Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

Downloads

This item is only available as the following downloads:


Full Text

PAGE 1

OctoberDecember2006Perspective1MGRussellJ.CzerwCertificationinMilitaryMedicine:TheTimeisNow3COLMichaelJ.Roy,MC,USA,etalUSArmyClinicalInvestigation13COLJamesM.Lamiell,MC,USA,etalExpandingtheRoleoftheNursePractitionerintheDeployedSetting20MAJ(P)EdwardE.Yackel,AN,USA,etalForwardDeployedNeurologists?ButThatsWheretheTroopsAre!26LTCRomanBilynsky,MC,USATheaterImmersion:TrainingaMedicalTaskForceforOperationsinIraq28COLJamesB.Henderson,USAApplicationofGeographicInformationSystemTechnologyto34PreventiveMedicineInterventionsJoelReyes,BS,etalFeaturedTopic:ElectronicMedicalRecordsTheNewNameoftheMilitaryElectronicMedicalRecord40LTCRonMoody,MC,USA;DavidFreemanAGlobalElectronicMedicalRecord,TodaysReality42LTCRonMoody,MC,USA;DavidBlair,MDAHLTADeploymentStatusandDevelopmentStrategy46LTCRonMoody,MC,USA,etalElectronicMedicalRecords,MedicalCoding,andOutcomeImprovement51LTCRonMoody,MC,USATheTacticalElectronicMedicalRecord:TheKeytoMedicalTransformation56LTCEdwardMichaud,MC,USA,etalImplementationoftheTheaterMedicalInformationProgram65DuringOperationIraqiFreedomIVMAJMarkL.Higdon,MC,USA

PAGE 2

LTGKevinC.Kiley TheArmySurgeonGeneral Commander,USArmyMedicalCommandMGRussellJ.CzerwCommandingGeneral USArmyMedicalDepartmentCenterandSchool OctoberDecember2006 TheArmyMedicalDepartmentCenter&School PB8-06-10/11/12 0625501 PETERJ.SCHOOMAKER General,UnitedStatesArmy ChiefofStaff DISTRIBUTION:Special AdministrativeAssistanttothe SecretaryoftheArmy ByOrderoftheSecretaryoftheArmy: Official: JOYCEE.MORROW Onlineissuesofthe AMEDDJournal areavailableathttps://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 AProfessionalPublication oftheAMEDDCommunity The ArmyMedicalDepartmentJournal [ISSN1524-0436]ispublishedquarterlyfor TheSurgeonGeneralbytheUSArmyMedicalDepartmentCenter&School,ATTN: MCCS-DT,2423FSH-HoodST,FortSamHouston,TX78234-5078. CORRESPONDENCE: Manuscripts,photographs,officialunitrequeststoreceive copies,andunitaddresschangesordeletionsshouldbesenttothe Journal atthe aboveaddress.Telephone:(210)221-6301,DSN471-6301 DISCLAIMER: The Journal presentsclinicalandnonclinicalprofessionalinformation toexpandknowledgeofdomestic&internationalmilitarymedicalissuesand technologicaladvances;promotecollaborativepartnershipsamongServices, components,Corps,andspecialties;conveyclinicalandhealthservicesupport information;andprovideapeer-reviewed,highquality,printmediumtoencourage dialogueconcerninghealthcareinitiatives. Viewsexpressedarethoseoftheauthor(s)anddonotnecessarilyreflectofficialUS ArmyorUSArmyMedicalDepartmentpositions,nordoesthecontentchangeor supersedeinformationinotherArmyPublications.The Journal reservestherighttoedit allmaterialsubmittedforpublication(seeinsidebackcover). CONTENT: Contentofthispublicationisnotcopyrightprotected.Materialmaybe reprintedifcreditisgiventotheauthor(s). OFFICIALDISTRIBUTION: ThispublicationistargetedtoUSArmyMedical Departmentunitsandorganizations,andothermembersofthemedicalcommunity worldwide.

PAGE 3

OctoberDecember20061IremainimpressedwiththedistinctauthorshipandrelevanceofthearticlespublishedinourAMEDDJournal.YouwillfindthatthiseditionvalidatestheAMEDDJournalscontinuedsuccessasadynamicandrelevantpeer-reviewedpublication.Wearefortunatetobeginthiseditionwithareprintofaverytimelyarticlewhichpreviouslyappearedinaninternationalmilitarymedicaljournal.COLMikeRoy,etalmakeanexcellentcaseforaprocesstoconferformalcertificationinmilitarymedicine,andhowtheelementsofthatskillsethavewideapplicationsinthecivilianmedicalsector.Suchcertificationwouldrecognizetheuniqueandchallengingdemandsofmedicalcareincombatenvironments,aswellasresultinamuchbetterpreparedandcapablemilitarymedicalprofessionalchargedwiththecareofourmostpreciousresource,thecombatSoldier.Researchisfundamentaltothescienceofmedicine.COLJamesLamiell,agiftedmedicalresearcher,andhisteampresentadetailedpictureoftheAMEDDClinicalInvestigationProgram,theformalstructuredefininghowclinicalresearchisconductedwithinArmymedicine.Thisinterestingandinformativearticledescribesboththehistoryandcurrentstatusoftheprogram,anddiscussestherationaleandstrategicvisionthatframestheseextremelyimportantresearchefforts.ThearticlenotonlyreflectstheAMEDDsconsiderableinvestmentinandsupportofclinicalinvestigation,butalsounderscoresourunwaveringcommitmenttomaintainingthehigheststandardsofmedicalexpertiseandpractice.AstheAMEDDadaptstothelong-termchallengesofthenewcombatenvironmentposedbytheGlobalWaronTerror,realworldexperiencesareparamountinthegenerationofnewideasandtheadaptationofexistingmethodsandprotocols.Threearticlesinthisissuedirectlyaddresseffortstoensurethedeliveryofqualityhealthcareduringoperationaldeployments.First,intheirarticle,MAJ(P)EdYackelsgroupofhighlyexperiencedNursePractitioners(NP)presentaverystrong,thoughtfulcaseforformalizingexpandedrolesoftheNPsindeployedenvironments.ForyearstheNPhasbeenavitalelementinthedeliveryofhealthcareinthefixedfacilityenvironment,bothprovidingprimarycaredirectlyandservinginsupervisorypositionsoverclinicsanddepartments.TheexperiencesrelatedinthearticleshowthattheexigenciesofoperationsplaceNPsinthesameroleswhiledeployed.Unfortunatelysuchassignmentsarenotdirectlyaddressedindoctrine,leadingtoinconsistencies,confusion,andsuboptimaluseofvitalresources.Next,inasimilarlookatresourceutilizationfromtheperspectiveofreal-worldexperience,LTCRomanBilynskisconcise,thought-provokingarticleproposesapracticalchangeinthedoctrinaluseofNeurologistsincombatdeployments.Thethirdarticlelooksatpredeploymenttraininginrealisticcombatenvironments.Suchtrainingisasabsolutelyimportantformedicalunitsasitisforcombatforces.COLJamesHendersonpresentsadetaileddescriptionoftheplanning,coordination,attentiontodetail,resources,andsheerhardworkthatisrequiredtodeliverthepractical,intensivetrainingnecessarytothoroughlyprepareaunitforimminentPerspectiveMajorGeneralRussellJ.Czerw

PAGE 4

2ArmyMedicalDepartmentJournaldeployment.Unitsarecompletelyimmersedinrealisticenvironmentsandintensesituationswhichreplicateascloselyaspossibletheconditionstheyshouldexpect.COLHendersonshowshowtrainingplannersespeciallydrawupontheexperiencesofthosewhohavegonebeforetodesignandrefinetheirtrainingplans.Thisisaneye-openingportrayalofthetoooftenoverlookedeffortsofdedicatedtrainingsupportprofessionalswhoworktirelesslytoprepareourmedicalpersonnelfortheircriticalrolesavingthelivesofourcombatSoldiers.ThecreativeuseofemergingtechnologieshaslongbeenahallmarkoftheUSmilitary.JoelReyes,etalgiveusalookathowaseeminglyunrelatedtechnologyisbeingusedwithourmedicalapplicationsanddatatocreateanotherimportanttoolformedicalplanners,especiallyinpreventivemedicine.Geographicinformationsystemsarerapidlybecominganindispensablepartofmedicalplanningfortransportation,naturaldisasters,andepidemiologicalresponses,tonameafew.Recenteventshavegreatlyincreasedtheimportanceofregionalplanningformasscasualtyevents,introducingtherealpossibilityofunconventionalthreatsbiological,chemical,andradiologicalwhichcouldappearanywhereatanytime.Youwillfindthatthisarticleprovidesagoodoverviewofhowapplicationsofthistechnologyarebeingadaptedbyimaginative,energeticpeople,notonlytoplanforfuture,largescaleevents,butalsotosimplifyexisting,routinerequirements.ThefeaturedtopicofthisissueisfocusedonanevolvingtechnologicalapplicationwhichisalreadybecomingindispensableinthedeliveryofhealthcareintheUSmilitary,theelectronicmedicalrecord(EMR).LTCRonMoodyandmembersofhisAMEDDAHLTAimplementationteamhaveprovided3veryinformativearticleswhichdescribethebackgroundofAHLTA,thedevelopmentanddeploymentstrategy,anditscurrentstatus.Thesearticlespresentexcellentinformationastothehow,when,and(especially)whyAHLTAhasevolvedasithas.AllAMEDDprofessionalsinvolvedinhealthcaredeliverywillfindthesearticlesextremelyvaluableinhelpingtofurtherunderstandandappreciatethetoolyouusemultipletimeseveryday.Inaddition,LTCMoodyhaswrittenanarticleemphasizingtheimportanceofaccuracyofthecodesusedinAHLTArecords.Hisarticleexplainstheclassificationschemes,discussesthemetricsusedtoassesstheeffectivenessofthecoding,andexplainstheimpactofaccuratecodingonoutcomesandcost.HemakesitclearthatthefullpotentialbenefitsofAHLTAwillnotberecognizedunlesspractitionerscarefullyanddiligentlyapplythemselvestoensuringtheaccuracyoftheenteredinformation.Thelast2articlesexpandthediscussionofelectronicmedicalinformationtotheuserlevel,includingitsvaluetoandimpactontheSoldier,howoperationalunitshaveusedit,andthebenefitsderived.LTCEdMichaudandhiscoauthorspresentaneasilyreadable,veryinformativediscussionoftheirexperiencesusingthetacticalapplicationsoftheEMR.Theirapproachdiscussesbothpracticalandtheoreticalconsiderations,coveringbenefitsanddisadvantages.ThisarticleprovidesaninterestingperspectiveonourevolvingEMRtechnologyfromperhapsthemostimportantuser,thebattlefieldmedicalstaff.MAJMarkHigdonthendiscussestheflowofdigitalmedicaldataacrossthebattlefield,outoftheater,andultimatelyintotheSoldiersrecord.Writingfromhisexperiencewhiledeployed,hecarefullyandclearlyexplainstheArmysTheaterMedicalInformationProgram,itshistory,functionality,successes,andshortcomingsintheoperationalenvironment.Asusual,thisisanotherexcellenteditionoftheAMEDDJournalthatIhopeallofyouwilltaketimetoread.ThereisanicevarietyofcontentandIamsurethatyouallremainasimpressedasIamwithwhatourgreatAMEDDSoldiersdoeverysingleday!Perspective

