerstones of future military medical recordkeeping systems—are ambitious products of collaborative efforts led by DoD (Health Affairs). The PIC may be on the horizon, but the CPR is only in the initial stages of development. Each will require substantial time and effort to acquire, deploy, and fully integrate into an existing paper-based recordkeeping infrastructure that must continue to function as both a foundation for, and bridge to, the future.

Major initiatives: DoD (Health Affairs) is focused on the development and implementation of automated medical information systems as solutions to historical, current, and anticipated deficiencies in medical recordkeeping, especially during deployments. Under a strong mandate from President Clinton to "…create a new Force Health Protection Program…[in which]…every soldier, sailor, airman, and marine will have a comprehensive, life-long medical record of all illnesses and injuries they suffer, the care and inoculations they receive and their exposure to different hazards,"[147]  the DoD is working with the Department of Veterans Affairs and the Indian Health Service on joint development of a computerized patient record. A parallel and complementary DoD initiative is underway to develop a personal information carrier that would serve as an automated medical record during deployments. At a major 1999 DoD (Health Affairs) conference, senior staff noted that better recordkeeping is critical to the success of the military health system. Improved interoperability and medical record documentation were among the challenges cited.[148]

The DoD’s medical recordkeeping initiatives are grounded in advanced technologies and broadly referenced in two of the six goals in the updated (late 1997/early 1998) Military Health System Strategic Plan as follows:[149]

The Department of Defense Medical Readiness Strategic Plan (1998-2004) mentions the computer-based patient record and the personal information carrier within the context of documenting and enabling access to health information during contingency operations.[150] Internal planning documents from DoD (Health Affairs) explicitly state that "a longitudinal, electronic, computer-based patient record will form the basis for health care recording."[151] Also, in testimony before Congress, DoD (Health Affairs) leadership has repeatedly commented on the importance of the CPR and the PIC to military medical recordkeeping and force health protection. Following are salient extracts from these 1998 testimonies:

To support medical record keeping during deployments and throughout the Military Health System, we are establishing the needed information system. The Gulf War showed us that we can no longer rely on paper-based medical records. The computer-based patient record (CPR), the Theater Medical Information Program (TMIP), and the personal information carrier (PIC) are major information systems initiatives designed to create an effective medical tracking system and health record before, during, and after deployments. Our goal, in partnership with the VA, is an individual, comprehensive, life-long medical record for each military member of all illnesses and injuries, all health care (including vaccinations and preventive measures), and exposures to different occupational and battlefield hazards. These records will help both Departments provide care, prevent illnesses, and improve our knowledge of the health of our military members and veterans throughout their lives.[152]

Currently we are pursuing, in partnership with the Department of Veterans Affairs (DVA), a computerized patient record (CPR) that will enhance medical quality and improve cost effectiveness and efficiencies of DoD and DVA health care.… The CPR will also have the capability to provide a seamless exchange of complete patient information between DoD and DVA.… The technology to support [the] CPR is readily available; what is needed is to reengineer the process to both eliminate paper health records and ensure this seamless exchange of health care information…. [W]e are also pursuing development and acquisition of a personal information carrier (PIC) that will contain critical health information on our deployed forces. A PIC will be issued to each service member during pre-deployment processing to a theater of operations. Being a natural subset of the CPR, the PIC will provide access to information such as deployability status, medical history, immunization tracking, and demographics.[153]

To protect our military personnel, we have developed a new comprehensive force health protection (FHP) strategy…. The linchpin of FHP will be accurate capturing of information and then rapid access to that information. The medical personnel information carrier (PIC) will be one technology that will electronically document important information regarding various elements of FHP. The Medical PIC will be conveyed as an electronic medical dog tag for each Service member and will travel with the member during deployment…. The PIC capability will accommodate or be interoperable with military personnel and finance operational requirements.[154]

In a draft concept paper, DoD (Health Affairs) defines its computer-based patient record as "… an electronic patient health record that documents and provides access to complete and accurate health problems, the status, and treatment data; alerts and reminds healthcare providers; supports clinical decision and health care delivery; and provides links to medical knowledge." The DoD has indicated that current, paper-based medical records are not adequate repositories for health information because of force medical protection issues, the need to capture and transfer health-related information in support of military operations, and the desire to provide a seamless transfer of data between the DoD and the VA. Further, a paper-based longitudinal CPR is believed to be unattainable because medical records are not standardized, are frequently missing data, and are difficult to link into a view of the patient’s health over time.[155]