PAGE 5

OctoberDecember20063INTRODUCTIONOverthepasttwodecades,anincreasingamountofattentionhasbeenpaidtothetrainingofmilitaryphysiciansintheoperationalrealmpreparingthemforcombat-relatedandhumanitariandeployments.Militaryuniquecurricula(MUC)havebeenpublished1andupdated,2andvariouseffortshavebeenmadetotrytoimplementinstructionandskillstraining.3,4PiercefolloweduptheinitialMUCwitharecommendationthatadepartmentofmilitarymedicinebeestablishedateachoftheUSmilitarysmedicalteachingcenters,5butthishasnotoccurred.Wenowexaminesubsequenteffortstoenhancemilitarilyrelevanteducation,considerthebenefitsandcostsofcertificationinmilitarymedicine,evaluatepotentialmodelsforcertification,anddiscussmeasuresthatwouldbenecessarytoestablishameaningfulcertificationprogram.BACKGROUNDAreviewoftheliteratureyieldsanumberofthoughtfultreatisestouchinguponthesubjectofcertificationinmilitarymedicine.Eisemanemphasizedtheneedforphysicianstoengageinmasscasualtyplanning,especiallyasitmayapplytociviliansettings.6Henotedthatmobilizationfrompeacetimetoastateofformalwarfareorbattlerequiredweekstomonths,withphysiciansinvolvedinpreparingforthetypeofcasualtiesanticipated.However,hepropheticallypointedoutthatterroristattacksrequireasimilarresponsefromthemedicalcommunity,withlittleornolead-timetoprepare.Physiciansmustthereforebetrainedtodealwithawiderangeofpotentialscenarios.Acorollaryisthatmilitarymedicalresponsesmaywellneedtobedifferentfromstandardizedcivilianresponses,sothattrainingnormallyunavailableinciviliantrainingprogramsmustbeimplementedinordertofacilitateanappropriatemedicalresponsetotheseevents.Militaryphysiciansquicklyrecognizedifferencesbetweenwarandpeacetimemedicine,butthelessonslearnedinbattlehaveoftenbeenforgottenbetweenwars,onlytobepainfullyrelearnedbyothers.Bellamycommentsthatphysicianshavelongignoredknowledgeofmilitaryweaponry,believingtheknowledgetohavelittletherapeuticvalue.However,heasserts,onlyknowledgeablemedicalofficerswillunderstandtheintricaciesofwarinjuriesresultingfrombattle.7Forexample,woundsfrommissilesofhighvelocitymayrequirelessexplorationand CertificationinMilitaryMedicine:TheTimeisNowCOLMichaelJ.Roy,MC,USACOLJosephPalma,MC,USAFCOL(Ret)NormanRich,MC,USAABSTRACTInrecentyears,militarymedicalpersonnelinseveralnationshavebeenworkingtowardprovidingcertificationinmilitarymedicine.Reasonsforcertificationincludetheidentificationandrecognitionofexpertise,andtheabilitytomatchexpertisewithchallengingassignmentsandmissions.Wereviewtheliterature,examineseveraloptions,andproposeanewmethodforcertificationinmilitarymedicine.Ourmodelfeatures2levelsofcertificationinmilitarymedicine,operationalandexpert,withthelatterapotentialbasisforamastersdegreeinmilitarymedicine.Requirementswouldbecompletedthroughexperienceorcourseworkineachof7areas:leadership,preventivemedicine,fieldexperience,administrativehealthcare,casualtyandincidentmanagement,scholarlyactivities,andserviceandspecialtyspecificrequirements.Educationalobjectivesandmaterialshouldbedeveloped,standardized,andincorporatedintoaneducationalprogramleadingtocertification.Existingcoursesanddistancelearningmethodsshouldbeincorporatedwheneverpossible.Acertificationexamisrecommended. ThisarticleisreprintedfromInternationalReviewoftheArmedForcesMedicalServices(2006;79(1):46-53)withpermissionoftheauthors.

PAGE 6

4ArmyMedicalDepartmentJournaldebridementthanthosefromprojectilesthataredesignedtofragmentuponimpactandfurtherdisrupttissues.Militaryphysiciansshouldalsounderstandthedifferentphysical,physiological,andpsychologicalimpactsofwoundsresultingfromammunitionfiredfromfirearms,theblasteffectofexplosives,andflameorincendiarymunitionswiththeadditionalmedicalcompromiseofthermalinjury.Thesignificanceofsuchissueshighlightstheneedforspecificmedicalandsurgicaltrainingrequirementsandobjectivesbeyondthosethathavetraditionallyencompassedtrainingprograms.AseriesofarticlesinthejournalMilitaryMedicineintheearly1990saddressedtheissueofwhethermilitarymedicine,orsomeofitscomponents,hasuniquequalitiesthatauguraneedtostandardizethediscipline,and,inturn,whethertocertifythosethatcompletetherequirements.Thepurposeofcertificationwouldbetoidentifythosewithcompetenceintheirrespectivefields,facilitatingthefieldingofacapablemedicalforce.Rignaultinparticulararguedthatwarsurgeryshouldbeconsideredauniquespecialty.8,9Henotedthatsince1950,thepeacetimepracticeofcivilianandmilitarysurgeryhasbeenmarkedbyincreasingspecialization,andthatalthoughthesurgicalmanagementofwoundscontinuestorequireasolidfoundationingeneralsurgerytraining,additionalspecifictraininginwartimesurgery,historicallyunavailableineithercivilianormilitarypeacetimetrainingprograms,isnecessarytoavoidthesignificantchallengessurgeonsfaceintreatingandsustainingthewarwounded.Rignaultemphasizesseveralkeydifferencesbetweenpeacetimeandwartimesurgery.Warsurgerydealswithemergencies,providingalmostexclusivelylifesavingsurgery,tobefollowedbyevacuationandfurtherstagedsurgeriesindifferentlocationspossessingincreasingsophistication.Wartimesurgicalandmedicalcareisprimarilyprovidedinanunsophisticatedmedicalenvironment,withminimalornoadvanceddiagnosticequipment,suchasCTscans,requiringgreaterrelianceuponclinicaldiagnosticskills.Warsurgery,inlargepart,involvestheneedtosortlargenumbersofcasualtiessimultaneously,requiringtriage,stabilization(takentoanewlevelbythehighlysuccessfulFrenchForeignLegionreanimationteams,whosepurposewastoparachutein,stabilizecasualtiesinfarforwardareas,andevacuatethemtosaferareasfordefinitivehospitalcare,dramaticallyreducingmortalityinthe1970s),andevacuationtoahigherlevelofcare.Theinitialstabilizationofwar-injuredpatientsisthereforeincomplete.Themilitarymedicalofficermustexercisejudgmentbaseduponhisorherknowledgeofthemechanismofinjury,theinjuryorinjuriesthemselves,surgicalprocedure(s),naturalhistoryofthemilitaryinjuryorinjuries,thelogisticsandsustainabilityofthemilitaryoperation,andthemedicalevacuationchainandsystemcapabilityandcapacity.Theoutcomeforagivenpatientissignificantlyinfluencednotonlybythehost(injuredcasualty)andtheenvironmentsimultaneously,butalsothelagtimebetweentheinjuryandarrivaltoinitialmedicalorsurgicalcare,thequalityofthecare,andlevelofcareduringtransport.Warsurgeryisperformedinsequentialechelons(orlevelsofcare).Thisimpliesthatthemedicalofficeronthefrontlinesisresponsibleforinitiatingthesequenceofcare,butthatdefinitivecarewilllikelybeperformedatarearwardlocationwithgreatercapabilities,afterevacuation.Continuityofcareisthusprovidedbythesystem,whichstandardizesmedicalandsurgicalcaretothemilitaryenvironment,ratherthanbyasinglephysicianorteam.Thepathologyofwarisalsodifferent.Commonsurgicalinjuriesincludeblastandcrushinjuries,missileinjuries,andcomplextraumasofamagnitudeandscopebeyondthatoftheworstvehicularaccidents.Inaddition,thediseasesofwarmaydifferfrompeacetimeenvironments,withmalaria,epidemicdiarrhea,epidemicexposureinjuries,andevenbiologicalorchemicalwarfareinjuries.Thisposesgreaterchallengesintrainingphysiciansfordeployment.Uncheckedinafightingforce,suchconditionsmayresultindefeat.Alsoofimporttomilitaryphysiciansaretheimplementationofpublichealthorpreventivemedicinemeasuresthatmustbepresenttosustaintheeffectivenessofthefightingforce.Forexample,NapoleondiscoveredthathismightyarmycouldnotcaptureMoscowbecauseoftheweathersimpactonhisforce.Ultimately,surgicalproceduresandindicationsdifferinthewarenvironment,asdomedicalinterventions,dictatedbytheavailableresources.Onecanthereforeconcludethatmilitarymedicineisindeedauniquediscipline,warrantingstandardizationofeducation,training,andcertification.6-10Poriesassertsthatmilitarysurgeryisalreadyaspecialtyandoutlinesitscomponents.11Inhisopinion,certificationislongoverdue.Fiftyyearsago,generalsurgeonstreatedcancerandperformedgastrectomies,CertificationinMilitaryMedicine:TheTimeisNow

PAGE 7

OctoberDecember20065Whippleprocedures,pediatricandcardiacsurgery,andorthopedicprocedures.Today,increasedtechnologyandspecializationhasresultedineachofthesefunctionsbeingperformedbysubspecialists,notgeneralsurgeons.IntheUnitedStates,TheAccreditationCouncilforGraduateMedicalEducation(ACGME)recognizesanddefinessubspecialtiesasareasofgraduatemedicaleducationwhichhaveaprerequisiteforenrollment,andrequirethecompletionofanaccreditedresidencyand/orcertificationinadisciplineinwhichthereisaprimaryorconjointAmericanBoardofMedicalSpecialties(ABMS)board.Militarysurgeons,andothermedicalofficers,completetheirprimaryresidenciesandbecomeboardeligibleorcertifiedandaretheneligibleforsubspecialtytrainingandeducation.TheACGMEalsorequiresthatasubspecialtyhaveauniquebodyofscientificmedicalknowledgesufficientforeducationinaclinicalfield,notsimplylimitedtolearningaprocedureorothermorecircumscribedobjective.Inthisrespect,militarymedicinealsoqualifiessincecompetenceinmilitarymedicineisnotjustamatteroflearningasinglenewprocedure.Forexample,PoriespointsoutthatduringtheVietnamWar,thesurgicalworkoffield-experiencedsurgeonswasreadilydistinguishablefromthatofnewlyarrivedsurgeonsapplyingsurgicalskillsandstandardslearnedforanexclusivelycivilianpractice.Thelatterresultedinsignificantlypooreroutcomesduetothelackofknowledgeoftheintricaciesofwarcasualtytreatmentandmanagement.11EFFORTSTOESTABLISHAMILITARYUNIQUECURRICULUMInresponsetotheDepartmentofDefenseeffortstoestablishamilitaryuniquecurriculum,someUSmilitarytrainingprogramshaveincorporatedelementsofanMUC.ThefamilymedicineresidencyprogramatFortBenning,Georgia,designedaninnovativeprogramofrotationsthroughpertinentaspectsofmilitarymedicinefortheirresidents.Theprogramfeatures12garrison(ie,peacetime)medicinemodulesofinstructionrangingfrommanagementofatroopclinictonuclearandchemicalsuretyprograms.Thereisextensivecoverageofpredeploymentplanningandissues,deploymenttopicsincludingactivation,logistics,unitmovement,patientstabilizationandevacuation,andredeploymentissuesandconcerns.12TheDepartmentofMedicineatWalterReedArmyMedicalCenter(Washington,DC)implementedamilitaryuniquecurriculuminwhichinternalmedicineresidentsexperiencedidacticeducationinoperationallyrelevantaspectsofsubspecialtyareassuchascardiology,infectiousdiseases,andemergencymedicine,aswellasparticipatinginanoperationalrotationwithafieldunit.3,4Morerecently,the6USArmymedicalcentersbandedtogethertoestablishamilitaryuniquecurriculumof18onlinemodulesthatallArmyinterns,ineveryspecialty,mustcomplete.ThefamilymedicineprogramatMadiganArmyMedicalCenter(FortLewis,Washington)isalsoworkingtoestablishamilitaryuniquecurriculumforfamilymedicinephysicians.THEDIPLOMAINTHEMEDICALCAREOFCATASTROPHESTheBritishhaveestablishedwhatwebelievetobeaparticularlyvaluablemodelforcertificationinmilitarymedicine.In1993,theSocietyofApothecariesofLondon(incorporatedbyKingJamesIin1617)initiatedtheDiplomaintheMedicalCareofCatastrophes,whichincludesmanyoftheelementsofcompetencerequiredofmilitaryphysicians.Thepurposeistoidentifyexpertiseinuniqueaspectsofcontingencyresponse,forbothcivilianandmilitaryphysiciansinterestedinprovidingmedicalandsurgicalcareinmajormanmadeornaturaldisasters.Requirementsforcertificationaredividedinto7areas13:1.SurvivalSatisfiedthroughcompletionofa5-dayDisasterReliefOperationsCourse(DROC),oranotherequivalentcourse.2.FieldTeamTrainingTheDROCoranequivalentcoursealsoprovidescreditforthiselement.3.MultipleCasualtyManagementCanbecompletedthroughanumberofdifferentcourses,averaging3daysinlength.4.TraumaLifeSupportSatisfiedthroughcompletionofanyofavarietyofcoursessuchasadvancedcardiaclifesupportoradvancedtraumalifesupport.5.PreventiveMedicineAlsocoveredinDROC,orwithaseparate2-daycourse.6.WrittenDissertationFocusedonanaspectofmedicalcareincatastrophes,upto100pagesinlength.

PAGE 8

6ArmyMedicalDepartmentJournal7.SupplementaryModuleThisfeaturesapick-listoftopics,withcompletionofanytworequired(Note:Medicalpracticeand/ortraininginafieldoftenconferscredit.):WarmedicineorsurgeryPsychologicalworkshopGeneralpracticeworkshopTropicalmedicineIntensivecareAccidentandemergencymedicineForensicmedicinePediatricmedicineDEFINITIONOFMILITARYMEDICINEIn2002,weconvenedanexpertpaneltoconsiderthedevelopmentofaprogramforcertificationinmilitarymedicine.Priortothosedeliberations,thepanelagreeduponthefollowingworkingdefinitionformilitarymedicine:Militarymedicinerepresentstheknowledge,skills,andattitudesinherentinthepracticeofmedicineinaustereand/ormilitarilyuniqueenvironments,cognizantoftherolesandcapabilitiesofthemilitary,andthemeansforcoordinatingwithotherorganizations.ACADEMICFOUNDATIONWhiletherearevariationsbetweenbranchesoftheservice,betweenspecialties,andbetweennations,webelievethatthereisabodyofknowledgethatispertinenttoallmilitaryphysicians.TheMilitaryUniqueCurriculadocumentshaveoutlinedthisbodyofknowledge,andthevastTextbookofMilitaryMedicineseries*providesconsiderabledetail.Thereisalsoanever-expandingbodyofmilitarymedicalliterature,particularlyembodiedin,butnotlimitedto,thearchivesofthejournalsMilitaryMedicineandInternationalReviewoftheArmedForcesMedicalServices.ThereisalsoarangeofmilitarymedicalcoursessuchastheCombinedHumanitarianAssistanceResponseTeams(CHART)course,theMedicalManagementofChemicalandBiologicalCasualties(MMCBC)course,andtheMedicalEffectsofIonizingRadiation(MEIR)course,whichcoverspecificaspectsofmilitarymedicine.Morethan20nationshaveprogramsintropicalmedicineandhealth,**manyofwhichhavesignificantcomponentsofmilitaryrelevance.ADVANTAGESOFCERTIFICATIONPotentialadvantagesincludethefollowing:Recognitionofachievement,experience,and/orexpertiseAcademicrecognition,similartoboardcertificationBasisforfinancialrewardssuchasbonuspaymentAdvantageforpromotionIdentificationofacadreofexpertsthatcanbecalleduponinatimeofneed,ortoimparttheirknowledgeandskillstoothersToqualifyindividualsforparticularassignmentsorpositionsofleadershipwithinmilitarymedicineTheformthatcertificationtakescanhaveasignificantinfluenceuponwhichoftheabovegoalsareachieved.Assuch,itisimportanttoconsiderprioritizationoftheseadvantagesindeterminingthemodeofcertificationsettledupon.Webelievethateachadvantagehasimportance,butinourmindsthemostsignificantgoalofcertificationistorecognizetheexpertiseandexperienceofphysicianswhohavetakenituponthemselvestoestablishunambiguousproficiencyinoperationalmedicine.Therearealsopotentialobstaclestotheestablishmentofcertificationinmilitarymedicinethatmustbetakenintoaccount.First,certificationmustbeinexpensiveideally,cost-neutralsincemilitarymedicalbudgetsarealreadythinlystretched,andaprogramthatiscostlytoeitherindividualsorthemilitaryhealthcaresystemisunlikelytoachieveimplementation.Second,theremustbeacertifyingauthority,someonethatwillexaminecredentialsanddetermineorjudgeeligibilityforcertification,aswellasrecertification.CertificationinMilitaryMedicine:TheTimeisNow *AvailablefromtheBordenInstituteat:http://www.bordeninstitute.army.milAvailableat:http://coe-dmha.org/course_chart.htmAvailableat:https://ccc.apgea.army.mil/courses/in_house/brochureMCBC.htmAvailableat:http://www.afrri.usuhs.mil/www/outreach/meir/meir.htm**Listavailableat:http://www.astmh.org/oppor/training.html

PAGE 9

OctoberDecember20067ANALYZINGTHEALTERNATIVEMODELSFORCERTIFICATIONOneprominentmodelforcertificationistheboardcertificationsystemforphysicians.Atthepresenttime,theAmericanBoardofMedicalSpecialties(ABMS)has24memberspecialtyboards,rangingfromAllergyandImmunologytoUrology.Certificationisanarduousandexpensiveprocessforphysicians,butiswidelyrecognizedasawell-established,well-defined,andrigorousprocessthatoftenincreasesthecomfortlevelthatpatientshavewithphysicianstheyselectforcare.Amilitarymedicinecertificationprocessthatwouldcommensuratelyincreasetheconfidenceoflineservicememberswiththephysiciansthataredeployedwiththemisadesirablegoal.However,itmustalsoberecognizedthatmilitaryphysiciansalreadytypicallymaintainboardcertificationwithintheirrespectivespecialties,requiringsignificantinvestmentsoftimeandmoney.Inaddition,thebodyofknowledgeofmilitaryrelevancethatisimportantforaspecialisttomaster,butisuniquefromthatcoveredinthespecialty-specificcertificationprocess,maynotbelargeenoughtowarrantfollowingaboardcertificationmodel.TherearealsomanymorecertificationbodiesthatarenotrecognizedbytheABMS,frequentlyprovidinganeasierpathtoclaimcertificationintheeyesofaconfusedpublic,butfailingtomeettherigoroftheABMS.WhileitmaybedifficulttoachievecertificationinmilitarymedicinethroughtheABMS,theDepartmentofDefense(DoD)couldestablishanindependentcertifyingbody,butthecreationofameaningfulcertificationprocesswouldhavedifficultysurvivingthetwinobstaclesofcostandresourcesrequiredforitsestablishmentandmaintenance.AnothermodelisthepreviouslydescribedDiplomaintheMedicalCareofCatastrophes(DMCC).Uponcompletionofthe7modulesoutlinedabove,aprospectivediplomatemustthensitforatwo-partexamination.Thefirstpartisanoralexaminationofthematerialcoveredinthemodulesbeforeaboardofexaminers.Thesecondfeaturesanoralpresentationanddiscussionofthedissertation.InadditiontostrongsupportfortheprogramwithintheBritishmilitary,theexaminationisalsoprovidedattheUniformedServicesUniversityoftheHealthSciences(USUHS),Bethesda,Maryland,wherealargenumberoffacultyarediplomatesandserveasexaminers.Moreover,theDMCCisnowrequiredofmilitaryphysiciansinboththeUnitedKingdomandtheNetherlands.ThebroadscopeandmodularnatureoftheDMCCareparticularlyusefulcharacteristicstoincorporateintoplansforcertificationinmilitarymedicine.Thereisabookthatcodifiesacorrespondingbodyofknowledge.14However,itcanbearguedthattheorientationoftheDMCCisnotasspecifictomilitarymedicineasdesired,whichisperhapsnotsurprisingsinceciviliansareeligibleforthediploma,andtheorientationismoregearedtowardsdisasterandhumanitariancareratherthanthecombatenvironment.Anotherconsiderationasamodelismorespecificallygearedtowardthegoalofrecognitionratherthanprovidingacertificateperse,providingaribbon,patch,orotheremblemtobewornonthemilitaryuniform.Thisisnotnecessarilymutuallyexclusiveofbonafidecertification,andinfactcouldbeprovidedinconjunctionwithcertification,butthelevelofinfrastructureandrigorrequiredtoinstituteamoreclassicalcertificationprogramwouldnotnecessarilyberequiredforaward-typerecognition.Simplificationoftheprocess,atleastinitially,mightfacilitatemorepromptimplementation,whilestillachievingtosomedegreethegoalsofprovidingrecognitionandearninggreaterrespectintheeyesoftheline.If,ontheotherhand,acertaindegreeofrigorisnotincorporatedintheprocess,placementofanemblemontheuniformmightgeneratemoreresentmentthanrespect,especiallyifrecipientsofrecognitionsuchastheExpertFieldMedicalBadgeviewthisasacheaperpaththanwhattheyaccomplishedtoearnasymbolontheiruniforms.Alternatively,amorerobustapproachtocertificationmightgosofarastoconferamastersdegreeinmilitarymedicine.Thiscouldentailasmuchasoneortwoyearsofinresidence,acourseofshorterdurationinconjunctionwithasetofcoursescurrentlyavailabletomilitaryphysicians(eg,MedicalManagementofChemicalandBiologicalCasualties,MedicalEffectsofIonizingRadiation,etc.),orcoursestakenpart-timeorviadistancelearningmethodsoveralessrestrictedtimeframe.Thisapproachwouldbethemostambitiousandpotentiallyexpensive,butwouldachieveagreaterdegreeofcontrolovercontentandmoreeffectivelyensuremasteryofthetargetedcontentthananyothermethod.Thereareseveralmodels,albeitoflesserscope,thatprovideonsiteanddistancelearningalternativestoachievethesamegoal.OneistheGoodClinicalPracticetrainingforscientificresearchers,

PAGE 10

8ArmyMedicalDepartmentJournalwhichmaybecompletedatamultidaycourse,orcompletedwithself-paced,web-basedcoursesthatprovideinstructionfollowedbyexaminations.TheArmyprovides2differentalternatives.First,theOfficerAdvancedCourserequirescompletionofaseriesofself-pacedminicoursesandexaminations,followedbyseveralmonthsinresidenceattheUSArmyMedicalDepartmentCenterandSchoolatFortSamHouston,Texas.Inaddition,thenextlevelofofficertrainingistheCommandandGeneralStaffOfficerCourse,whichcanbecompletedthroughayearinresidenceattheCommandandGeneralStaffCollege,FortLeavenworth,Kansas,orinaself-pacedseriesofcourses,examinations,andwrittenessays,overasmuchas2years.Abroadrangeofalternatives,fromentirelyonsiteeducationtocompletelyself-paceddistancelearning,bestmeetstherangeofmotivations,learningpreferences,andschedulesofactivemilitaryclinicians.Inaddition,providingcreditforcompletionofothercoursesthatfulfillsomeoftherequirementsforamastersdegreehelpstoavoidneedlessrepetitionandunnecessaryexpense.Whileestablishmentofamastersdegreeprograminmilitarymedicineistheultimategoal,werecognizethatthismaytaketimetoestablish,andthataninterimbridgetothedegreeisasensiblebeginning.Weproposetheprovisionof2levelsofcertificationinoperationalmedicine,anoperationallevelandanexpertlevel,withthelatter,supplementedbyaresearchproject,formingthebasisforthemastersprogram.Completionofrequirementsthroughexperienceorcourseworkin7differentareas(presentedintheTableonthefollowingpages)wouldbenecessary.Inaddition,therewouldbearequirementfor3lettersofrecommendationfromsupervisorsorcolleaguestodescribeexperienceandqualificationsforcertification.Acertifyingboardwouldreviewcredentialsandawardcertification.Auniversitywouldbealogicalcertifyingauthorityifamastersdegreeisplannedorimplemented,withUSUHSoranothermilitaryinstitutionmostsensible.OtheralternativeswouldbeamilitarysocietysuchastheAssociationofMilitarySurgeonsoftheUnitedStates(AMSUS)ortheInternationalCommitteeofMilitaryMedicine(ICMM),dependingupontheformatthatischosen.Thedurationofcertification,andtheprocessofrecertification,willalsoneedtobedeterminedinthefuture.ANEWMODELFORCERTIFICATIONINMILITARYMEDICINEBasedontheacademicfoundationsofmilitarymedicineandmedicalexperiencesandlessonslearnedfromwarsoverthepastcentury,weidentifiedkeycurricularelements,relevantmilitarycourses,andfieldexperienceswithparticularutilitytomilitaryhealthcareprofessionals.Weincorporatedtheselectedelementsinto7modules,whicharemodifiedfromtheDMCCprogram(seetheTable).ItshouldbenotedthatmanyoftheexamplesthatareprovidedrepresentoptionswithintheUnitedStates,andthattherearemanyotheropportunitiesavailableinothernationsthatwouldfulfilltherequirements.Correspondingdetailededucationalobjectivesandmaterialmustbedeveloped,standardized,andincorporatedintoanyeducationalprogramleadingtocertification.Weproposetherecognitionof2levelsofexpertise,whichwedefineasoperational(basic)andexpert.Acertificationexamshouldfollowthecompletionofallmodules.Wefavorthedevelopmentofastandardized,comprehensivebankofquestionstobeusedforcertifyingexaminations.EDUCATIONALMODELSThemostrigorousofarangeofpotentialeducationalmodelsistheestablishmentofanorganized,dedicatedprogramsimilartotheserviceschools,whichrequirethemilitarymembertomovetoaspecificlocationandschoolforprolongeddedicatedstudyandpertinentexperiences.Attheotherextreme,lessdisruptivetoonescareeranddutystatus,isamodularapproachtolearningsuchastheDMCC,orthedistancelearningcoursesservicesuseinotherprofessionalmilitaryeducationcourses.Overall,webelievethelatterismorerealistic,giventhemanyconflictingdemandsfacingmilitaryhealthprofessionals.However,itisimportanttonotethatAustraliaestablishedamastersprograminmilitarymedicinethatbeganinJune2004,andboththeUnitedKingdomandtheNetherlandsanticipatethecommencementofdegree-grantingprogramsinmilitarymedicineinthenearfuture.DistanceLearning.Themostlikelytobecost-effectiveandmostexpedientinitialeffortisthedistancelearningmodel,whichrequiressignificantcostsforinitialdevelopment,butafterthat,onlylow-costmaintenanceisneeded.WebelievethatmilitarysocietiessuchasAMSUS,withtheassistanceoftheCertificationinMilitaryMedicine:TheTimeisNow