Advantages of the CPR over traditional paper-based medical records include: simultaneous accessibility by multiple users from a variety of locations; improved security through limiting access to that portion of the record which is pertinent for the user; greater "legibility" of information; and enhanced search, retrieval, and reporting capabilities that are especially conducive to quality assurance and clinical research requirements. Disadvantages associated with computerized records include a large financial investment, additional user training, hardware or connectivity failure (down time), and what might be termed "full appreciation lead time" (the time it takes for a system to become fully utilized and beneficial once it is installed).[156]

In concert with (or as an evolution of) its CPR development efforts, the DoD has entered into a partnership with the Department of Veterans Affairs and the Indian Health Service to define the technical and functional requirements for a Government Computer-based Patient Record (G-CPR). (The partnership originally included Louisiana State University Medical Center, but it was modified in early 1999 due to acquisition regulation restrictions involving partnerships with non-Federal agencies.[157] ) The goals of the G-CPR partnership are to create a collaborative effort for sharing clinical information through the development of standards and the establishment of a comprehensive, life-long medical record.[158] The DoD has also been actively communicating with industry and has solicited proposals from commercial vendors to accomplish the design, development, and implementation of the G-CPR Framework. This framework would enable the sharing of an individual’s health-related information from multiple locations, thereby forming the information foundation for the longitudinal medical record. It would also provide a means to access and update patient information, to document an individual’s medical status, and to analyze health-related threats and illnesses. [159] A G-CPR Framework vendor was selected in late 1998; initial deployment is scheduled for late 2000.[160]

From the standpoint of improving medical recordkeeping during deployments, the PIC is probably considered by the DoD to be the most important and imminent initiative currently under development. The DoD has been evaluating automated technologies for carrying information on individual servicemembers since the early 1990s. A multi-technology automated reader card (MARC, also referred to as a "smartcard") was tested over a two-year period (1994-1996) in response to a proliferation of single-use card programs throughout the military services. The MARC contained medical as well as personnel and financial information.[161] The Defense Information Systems Agency (DISA) has since prepared a formal DoD PIC guidance document, and offices within the DISA and the Defense Manpower Data Center (DMDC) are currently conducting further evaluations of a smartcard version of the PIC.[162]

Concurrently, senior medical leadership within the DoD has focused on developing a higher capacity personal information carrier for use as a deployable medical record in theaters where computer network connectivity is not available.[163] This medical PIC initiative is being managed by the Composite Health Care System II (CHCS II) program office within DoD (Health Affairs); the Army’s Medical Research and Materiel Command is the product developer.[164] Testing of seven competing (medical) PIC systems was conducted in 1998; final selection and limited field deployment are scheduled for 1999. The PIC system will consist of a portable storage device (on which medical information can be stored) and an adapter for integration of the storage device into a standard (PC) computer system. Initial procurement will consist of 20,000 data storage devices and 1,000 read/write adapters.[165] As noted in previously-cited testimony before Congress, the medical PIC will be designed to accommodate or be interoperable with military personnel and finance operational requirements.

Both the CPR and the PIC are also cited as major recordkeeping initiatives in a report by the National Science and Technology Council (NSTC). This report responds to a recommendation in the Presidential Advisory Committee Final Report that the NSTC develop an interagency plan to address health preparedness for and readjustment of veterans and families following future conflicts and peacekeeping missions. A recordkeeping task force, composed of representatives from DoD (Personnel & Readiness), DoD (Health Affairs), the VA, and the FDA, addressed both military personnel information and health information. The resulting recordkeeping strategies and recommendations focused heavily on automated information systems, such as the previously mentioned CPR and PIC, as well as numerous other health and personnel information programs currently under development. (See Other initiatives below.) The report also commented on the need for information to meet FDA requirements for investigational new drugs, and noted that government recordkeeping will be incomplete unless beneficiaries receiving care from civilians make their personal health information available to the DoD or the VA.[166]