PAGE 11

OctoberDecember20069 1.LeadershipOperationalCourseworkArmyofficeradvancedcourse,AirForcesquadronofficerschool,jointtaskforce(JTF)surgeoncourse,orequivalentExperienceSmallunitteamleader(eg,servicechiefatnonteachingmilitaryhospital,brigadesurgeon)ExpertCourseworkArmyCommandandGeneralStaffCollegeorequivalentservice-specificcourseExperienceLargeunitteamleader(eg,departmentchiefatnonteachingmilitaryhospital,servicechiefatteachingmilitaryhospital,divisionsurgeon,orunitcommander)2.PreventiveMedicineOperationalCourseworkTropicalmedicinecourse,CHARTorhumanitarianassistancecourse,USARIEMenvironmentalmedicinecourse,NavyEnvironmentalHealthCommandoperationalpreventivemedicinecourse,orAirForceaerospacemedicineprimarycourseorequivalentExperienceSmallunitpreventivemedicineresponsibilityforfieldsanitationinfieldexerciseordeployment(eg,Armybrigadesurgeon,AirForcesquadronmedicalofficer,Marinebattalionsurgeon),ordeploymentincombatstresscontrolExpertCourseworkMastersdegreeinpublichealthorresidencytraininginpreventivemedicine,publichealth,oroccupationalhealthExperienceResponsibilityforcareinlargerefugeecamp,jointtaskforceoperations,orcombat3.FieldExperienceOperationalCoursework/ExercisesCompletionoftrainingatJointReadinessTrainingCenter(JRTC,FortPolk,Louisiana),NationalTrainingCenter(NTC,FortIrwin,California),orotherfieldtrainingexercise(FTX);C4,militarycontingencymedicine(MCM),airassault,orsurvivaltrainingcourseExperienceDeploymentoflessthan3monthsExpertCourseworkAdvancedfieldcourseExperiencePositionofresponsibilityonjointdeploymentformorethan3months Categoriesofrequirementsforcertificationinmilitarymedicine,withproposedexamplesthatwouldfulfilleachrequirement.

PAGE 12

10ArmyMedicalDepartmentJournalCategoriesofrequirementsforcertificationinmilitarymedicine,withproposedexamplesthatwouldfulfilleachrequirement(continued) 4.AdministrativeHealthcareOperationalCourseworkFlightsurgeoncourse,commanderscourses,riskcommunicationcourseExperienceDepartmentchiefatnonteachingmilitaryhospital,servicechiefatteachingmilitaryhospital,orDivisionSurgeon;knowledgeandconductofservice-specificmedicalregulationsandstandardsExpertExperienceOversightresponsibilityforservice-specificand/orjointregulationsandstandards,orresponsiblepositionatmajorcommand,CINCSurgeon,serviceheadquartersstaff,deputycommanderforclinicalservices,orhospitalcommander5.Casualty&IncidentManagementOperationalCourseworkC4,air-evacuationcourse,MCM,MEIR,ACLS,ATLS,orequivalentExperienceOperationalleader,planner,orkeyproviderformasscasualty(MASCAL)exercise,medicalstaffforJRTC,NTC,orFTXExpertCourseworkJointtaskforcesurgeonscourseoremergencypreparednesscourse,emergencymedicineresidencyorotherpertinentspecialtytrainingsuchassurgeryorcriticalcare/pulmonarymedicineExperienceOperationalleaderorkeyproviderforreal-lifemasscasualtyincident;operationalleaderorkeyprovideronhumanitarianmissionorcombatdeployment6.ScholarlyActivitiesCertificationRequirementsOperationalShortanalyticpaperontopicrelevanttomilitaryandoperationalmedicine,orcontributingauthortoamilitarilyrelevantpublicationinthemedicalliteratureExpertPrimaryauthorofpublicationofsubstantivescholarlyworkinthepeer-reviewedmedicalliterature,orcompletionofadissertationrelevanttomilitarymedicineDevelopandprovideacourseorlectureseriesrelevanttomilitarymedicine,orauthorachapterinamilitarilyrelevanttextbook7.ServiceAndSpecialtySpecificCertificationRequirementsOperationalDemonstratedabilitytomanageelementsoffieldcareoutsideofusualpeacetimescopeofpracticeExpertSpecialtyboardcertificationanddemonstratedcapabilitytomanagethefullspectrumofthemedicalfieldsystem,suchassuccessfulexperiencesasJTFmedicalcommander,CINCsurgeon,UNpeacekeepingforcesurgeon,NATOorjointoperationornationalmedicalliaisonsduringdeploymentsand/orcontingencyoperations CertificationinMilitaryMedicine:TheTimeisNow

PAGE 13

OctoberDecember200611militarymedicinecommunity,mostnotablytheUniformedServicesUniversityoftheHealthSciences,couldprovidethisservice.Thisoptionrequiresdevelopmentofthecurriculumandthedistancelearningtools(website,CDROMs,standardsdevelopment,qualityreview,onlinetesting,etc),compilingofcoursematerials(TextbookofMilitaryMedicine,militarymedicinecurricularelementsfromUSUHS,service-specificandDoD-levelmilitarymedicinecurricularmaterial)anddevelopmentandmaintenanceofastandardbankofquestions.DistanceandIn-ResidenceLearning.Amoredesirablemodelincludestheabovedistancelearningelementfollowedbya2-weekin-residencerequirement,whichwebelievecanbesufficienttoprovidepracticeinthefield.In-ResidenceLearning.Asmallcapabilityshouldbedevelopedforafullin-residenceprogramofoneyear,equivalenttotheIntermediateServiceSchoolmodelforaselectgroupofoutstandingindividuals.Selectionshouldbebyserviceatpromotion,similartoselectionforothermilitaryschools,andshouldfulfillthepertinentprofessionalmedicaleducationrequirement.ItshouldnotbenecessaryforseniorpersonnelandisnotintendedtoreplacetheuniqueopportunitytoattendtheSeniorServiceSchools(AirForce,Navy,ArmyWarCollegesorNationalDefenseUniversity).IMPLEMENTATIONPROCESSImplementationofcertificationcouldbedonein2stages,thefirsttobeimplementedintheshortterm,whichwecallStageI.ThesecondwecallStageII.Amoreformalizedprocessshould,however,besoughtbytheestablishmentofaformaleducationprograminthisdiscipline.StageIApplicationaccompaniedbylettersofrecommendationSuccessfulcompletionoftherequirementsoutlinedinthemodulesnotedaboveReviewofapplication/credentialsbyaformallyappointedboardorcertifyingbodyCertifyingbodywillissueacertificate.AnonaffiliatedbodywithsubstantialknowledgeofcompetenceintheseareassuchasAMSUSorICMMisrecommendedasthemostappropriatecertifyingbody.StageII.Establishaformaleducationalprogramsuchasamastersdegreelevelcurriculum.FUTUREIMPLICATIONSThedevelopmentofacertificationexaminationwillberequiredtoaccomplishthegoalofcertifyingcompetenceinthisdiscipline.Theexaminationshouldbebasedonthecurrentlyavailablebodyofknowledgeinmilitarymedicine.Arecertificationprocesswillalsobenecessary.Werecommendtheestablishmentofamastersdegreelevelprogramasavehicletostandardizetheknowledge,skills,andattitudesrequiredforcompetenceandcertificationinmilitarymedicineasacapstoneopportunityforselectedmilitarymedicalofficersdesignatedasexpertsintheirprofession.REFERENCES 1.MilitaryUniqueCurricula:InstructionalObjectivesforMilitaryPhysiciansandGraduateMedicalEducationPrograms.1989,UniformedServicesUniversityoftheHealthSciences,Bethesda,MD.2.MilitaryUniqueCurricula.1999,UniformedServicesUniversityoftheHealthSciences,Bethesda,MD.3.RoyMJ,PerkinsJG,BolanCD,PhillipsYY.Operationalexperiencesduringmedicalresidency:perspectivesfromtheWalterReedArmyMedicalCenterDepartmentofMedicine.MilMed.2001;166:1038-1045.4.RoyMJ,BrietzkeS,HemmerP,PangaroL,GoldsteinR.Teachingmilitarymedicine:enhancingmilitaryrelevancewithinthefabricofcurrentmedicaltraining.MilMed.2002;167:277-280.5.PierceJR,BrennanM,CampbellJ,McClurkanM,MorganJL,StracnerCE.TheDepartmentofMilitaryMedicineagraduatemedicaleducationideawhosetimehascome.MilMed.1989;154:536-537.6.EisemanB.Casualtycareplanning.JTrauma.1979;19:848-851.7.BellamyRF,ZajtchukR.Theweaponsofconventionallandwarfare.In:ZajtchukR,JenkinsDP,BellamyRF,QuickCM,eds.TextbookofMilitaryMedicine:ConventionalWarfare;Ballistics,BlastandBurnInjuries.Washington,DC:USDeptoftheArmy,OfficeoftheSurgeonGeneral;1991:1-52.