Other initiatives: Telemedicine is another health information modality that will have an impact on military medical recordkeeping, especially during deployments. Telemedicine may be defined as the use of electronic communication and information technologies to provide and support health care when distance separates the participants. It encompasses the potential use of a wide range of technologies such as the internet, intranet, personal computers, satellites, telephones, and video conferencing. The DoD (as well as the VA) has used telemedicine in some of its stateside medical treatment facilities and to support deployments such as those in Bosnia.[167] Telemedicine is an especially attractive medium for delivering health services at small, remote, or deployed locations where specialized medical providers and expensive medical equipment are generally not available. On-scene medics transmit words, video, diagnostic images, and test data by satellite to specialists in the United States, and the specialists then provide expert treatment advice. The US Army Medical Research and Materiel Command (USAMRMC) is leading a DoD effort to systematically develop practical telemedicine systems for military applications.[168] One of the challenges telemedicine presents for recordkeeping is how to document the encounter, not only in today’s paper-based record system, but also in the computer-based medical record of tomorrow.

Although not specifically a device for medical recordkeeping, the Theater Medical Information Program (TMIP) is an important DoD (Health Affairs) initiative designed to support field medical operations and the delivery of seamless combat medical care. TMIP is envisioned as providing integrated and automated medical information for such functional areas as command and control, medical logistics, blood management, patient regulation and evacuation, and health care delivery.[169] TMIP is being designed to capture and record the health-related information of deployed forces "…so the warfighting CINC can generate the medical surveillance data necessary to assess the medical readiness of the deployed force and engage in requisite force health protection support."[170] DoD-wide functionality for TMIP is anticipated in fiscal year 2002. In order to comply with presidential direction on force health protection, DoD (Health Affairs) plans to integrate TMIP with the PIC and the Preventive Health Care System (PHCS).[171]

The DoD’s concept for the Preventive Health Care System (now more typically referred to as the Preventive Health Care Application or PHCA) integrates the delivery, recordkeeping, and tracking for such deployment-related activities as clinical preventive services, immunizations, and individual medical readiness indicators. It includes an immunization tracking system as well as automation of pre- and post-deployment health questionnaires and the Health Enrollment Assessment Review (HEAR) questionnaire.[172] PHCA operational testing and evaluation was completed in December 1998, and implementation began in 1999.[173]

Recognizing that "…the increasing number of vaccines and the increasing complexity of immunization schedules requires more efficient methods of recording and tracking immunizations," the DoD has established an interim tracking system for its anthrax vaccination program pending full PHCA implementation. Currently, the Army uses the Medical Occupational Data System (MODS), the Air Force uses its Military Immunization Tracking System (MITS), and the Navy and the Marine Corps use the Shipboard Automated Medical System (SAMS). In addition to capturing and retaining anthrax immunization data locally, each system transmits a core set of information to the DoD’s Defense Eligibility Enrollment System (DEERS). This allows for decentralized confirmation of an individual’s vaccination status and updating of the servicemember’s immunization record.[174]

The DoD’s current Composite Health Care System (CHCS) supports the electronic capture of laboratory, radiology, pharmacy, and patient administration data within a medical treatment facility. A near-term upgrade will include a medical records disposition and archiving function, as noted previously. (See section III.E. Post-Gulf War Practice - Custody of the record.) DoD’s next generation health information system, CHCS II, will move toward a common database that links data between medical facilities. It would also add new areas such as surgical services and ambulatory care; facilitate data exchange on the tracking of patients and location of medical information with other DoD functions (for example, military personnel); and generally support development of the computer-based patient record (CPR). Increments of CHCS II are projected to be fielded through fiscal year 2006.[175]

Military medical recordkeeping and medical surveillance activities during deployments are directly and necessarily linked to military personnel functions and information systems. A new personnel information system, the Defense Integrated Military Human Resources System (DIMHRS), is being developed to standardize military personnel data among the services and their components. Currently, the different services and their components collect data that are incomplete and inconsistent, making management of personnel in-theater and through mobilization problematic.[176] This new personnel information system would give the DoD the capability to track personnel in the theater of operations, support collection of casualty and patient evacuation information that will be integrated with medical management systems, and provide data for use by outside agencies such as the VA and the Red Cross. The DIMHRS development team members will also participate in a DoD (Health Affairs) project to define requirements for tracking the use of investigational drugs, and to ensure that these requirements are incorporated in the military personnel system. Initial operating capability for this system is planned for the year 2003.[177]

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