PAGE 14

12ArmyMedicalDepartmentJournal8.RignaultDP.Iswarsurgeryaspecialty?PartI.MilMed.1990;155:91-97.9.RignaultDP.Howtotrainwarspecialists.PartII.MilMed.1990;155:143-147.10.SmithAM,HazenSJ.Whatmakeswarsurgerydifferent?MilMed.1991;156:33-35.11.PoriesWJ.Militarysurgery:certificationislongoverdue.MilMed.1995;160:100-103.12.GoodellTP,JonesRJ.Curriculumdesign:operationalmedicine.MilMed.1989;154:36-37.13.TheSocietyofApothecariesofLondon.ExaminationRegulationsandSyllabusRelatingtotheDiplomaintheMedicalCareofCatastrophes.March2004/6.Availableat:http://www.apothecaries.co.uk/index.php?page=26.14.LumleyJSP,RyanJM,BaxterPJ,KirbyN.HandbookoftheMedicalCareofCatastrophes.London:RoyalSocietyofMedicinePress,1996.CertificationinMilitaryMedicine:TheTimeisNow AUTHORSCOLRoyistheDirector,DivisionofMilitaryInternalMedicine,DepartmentofMedicine,UniformedServicesUniversityoftheHealthSciences,Bethesda,Maryland.COLPalmaistheDeputyAssistanttotheSecretaryofDefenseforChemicalandBiologicalDefensePrograms,Washington,DC.COL(Ret)RichistheChairEmeritus,DepartmentofSurgery,UniformedServicesUniversityoftheHealthSciences,Bethesda,Maryland. UNIFORMEDSERVICESUNIVERSITYoftheHealthSciences

PAGE 15

OctoberDecember200613INTRODUCTIONMostdefinitionsofresearcharegeneral.Forexample,DoDDirective3216.2defineshumanresearchasanysystematicinvestigation,includingresearch,development,testing,andevaluation,designedtodeveloporcontributetogeneralizableknowledge.1Researchmaybemedicalornonmedical.Medicalresearchcanbeclinicalornonclinical.Nonclinicalmedicalresearchstudiesincludebench,invitro,animal,andengineeringstudies.Clinicalresearch(orclinicalinvestigation)studiesincludepatient-oriented,epidemiologicandbehavioraloutcomes,andhealthservicesstudies.Patient-orientedstudiesgenerallyincludestudiesofhumandiseasemechanisms,therapeuticinterventions,clinicaltrials,andtechnologydevelopment.Clinicalresearchcanbemoredifficultthanpreclinicalorbasicresearchforthefollowingreasons:Subjectsaremorevariable.Measurementsarelesspreciseandaccurate.Thereislesscontroloverstudyconditions.Ethicalissuesaremorecommonandcomplex.Thereislimitedabilitytodiscerndiseasemechanisms.Studydesignerrorstendtobemorecommon.Studydesignandanalysisrequiregreatervigor.Studyreviewandapprovalbureaucracyismoreburdensome.Overcomingthesechallengestendstomakeclinicalresearchmorerewardingandrelevant.ThefundamentalArmyMedicalDepartment(AMEDD)philosophyhasalwaysincorporated3interrelatedgoals:providequalityhealthcare,traintoprovidehealthcare,andconducthealthcareresearch.Herein,wedescribeArmyclinicalinvestigationwithintheAMEDDClinicalInvestigationProgram(CIP).Wedescribetherationale,history,currentstatus,impact,andstrategicvisionoftheCIP.WeplantopublishfuturearticlesdescribingUSArmyMedicalResearchandMaterielCommand(USAMRMC)clinicalinvestigations,MultinationalCorpsIraqclinicalinvestigations,theUSArmyhumansubjects'protectionprogram,andapracticalguidetoconductingmedicalresearchintheUSArmy.AMEDDCLINICALINVESTIGATIONPROGRAMDoDDirective6000.8clearlydescribesthefundamentalCIPrationale,ie,theCIPisanessentialcomponentofmedicalcareandteachingintendedtoimprovepatientcarequality,supportgraduatemedicaleducation(GME)programs,generateanatmosphereofinquiryresponsivetothedynamicnatureofmedicine,andpromotehighprofessionalstandingandGMEprogramaccreditation.2ArmyRegulation(AR)40-38istheonlyUSArmyCIP-specificregulation.3AR40-38definestheCIPasincorporatingthatmedicalresearchconductedatactiveArmyfixedmedicaltreatmentfacilities(MTFs).AR40-38requiresthataheadquarterslevelofficecoordinateandmonitorCIPactivity,andserveasapointofcontactforrelevantpoliciesandregulations.ThisofficeisnowknownastheClinicalInvestigationRegulatoryOffice(CIRO),anditispartoftheAMEDDCenterandSchool(AMEDDCS)specialstaff.CIROmaintainstheCIPrecordsthatarethesourceofmostoftheCIPdescriptiveinformationcontainedherein.EarlyCIROrecordsareincomplete,butavailabledocumentationindicatesthatadistinctResearchandDevelopmentProgramcommencedatMadiganGeneralHospitalin1963,aResearchandDevelopmentServicewasestablishedatTriplerArmyMedicalCenter(TAMC)in1967,andaClinicalUSArmyClinicalInvestigationCOLJamesM.Lamiell,MC,USACOLKentE.Kester,MC,USACOLCharlesE.McQueen,MC,USALTCJenniferC.Thompson,MC,USACOLLauraR.Brosch,AN,USA

PAGE 16

14ArmyMedicalDepartmentJournalResearchServicewasestablishedatBrookeGeneralHospitalin1971.TheseentitiesweretheforerunnersofthecurrentArmyMedicalCenter(AMC)DepartmentsofClinicalInvestigation(DCIs),andtheircreationroughlycoincideswiththeinitial1971publicationofAR40-38.However,numerousclinicalresearchstudies(eg,MAJWalterReedconductedyellowfeverstudiesin1900andtheMedicalResearchDivisionwasestablishedwithintheChemicalWarfareServicein1922)wereconductedatArmyMTFspriorto1963.TheUSArmyMedicalResearchandDevelopmentCommand(USAMRDC)wasestablishedin1958,andtheinitialversionofAR70-25,thegoverningArmyregulationentitledUseofVolunteersasSubjectsofResearchwaspublishedin1962.4TheHumanUseReviewOffice(HURO)wasestablishedwithinUSAMRDCatFortDetrick,Marylandin1973.In1978,theClinicalInvestigationsProgramDivisionofHUROwastransferredtotheHealthServicesCommandinSanAntonio,Texas.WhentheHealthServicesCommandtransformedintotheUSArmyMedicalCommand,theClinicalInvestigationsProgramDivisionmovedtotheAMEDDCStobecomeCIRO(ClinicalInvestigationRegulatoryOffice).Adatabase(knownastheClinicalInvestigationResearchSystemorCIRS)ofCIPresearchstudycharacteristicsisderivedfromthewrittendescriptionsofCIPstudies(protocols)receivedatCIRO.MostoftheseCIPprotocolsarefromAMCDCIs,includingWalterReedAMC(WRAMC),EisenhowerAMC(EAMC),BrookeAMC(BAMC),WilliamBeaumontAMC(WBAMC),FitzsimmonsAMC,LettermanAMC,MadiganAMC(MAMC),andTAMC.RegularentryofCIPstudyprotocolinformationintoCIRScommencedabout1980.TherearecurrentlyCIRSrecordsforalmost18,700CIPstudies.Figure1showsthenumberofnewandongoingstudies(foreachfiscalyear)recordedinCIRSsinceits1978inception.CIROstoppedreceivingnewstudiesfromLettermanAMCin1992andfromFitzsimmonsAMCin1997.CIRSrecordaccrualisnowrelativelystablewithabout700newstudiesperyearandabout1,700ongoingstudies.WewereinterestedincurrentCIPstudycharacteristics.Therefore,wequeriedCIRSforstudiesactiveon1December2005,andidentified1,764studies.Table1showsthegeneraltypesoftheseactiveCIPstudies.About95%ofthestudiesinvolvehumansand5%involveanimals.Table2showstheclassofsubjectsenrolledintheactiveCIPstudies.About9%ofthestudiesinvolvechildren.PediatricstudiesareuniqueinthatthereshouldbeintenttobenefitallsubjectsinaccordancewithSection980ofTitle10,UnitedStatesCode.USArmyClinicalInvestigation FiscalYear N u m b e r o f S t u d i e s 200520001995199019851980 25002000150010005000 VariableNewOngoingCIPStudies(CIRSDatabase) Figure1.NewandongoingCIPstudies(foreachfiscalyear)recordedinCIRSsinceits1978inception. Table1.TypesofActiveCIPStudiesStudyTypeNumberPercent Morethanminimalrisk1,06060% Minimalrisk59734% Animal955% Exempt121% Total1,764100% Table2.ClassificationofSubjectsofActiveCIPStudiesSubjectClassificationNumberPercent Adult1,47784% Other1297% Adult/Child875% Child714% Total1,764100%

PAGE 17

OctoberDecember200615Table3showsthegenderofsubjectsenrolledintheactiveCIPstudies.About17%ofthestudiesinvolveonlyfemalesubjectswhileabout10%involveonlymalesubjects.Table4showsthesourceofsubjectsenrolledintheactiveCIPstudies.About70%ofthestudiesinvolvepatients.Weobservedthat686ofthe1,764activeCIPstudies(39%)involveatleastonedrug,while81ofthe1,764activeCIPstudies(5%)involveatleastonemedicaldevice.Table5showsanotheractiveCIPstudyclassification.Importantly,about32%ofthesestudiesinvolveoncologyresearchwhereinthereissignificantoverlapbetweenresearchandpatientcare.Theonlywaytoobtainpromisingbutasyetunproventreatmentsforsomemalignanciesisthroughparticipationinclinicalresearch.Ofcourse,theseemergingtherapiesmaybenobetterthanconventionalornotherapyatall(bythenullhypothesis),whichiswhytheyarethesubjectofrigorousscientificexamination.Table6showsthefundingfortheactiveCIPstudies.Atleast53%ofCIPstudyfundingcomesfromsourcesoutsidetheMTFconductingthestudy.CIROwasgrantedcooperativeresearchanddevelopmentagreement(CRADA)approvalauthorityin1994.CRADAsprovideastudy-specificlegalmechanismenablingCIPstafftocollaboratewithnonfederalpartners(eg,pharmaceuticalcompanies)toconductCIPstudies.Since1995,CIROhasnegotiatedandapproved923CRADAspotentiallyworthalmost$88million.Table7showstheactiveCIPstudiessites.The3busiestCIPsitesaccountforabout75%ofactiveCIPstudieswhileoveralltheAMCsaccountfor97%ofthem.Table8showstheprincipal(PI)andassociateinvestigator(AI)statusfortheactiveCIPstudies.About80%ofallCIPstudyinvestigatorsareactivedutymilitarypersonnel,whiletherestareciviliangovernmentemployees. Table3.GenderofSubjectsofActiveCIPStudiesSubjectGenderNumberPercent Both1,13264% Female30217% Male17510% Other1559% Total1,764100% Table5.ClassificationofActiveCIPStudiesStudyClassificationNumberPercent Other1,16566.0% Oncology56031.8% Behavioral/psychosocial341.9% Radioisotope30.2% Alcohol/drug20.1% Total1,764100% Table4.SourceofSubjectsofActiveCIPStudiesSubjectSourceNumberPercent Patient1,24070% Other38422% Healthy/normal1408% Total1,764100% Table6.DistributionofFundingSourcesofActiveCIPStudiesFundingSourceNumberPercent Other64636% NIH45226% CRADA36020% Local18711% USAMRMC684% Grant513% Total1,764100%

PAGE 18

16ArmyMedicalDepartmentJournalTable9showstherespectiveprofessionalcorpsaffiliationsofthemilitaryinvestigatorsfortheactiveCIPstudies.Notethat1,446of1,764PIs(82%)areMedicalCorps(MC)officers.Wefoundthat1,283individualArmyMCofficerswereinvestigators(PIorAI)on1,555ofthe1,764activeCIPstudies,ie,ArmyMCofficersaredirectlyinvolvedwith88%ofactiveCIPstudies.Table10showstheranksofinvestigatorsfor1,725ofthe1,764activeCIPstudies.ThenumberofinvestigatorsperactiveCIPstudyaredepictedinFigure2.Everystudyhasatleastoneinvestigator(PI),andthegreatestnumberofinvestigatorsperactiveCIPstudyis19.Thedistributionisskewed,butthereisanaverageof3.3investigatorsperstudywithastandarddeviationof2.1investigators.Conversely,weexaminedthenumberofactiveCIPstudiesperinvestigator.Figure3displaysthenumberofactiveCIPstudiesperPI.TwelveinvestigatorsareUSArmyClinicalInvestigation Table7.ActiveCIPStudySitesMilitaryTreatmentFacilityNumberPercent WRAMC66537.70% BAMC35620.18% MAMC28716.27% TAMC20811.79% EAMC1166.58% WBAMC482.72% WAMC321.81% WestPoint261.47% FtHood110.62% FtCarson40.23% FtBenning20.11% FtPolk20.11% FtSill20.11% FtIrwin10.06% FtStewart10.06% Heidelberg10.06% LandstuhlRMC10.06% Wurzburg10.06% Total1,764100% Table8.ProfessionalStatusofActiveCIPStudyInvestigatorsStatusPI*AITotalPercentofTotal USA1,5872,9974,58478.03% Civilian1361,0151,15119.59% USN31741051.79% USAF1024340.58% USPHS0110.02% Total1,7644,1115,875100.00% *PrincipalInvestigatorAssociateInvestigator Table9.ProfessionalCorpsAffiliationofMilitaryInvestigatorsinActiveCIPStudiesCorpsPIaAIbTotalPercentofTotal MCc1,4462,7174,16388.1% MSd/MSCe/BSCf471622094.4% ANg/NCh751111863.9% SPi1939581.2% DCj1834521.1% VCk2218400.9% ENl012120.3% Other1340.1% Total1,6283,0964,724100.0% a.PrincipalInvestigatorb.AssociateInvestigatorc.MedicalCorps(Army,Navy,AirForce)d.MedicalServiceCorps(Army)e.MedicalServiceCorps(Navy,AirForce)f.BiomedicalSciencesCorps(AirForce)g.NurseCorps(Army)h.NurseCorps(Navy,AirForce)i.MedicalSpecialistCorps(Army)j.DentalCorps(Army,Navy,AirForce)k.VeterinaryCorps(Army)l.AMEDDEnlistedCorps(Army)

PAGE 19

OctoberDecember200617thePIformorethan18differentCIPstudies,andthegreatestnumberofstudiesperindividualPIis71.Generally,oncologyinvestigatorsarePIsformultiplestudies,manyofwhichareopenonlyforsubjectfollowupandclosedtonewsubjectaccrual,orarequiescentsincetheyconcernveryraremalignancies.Thedistributionisskewed,butthereisanaverageof2.3CIPstudiesperPIwithastandarddeviationof5.4studies.ThenumberofactiveCIPstudiesperAIisshowninFigure4.TwelveinvestigatorsaretheAIformorethan20CIPstudies,andthegreatestnumberofstudiesperindividualAIis67.AsisthecaseforPIs,oncologyinvestigatorsareusuallyAIsformultiplestudies.Thedistributionisskewed,butthereisanaverageof2.2CIPstudiesperAIwithastandarddeviationof3.4studies.Figure5depictsthedurationofcurrentlyactiveCIPstudies.Onestudyhasbeenactiveforalmost27years(theageofCIRS).Generally,oncologytreatmentstudiesarethemostpersistent,closingtoaccrualofnewsubjectswhileremainingopenandactiveforenrolledsubjectfollowup.Thedistributionisskewed,butthereisanaverageof3.7yearsperCIPstudywithastandarddeviationof3.9years.Table11showstheinvolvementof4,221currentlyactiveArmyMCofficerswithCIPstudies.ArosterofactiveMCofficerswasobtainedfromtheMedicalOperationalDataSystems(MODS)on1December2005.TheTable11crosstabulationwasgeneratedbycomparingtheMODS-derivedactiveMCOfficerroster Table10.RankDistributionofActiveCIPStudyInvestigatorsInvestigatorRankPI*AITotalPercentofTotal MAJ/LCDR(O4)4731,1221,59530% LTC/CDR/LtCol(O5)5298331,36226% COL/CAPT(O6)36358995218% CPT/LT/Capt(O3)25552177614% PhD(civilian)602352956% MD(civilian)452492946% Total1,7253,5495,274100% *PrincipalInvestigatorAssociateInvestigator Investigators/Study N u m b e r 19181716151413121110987654321 5004003002001000 Investigators/ActiveCIPStudy Figure2.NumberofinvestigatorsperactiveCIPstudy. Studies/AI N u m b e r 2019181716151413121110987654321 1400120010008006004002000 ActiveCIPStudies/AI Figure4.NumberofactiveCIPstudiesperassociateinvestigator. Studies/PI N u m b e r 181716151413121110987654321 6005004003002001000 ActiveCIPStudies/PI Figure3.NumberofactiveCIPstudiesperprincipalinvestigator.

PAGE 20

18ArmyMedicalDepartmentJournalwithaCIRS-derivedCIPstudyinvestigatorroster.Notethat1,824of4,221(43%)currentlyservingArmyMCofficershavebeenaCIPstudyPIorAIsometimeduringtheiractivedutyservice.Ananalysisbyrankshowsthat413of1,729MCcaptains(24%),642of1,299MCmajors(49%),410of664MClieutenantcolonels(62%),and359of529MCcolonels(68%)havebeenaCIPstudyPIorAIsometimeduringtheiractivedutyservice.ItisdifficulttocompareUSArmymilitaryphysicianstonon-Armyphysicianswithrespecttoclinicalresearchparticipation.Onegroupqueriedgraduatesofthe1985through1995classesofthePennsylvaniaStateCollegeofMedicine.5Questionnaireswesenttoallgraduates(n=1,013),andtherewereresponsesfrom42%(n=428).AmongthePennsylvaniaStaterespondents(ie,physiciansinpracticefor10to20years),34%claimedtobecurrentlyparticipatinginclinicalresearch.ItisunclearhowmanyofthePennStaterespondentswereonactivedutyintheArmy.Nevertheless,thisgroupiscomparabletotheArmycohortofMAJCOL,inwhich1,411of2,492(57%)haveparticipatedinresearch(Table11).Clinicalresearchisanessentialpartofgraduatemedicaleducation(GME).6NoArmyGMEprogramhaseverfailedaccreditationbecauseofinsufficientorinadequateclinicalresearch.TheClinicalInvestigationRegulatoryOfficehastrackedtheannualnumberofpublishedmanuscripts,abstractsandpresentationsgeneratedbytheCIPsince1994.AgraphofthisacademicachievementisshowninFigure6.InFY2004theentireCIPwasfundedwith$11.8millionfromDefenseHealthProgramfunds(asallocatedbyMTFcommanders,includingDCIstaffwages)and$25.5millionfromnon-MTFfunds(including$13millionfromcooperativeresearchanddevelopmentagreements).TheFY2004CIPDCIstaffincluded29officer,28enlisted,and121civilianpersonnel.Intotal,theFY2004CIPwasfundedwith$37.8millionandadedicatedsupportstaffof178people.CONCLUSIONSClinicalInvestigationProgramresearchstudiesareusuallygreaterthanminimalrisk(60%),andtheyusuallyinvolveadultpatients(70%).DrugsarefrequentlyinvolvedinCIPstudies(39%).ThemostcommonclassofCIPstudiesisoncology(32%).Atleast53%ofCIPstudyfundingcomesfromnon-MTFsources.MostCIPresearchisconductedatAMCs(97%).MostCIPprincipalinvestigatorsareMCUSArmyClinicalInvestigation Years N u m b e r 24201612840 5004003002001000 CIPStudyDuration Figure5.DurationofactiveCIPstudies. Table11.DistributionofActiveArmyMCOfficerInvolvementinCIPStudiesPI*AICPTMAJLTCCOLTotal NoNo1,3166572541702,397 YesYes93266204209772 NoYes154206120102582 YesNo1661708648470 Total1,7291,2996645294,221 *PrincipalInvestigatorAssociateInvestigator Year N u m b e r 20042003200220012000199919981997199619951994 1400120010008006004002000 VariablePresentationsManuscriptsAbstractsCIPAcademicPerformance Figure6.Annualnumberofpublishedmanuscripts,abstractsandpresentationsgeneratedbytheCIPsince1994.

PAGE 21

OctoberDecember200619officers(82%),andMCofficersaredirectlyinvolvedin88%ofCIPstudies.AtypicalCIPstudyhas3investigators,andlastsabout2years.TheArmyCIPcontributessignificantlytotheArmymission.TheCIPimprovesSoldierhealthcare,providesDoDbeneficiaryhealthcare,andtrainshealthcareproviders.TheCIPprovidesanimportantcomponentofAMEDDofficerdevelopment.Atleast42%ofallcurrentactiveMCofficershavebeeninvolvedinaCIPstudy.Furthermore,CIPinvolvementiscontinuousforMCofficerssothatatleast24%ofcurrentcaptainshavebeeninvolvedinCIPstudieswhileatleast68%ofMCcolonelshavebeeninvolvedinCIPstudies.Thiscomparesfavorablytoestimatednon-Armyphysicianclinicalinvestigation(CI)involvement.CIexposureisimportantforAMEDDofficerprofessionaleducationbecauseitfostersanddevelopscriticalthinking,attentiontodetail,scholarship,inquisitiveness,skepticism,creativity,andtenacity.AMEDDofficerCIexperiencealsohelpsdevelopskillstobetterperformthesecriticalfunctions:1.Formulatequestions2.Usedatatoanswerquestions3.Accuratelycollectandanalyzedata4.Conciselydescribeastudywithaprotocol5.Organizescarceresourcestoconductstudies6.Presentanddefendstudiestocommittees7.Ethicallydealwithpeople(subjects)outsidetheprovider-patientrelationship8.Presentanddefendstudyresults9.Assessandassimilateothers'researchresultsintomedicalpracticeItiscommonforAMEDDofficerstohavelong-term,fulfilling,andmeaningfulclinicalresearchexperiences.7OurCIPstrategyforthefutureisprimarilydirectedtowardenhancingcollaborationbetweentheCIPandUSAMRMC.Tothisend,weintendtoupdateAR40-38andAR70-25asoneregulation,andwewillexchangeandcross-trainCIPDCIandUSAMRMCstaffasmuchaspossible.REFERENCES 1.DoDDirective3216.2,ProtectionofHumanSubjectsandAdherencetoEthicalStandardsinDoD-SupportedResearch.Washington,DC:USDeptofDefense;March25,2002.2.DoDDirective6000.8,FundingandAdministrationofClinicalInvestigationPrograms.Washington,DC:USDeptofDefense;November3,1999.3.ArmyRegulation40-38,ClinicalInvestigationProgram.Washington,DC:USDeptoftheArmy;September1,1989.4.ArmyRegulation70-25,UseofVolunteersasSubjectsofResearch.Washington,DC:USDeptoftheArmy;January25,1990.5.LloydT,PhillipsBR,AberRC.Factorsthatinfluencedoctors'participationinclinicalresearch.MedEduc.2004;38:848-851.6.LamiellJM.Researchforgraduatemedicaleducation.MilMed.1994;159:698-704.7.LamiellJM.ArmyclinicalinvestigationofvonHippel-Lindaudisease.1977-2000.MilMed.2001;166:839-842.AUTHORS COLLamiellistheChief,ClinicalInvestigationRegulatoryOfficeattheAMEDDCenterandSchool,FortSamHouston,Texas.COLLamiellisalsotheChairmanoftheAMEDDJournalEditorialReviewBoard.COLKester,COLMcQueen,andLTCThompsonareassignedtotheWalterReedArmyInstituteofResearch,USArmyMedicalResearchandMaterielCommand,SilverSpring,Maryland.COLBroschisassignedtotheOfficeofResearchProtections,USArmyMedicalResearchandMaterielCommand,FortDetrick,Maryland.

PAGE 22

20ArmyMedicalDepartmentJournalINTRODUCTIONOperationIraqiFreedomhasresultedinaparadigmshiftawayfromtheconceptoftraditionalwarandpeacekeepingoperationstothatofcombatingterrorismdirectlyandurbanwarfare.TheUSArmyistransformingitselfintoaFutureForcecapableofrapidlyprojectingscalableandmodularcombinedarmsformations,tailoredinforcecapabilitypackagestomeettherequirementsofdiversecontingencies.1TheArmyMedicalDepartment(AMEDD)isalsoundergoingtransformationbyredesigningtheaterhospitalassetsintomodularmedicalelementscapableof24-houroperationswithreducedadministrativeoverhead,asmallerfootprintintheareaofoperations,andgreatermobilitytoperformspecificbattlefieldfunctionsasrequiredbythemission.1InlightofthefutureAMEDDtransformation,carefuldeliberationmustbegiventoexpandingtheprimarycareroleofthedeployedadvancedpracticenurse(APN).Theadvancededucationaltraining,clinicalexpertise,andabilitytoofferprimaryhealthcaremaketheAPNaninvaluableresourcetodeployedmilitaryhealthcareteams.2Thenursepractitioner(NP),anAPN,iseducatedtomakeindependentdecisionsandsynthesizetheoretical,scientific,andcontemporaryclinicalknowledgeforhealthpromotionandtheassessment,management,anddiagnosesofillnessandhealthstates.2-4Amastersdegreeisrequiredforentrylevelpractice.TheprofessionalroleofanNPisprimarycareproviderwhopracticesinambulatory,acuteandlong-termcaresettings.4,5Nursepractitionersareabletoorderandinterpretdiagnosticandlaboratorytests,aswellasprescribepharmaceuticals.TheAmericanNursesAssociationsupportstheroleofNPsasadvocatesofhealthpromotionanddiseasepreventionwithanestablishedrecordofprovidingexcellentprimarycareindiversesettings.6ItistheabilityofNPstoprovideprimarycaretoadiversepopulationthatenablesthemtoworkinavarietyofpracticesettings.Onesuchpracticesettingisthemilitaryhealthcaresystem.ArmyRegulation(AR)40-68authorizesNPstoprovidemedicalhealthcarefordiversepopulationsinprimary,acute,andlong-termhealthcaresettings.5TheroleoftheNPasaprimarycareproviderinpeacetimehealthcarehasbeenwellestablished,however,theroleoftheNPinwartimemedicalcarehasyettobedefined.NotablyabsentfromAR40-68isanymentionofNPsasprimarycareprovidersindeployedsettings.Therolesandexperiencesof5NPsdeployedtoOIFarepresentedbelowtoprovideabetterunderstandingofthecontributionsNPscanmakeinprovidingprimarycareinanausterewartimeenvironment. ExpandingtheRoleoftheNursePractitionerintheDeployedSettingMAJ(P)EdwardE.Yackel,AN,USAMAJJulieDargis,AN,USALTC(Ret)TheresaHorne,AN,USALTCSophiaTillman-Ortiz,AN,USALTCDianeScherr,AN,USAABSTRACTTodaysmilitaryisexperiencingrapidadvancesintechnologyandmanpowerutilization.TheArmyMedicalDepartmentisredesigningthestructureandfunctionofdeployablehospitalsystemsaspartofthiseffort.AcriticalanalysisofmanpowerusenecessitatesthatanexaminationoftherolefunctionofassignedpersonnelbeundertakentooptimizetheemploymentofeachSoldier-medic.ThisarticlediscussestheuseofNursePractitionersasprimarycareprovidersduringdeployment.Therealworldexperiencesof5NursePractitionersdeployedtoOperationIraqiFreedomarepresented.Datagatheredduringthedeploymentandananalysisoftheliteratureclearlysupporttherationaleforexpandedandlegitimizedrolesforthesehealthcareprofessionalsinfutureconflictsandpeacekeepingoperations. ThisarticleisreprintedfromMilitaryMedicine:InternationalJournalofAMSUS(2006;171(8):770-773)withpermissionofthepublisher.

PAGE 23

OctoberDecember200621NURSEPRACTITIONERROLES&EXPERIENCESAlltheauthorsofthisarticledeployedtoOperationIraqiFreedom(OIF)withthe28thCombatSupportHospital(CSH),a296-bedcorpslevelfacilitystaffedbyaninterdisciplinaryhealthcareteamof500militaryhealthcareprofessionals.The28thCSHhadthecapabilitytoprovideLevelIIIcombatcareandofferedthefollowingservices:Emergency/traumaOperatingandrecoveryroomIntensivecarenursingMedical/surgicalnursingPhysicaltherapyOutpatient/sickcallRadiologyLaboratoryPharmacyMedicalmaintenanceCombatstresscareChaplainPatientadministrationNursepractitionersaretraditionallyassignedtoworkasmedical/surgicalnursesinaCSH,however,thechangingoperationalrequirementsofOIFnecessitatedtheuseoftheseprimarycarespecialistsinavarietyofpositions.ChangingoperationalrequirementsandphaseofdeploymentwereprimarydeterminatesofroleassignmentforNPs.Thewarningordertodeploythe28thCSHwasissuedinFebruary2003.Thepredeploymentphaseofoperationsreadiedpersonnelphysicallyandmilitarilyfortheimpendingmission.Anursepractitioner,assignedastheprimarycareproviderforthe28thCSH,servedasthecommandersadvisoronmedicalissuesandwasresponsibleforthephysicalreadinessofallpersonnelassignedtotheunit.TheNPpreparedpersonnelfordeploymentbyreviewingmedicalrecordsandfacilitatedmedicalcareforindividualswithoutstandingmedicalproblemsbycoordinatinghealthcarewiththelocalmilitarymedicaltreatmentfacility.TheNPalsoservedastheimmunizationcoordinatoraftercompletinganonlinedidacticmoduleandareal-time,hands-on,certificationprogramsupervisedbyanimmunologist.Asadirectresultofhavinganimmunizationcoordinatoravailablewithintheorganization,over50028thCSHSoldierswerescreenedfortheimmunizationsnecessarytoprotectthemagainstbiologicalwarfareagents.Furthermore,theabilitytofieldanimmunizationcoordinatorenhancedtheflexibilityofthe28thCSHinacceptingsimilarmissionsinthedeploymentphaseofoperations.The28thCSHarrivedatCampDoha,KuwaitinincrementsintheperiodMarch810,andwasbilletedinwarehouseswhileawaitingmissionorders.Ataskingfromhighermedicalheadquartersdirectedthatthe28thCSHsendmobileimmunizationtreatmentteams(MITT)tostagingareasontheIraqibordertoinoculatetroopsagainstsmallpoxandanthrax.TheNP,asimmunizationcoordinator,assembledandeducated4MITTscomprisedofphysicians,nurses,andmedicswhichinoculatedover2,000troops.Theimmunizationmissioncontinuedasthe28thCSHmovedtoitsstagingareaatCampVictory,KuwaitonMarch24andassumedanoutpatienttroopmedicalclinicmission.CampVictorywasaholdingcampfortroopsawaitingordersformovementintoIraq.Atthetimethe28thCSHarrived,CampVictorywasinastateofbriskconstruction.Medicalsupportwasexceedinglylimited,consistingofanambulancesquadwith4medicsand2fieldambulances.Themedicsprovidedtriageandtreatmentforminorillnessesoutoftheirsleepingtent.Patientswithacute/urgentmedicalneedsweretransportedtoanearbyAirForcehospitalforadvancedcare.Itsoonbecameapparentthattherapidinfluxoftroopscreatedtheneedforthedefinitive,on-sitemedicalcarethatcouldbeablyprovidedbythehealthcareprofessionalsofthe28thCSH,alongwiththenewlyarrived21stCSH.The21stCSH,withafullmedicalcomplement,wasalsoawaitingmovementordersintoIraq.TwoseniorNPsassignedtothe28thCSHwereselectedtoorganize,equip,andstaffanoutpatienttroopmedicalclinic(TMC)asOfficer-in-Charge(OIC)andAssistantOIC.TheNPsobtainedpermissiontoestablishaninterimTMCthroughclosecoordinationwiththeleadershipofCampVictory,the28thCSH,andthe21stCSH.An8-sectiontentwithlightsandairconditioningwasrapidlyassembled.Itcontainedawaitingarea,screeningsection(withapharmaceuticaldistributionpoint),andtreatmentareawith6cots/beds.TheTMCwasopen7daysaweek,24hoursaday,withsickcalleachmorningandanimmunizationperiodeachafternoon.TheOICand

PAGE 24

22ArmyMedicalDepartmentJournalAssistantOICmadestaffingdecisionsfortheTMCwithresponsibilityforcoordinatingtheworkschedulesofphysicians(familypractice,internalmedicine,andgeneralsurgery),NPs,registerednurses(RN),medics,aphysicaltherapist,psychiatricnurse,pharmacist,andadministrativepersonnel.Qualifiedstaffmemberswereabletosuturelacerations,drainsimpleinfections,dresswounds,tapeanklesprains,provideintravenousrehydration,anddiagnosesimpleacuteproblemssuchasupperrespiratoryinfections,gastroenteritis,andconjunctivitis.The8NPswhodeployedwiththe28thCSHwereanintegralpartofthehealthcareteamthatprovidedexcellentprimarycareservicesattheCampVictoryTMC.Tables1and2illustratethevarietyofpatientcareandworkloaddatadocumentedduringa9-dayperiodattheTMC.Notethatmanyofthediagnoses/illnesseslistedinTable2arecommoninbothpeacetimeandwartimeprimaryhealthcaresettings.TheabilityofNPstotreatthesecommonillnessesinpeacetimereinforcesthecontinuedemploymentofNPsasprimarycareprovidersduringdeployment.ThetwoNPswholedtheCampVictoryTMCwereexperiencedprofessionalswhodemonstratedtheirexpertabilitiesandexperienceasprimarycareprovidersandleadersinthatsuccessfuleffort.TheNPsnotonlysupervisedclinicoperations,butalsotreatedpatientsdaily,coordinatedwithhighercommandandthemedicalregulatingofficeronevacuationissues,andprocuredmedicalandadministrativesuppliesfortheTMC.AdvancedknowledgeofpathophysiologyandpharmacologyenabledtheNPstoteachcriticalthinkingskillsandasystemsapproachtoassessment,management,anddiagnosisofcommonillnessestomedicsandRNsworkingintheprimarycaresetting.ThesuccessoftheCampVictoryTMCisatellingexampleofthebenefitsinherentinhavingexperienced,seniorNPsinthedeployedenvironment.FlexibilityinacceptingroleassignmentsenabledalltheNPsinthe28thCSHtomakevaluablecontributionsineachphaseofoperations.Forexample,theNPassignedastheimmunizationExpandingtheRoleoftheNursePractitionerintheDeployedSettingTable2.PatientDataattheCampVictoryTroopMedicalClinic3-12April200330-DayTotal TotalNumberofPatientsSeeninClinic5201,560 Anthraximmunizations132396 Smallpoximmunizations40120 Prescriptionsfilledinclinic206618 Prescriptionssentoutfornextdaypick-up142426 Note:30-daytotalisestimated. Table1.DistributionofDiagnosesofPatientsattheCampVictoryTroopMedicalClinicDiagnosis3-12April200330-DayTotal Psychiatric(allreasons)824 Dermatologic54162 GI,infectious60180 Gynecologic2472 Heat/cold2575 Injury,rec/sports26 Injury,MVA13 Injury,work/training43129 Injury,other26 Ophthalmologic44132 Respiratory111333 STDs26 Fever(unexplained)00 Allothermedical/surgical182546 Dental*1751 Misc/admin/followup59177 Viralillnesses1030 Chem-biocasualties00 Medicalevacuations824 Total6521,956 *DentalpatientsweresenttothelocalDentalClinicatAuAlSalemPrimarilyotherorthopedicdiagnosesandspecialprescriptionrefillsAirandGroundEvacuationNote:30-daytotalisestimated.

PAGE 25

OctoberDecember200623coordinatorinthepredeploymentphaseofoperationswasreassignedasaprimarycareprovideratCampVictory.UpondeploymentintoIraq,thisNPwasthenemployedasanevening/nightsupervisorandworkedintheemergencymedicaltreatmentsectionofthehospitalprovidingprimarycare.Themovementofthe28thCSHfromCampVictoryintoIraqrequiredrolereassignmentsoftheNPsbecauseoperationalordersdirectedthe28thCSHtoreconfigurefroma296-bedCSHinto2separateautonomousandfunctionalhospitalunits.Thefirstincrementofthe28thCSHenteredIraqasa42-bedpackagedesignatedastheRapidMobileSurgicalHospital(RMS).ThemissionoftheRMSwastoprovideemergency,surgical,andintensivecareserviceswhereverandwhenevermissionrequirementsdictated.The28thRMSdeployedintoIraqonMarch29,2003,travelingthroughthewar-torncountrytoarriveattheirfinaldestinationofForwardLogisticsBaseDogwoodonApril6,2003.TwoNPsdeployedforwardwiththeRMS.OneoftheNPshadextensiveexperienceasacriticalcarenurseanddemonstratedleadershipability.Therefore,shewasselectedastheheadnurseofabusyintensivecareunit(ICU)thatcaredforwoundedUSSoldiers,coalitionpersonnel,Iraqicivilians(includingwomenandchildren),andenemyprisonersofwar.AsecondNP,whohadexperienceinemergencynursing,workedintheemergencymedicaltreatmentarea,providingacuteandprimarycarenotonlyasaclinicalstaffnurse,butalsoasanNP.TheadvantageofassigninganNPasanICUheadnursewastheabilityofthisprimarycareprovidertocollaboratebetweennursingandphysicianstaffwithregardtopatientadmission,discharge,clinicalcare,andevacuationissues.Inthissituation,theNPassistedphysiciansinwritingadmissionanddischargeordersduringrapidinfluxesofcasualties.AnadditionalbenefitofemployinganNPintheICUenvironmentwasthepresenceofahealthcareproviderwhocancommunicateadvancedclinicalknowledgeandskillstoothers.TheNPwastheleadeducatorforICUnursesandmedicsandtaughtcriticaltopicssuchasAdvancedPhysicalAssessmentandCareofthePediatricPatient.TheopportunitytolearnadvancedassessmentskillswasexceptionallyimportantfortherelativelyinexperiencedICUstaffthatcaredforalargenumberofcriticallyinjuredpatientswithavarietyofinjuries,includingblastinjuries,gunshotwounds,burns,fractures,blunttrauma,andpsychiatricillness.TheversatileclinicalskillsandleadershippossessedbytheNPweretremendousassetstoamedicalteamthatwaschallengedtoidentifyandovercomebarrierstopatientcareinthemidstofwar.AdvancededucationandthecriticalthinkingskillsofaprimarycareprovidermakeNPsavaluableresourcethatcanbeemployedinavarietyofpracticesettings.Forexample,anNPfromthe28thCSHwasdirectedtoexchangepositionswithapediatricianassignedtothe549thAreaSupportMedicalCompany(ASMC).TheASMChadaneedforaprimarycareproviderandthe28CSHneededaspecialisttocareforcriticallyillandinjuredIraqichildren.TacitrecognitionoftheNPsabilitytoprovideprimarycareresultedinanequalexchangeofqualifiedpersonneltoaccomplishbothorganizationsmissions.TheNPquicklybecameanintegralmemberofthe549thASMCprimarycareteam.TheASMCwasresponsibleforprovidingbasicfieldmedicalcare(outpatientservices)andreliedonthe28thCSHforspecialtycare.LimiteddiagnosticequipmentdictatedthatASMCcliniciansuseastutephysicalexamandassessmentskillstoarriveatdiagnosesandtreatmentoptionstoreturnSoldierstodutyasquicklyaspossible.Anoutbreakofgastroenteritisintheearlysummermonthsof2003resultedinover100patientsbeingtreatedatthe549thASMCeveryday.Itwasestimatedthat85%ofpatientstreatedforgastroenteritiswerereturnedtodutywithin48hoursofpresentingsymptoms.ExpertprimarycareknowledgeandassessmentskillsequippedtheNPassignedtothe549ASMCwiththeexpertisenecessarytodiagnoseandtreatpatientswithgastroenteritisandotherillnesses.InJune2003,the28thCSHwastaskedtodeploya32-bedsurgicalhospitaltoTikritinsupportthe4thInfantryDivision.Nursepractitionerswereonceagaintaskedtoleadtheprimarycaremissionfortheorganization.ThenewlyestablishedhospitalinTikritventuredintounfamiliarterritorywhenitcreatedanacutecareclinictomeetanexpandedmissionofprovidingprimarycaresickcallforactivedutytroops.Theacutecareclinicwassituatedadjacenttotheemergencymedicaltreatment(EMT)sectionandcontainedorthopedic,physicaltherapy,andcomprehensivemedical/surgicalsickcallcapabilities.

PAGE 26

24ArmyMedicalDepartmentJournalTwoseniorNPswereassignedastheprimarycareprovidersfortheclinic.OneNPservedintheadditionalcapacityasOIC.Theacutecareclinicservedasthegatewayintothehospitalsystemforpatientswithnonemergencyillnessesandinjuries.Redirectinganestimated800patientsamonththroughtheacutecarecliniccreatedtheflexibilityneededwithinthehospitaltoconcentrateontrulyemergencycasesintheEMT.TheemploymentofNPsasprimarycareprovidershadameasurableeffectontheorganizationsabilitytoprovideexpandedmedicalservices.DISCUSSIONMilitarytacticalandtechnicalpreparednesswereessentialelementsinassistingNPstotransitionfromthepredeploymentphaseofoperationstothedeployedenvironment.Soldiersofthe28thCSHwererequiredtoqualifywiththeirassignedweapons,practicewearingtheprotective(gas)maskandchemicalprotectiveovergarments,andperformself-decontaminationprocedures.ParticipationinhospitalequipmentandtentassemblytrainingandorientationtostandardoperatingproceduresassistedSoldiersinbecomingtechnicallyproficientintheirassignedroles.Clinicalpreparednesswasanotherimportantelementinthedeploymentprocess.NPslistedAdvancedCardiacLifeSupport,AdvancedTraumaLifeSupport,andtheFieldMedicalChemicalBiologicalCoursesasimportantadjunctstobuildingaknowledgebaseessentialtodeployment.ThesimulatedwarenvironmentcreatedattheJointReadinessTrainingCenter(JRTC),FortPolk,Louisiana,presentedanopportunityfortwooftheNPstointegratetheirclinical,tactical,andtechnicalskills.TheNPsconsideredtheirJRTCexperienceasapivotaltrainingeventinpreparationtogotowar.TheroleoftheNPasaprimarycareproviderhasbeenwellestablishedintheliterature,4,6however,ArmyRegulation40-68doesnotaddresstheroleoftheNPinadeployedcombatsetting.5Itshouldbenotedthatcombatmedicalunitshavepositionsdesignatedforadvancedpracticenurses(APN)workingintheoperatingroom,butnotforAPNsworkinginprimarycare.ThefailureofregulationanddoctrinetodefinethewartimeroleoftheprimarycareNPdirectlyinfluencesroleassignmentsinthecombatmedicalunit.Nursepractitionersdeployasmedical/surgicalRNsandareoftenassignedasastaffnurse,nurseadministrator,orheadnurse,dependingontheneedswithintheorganization.Incomparingdoctrineandthefreshlyexperiencedrealitiesofwar,severalquestionsregardingtheuseofNPsinatraditionalRNrolearerelevant:DotheprimarycareskillsofNPsdegradeovertimeduringextendeddeployments?Ifdatashowthatskillsdodegradeovertime,whatimpactdoesthishavewhenNPsresumetheirpeacetimeprimarycaremission?AreNPsabletotransitionfromaprimarycareroletotheRNroleinaseamlessmanner,orisreeducationneeded?SevenoftheNPsassignedtothe28thCSHweretaskedasprimarycareprovidersinatleastonephaseofthedeployment.SlottingNPsinaprimarycareproviderrolerequiredsubtleshiftsinstaffingtoaccommodaterolereassignments.PerhapsfewerstaffingshiftswouldhavebeennecessaryhadseveralNPslotsbeendesignatedontheunitsstaffingmatrixpriortodeployment.AcarefulanalysismustbeconductedtoreevaluatetherequirementsofNPsonthebattlefield,thestaffingplanfordeployablehospitals,andtherequisitenumberofprimarycareslotsforNPsindeployedmedicalorganizations.Whenanalyzingfuturestaffingplansfordeployablemedicalorganizations,itisimportanttoconsidertheinterchangeablenatureofthephysicianassistant(PA)andNProlesinpeaceandwar.BothPAsandNPsareintermediateormidlevelcareproviders.ThedifferentiationbetweenthetwogroupsisthatPAsaretypicallyassignedtounitslocatednearthefrontlinesofbattle,whereasNPsaretypicallyplacedinrear-echelonmedicalunitssuchasaCSH.7TheunprecedentedtransformationoftheArmyintoaFutureForcenecessitatesareexaminationofpreviouslyassignedrolesforNPsinpeacetimeandwartimeforvalidityandapplicabilityintodaysworld.ArmyRegulation601-280envisionstheFutureForceasanorganizationthatisflexible,proactive,andresponsive,withmanagementandsupportprocessestotakecareoftheSoldier.8RecentacademicinitiativesattheUniformedServicesUniversityoftheHealthSciencesaretransformingtheFutureForcevisionintoareality.Thegraduatenursingfacultyhasdevelopedacomprehensiveprogramofpracticumsandspecialtyrotationsinsuturing,orthopedics,podiatry,ExpandingtheRoleoftheNursePractitionerintheDeployedSetting

PAGE 27

OctoberDecember200625dermatology,emergencyandburncarewhichprovidesNPstudentswiththeadditionalskillsetsnecessaryforemploymentasmidlevelprovidersindeployablemedicalorganizations.TheproactiveandresponsiveadditionofskillsetstotheNPprogramhasgiventheArmyMedicalDepartmenttheflexibilitytoconsidersubstitutingNPsforPAsinfuturedeployments.Workingtogether,NPsandPAshavearareopportunitytoshapethefutureofmedicalcarefordeployedSoldiers.Validationoftheinterchangeablenature/rolesofPAsandNPsmustbeanalyzedintermsofclinicaloutcomecriteriaandwarrantsfurtherstudy.TheversatilityoftheNPsassignedtothe28thCSHwasclearlydemonstratedbytheirabilitytofunctioninsuchcriticalrolesasheadnurse,primarycareprovider,OIC,andevening/nightsupervisor.Nursepractitionersselectedclinicalacumenandexperiencelevelasimportantpredictorsoftheirabilitytoperformthesecriticalroles.Thereal-worldexperienceandprovenperformanceofdeployednursepractitionersaretruetothehistoricreputationofArmynurses:ALWAYSABLETOGETTHEMISSIONDONEACKNOWLEDGMENT TheauthorsthankLindaYoderRN,PhD,AOCN(AN,USA(Ret))forhervaluableassistanceinthepreparationofthisarticle.REFERENCES 1.ArmyConceptBranch,ConceptDevelopmentDivision,Concepts&ExperimentationDirectorate,TRADOCFuturesCenter.ArmyConceptSummaries;2004.2.DavisU,ScherrD,ParsonsT.Meetingwomensneedsduringdeployments:AcasefortheincreaseduseofAPN.USArmyMedDeptJ.July-August1997;PB8-97-7/8.3.MezeyMD,MCGivernDO.Nurses,nursepractitioners:Evolutiontoadvancedpractice.3ed.Philadelphia,PA:W.B.Saunders;1998.4.AmericanAcademyofNursePractitioners.Nursepractitionersasanadvancedpracticenurserolepositionstatement;2002.Availableat:www.aanp.org. 5.ArmyRegulation40-68.MedicalServices:ClinicalQualityManagement.Washington,DC:USDeptoftheArmy;February2004;26-30.6.AmericanNursesAssociation.AdvancedPracticeNursing:Anewageinhealthcare.NursingFacts.1995;ItemPR-li.Availableat:www.nursingworld.org.7.Knopper,M.Forclinicianswhopracticeinuniform:Aretraditionalroleschanging?.ClinicianNews.2004;8:No.2:18-19.8.ArmyRegulation601-280.PersonnelProcurement:ArmyRetentionProgram.Washington,DC:USDeptoftheArmy;31March1999;1-137.AUTHORS MAJ(P)YackelistheOfficerinChargeoftheTroopMedicalClinicandAviationMedicineattheTriplerArmyMedicalCenter,Hawaii.MAJDargisisaFamilyNursePractitionerintheDepartmentofPrimaryCareatRobinsonFamilyMedicineClinic,FortCarson,Colorado.LTC(Ret)HorneisDirectorofNursing,MaternalChildHealth,LakelandRegionalMedicalCenter,Lakeland,Florida.LTCTillman-OrtizistheOfficerinCharge,BennettHealthClinic,FortHood,Texas.LTCScherrisChiefofHospitalServices/AssistantChiefNurseatKellerArmyCommunityHospital,WestPoint,NewYork.

PAGE 28

26ArmyMedicalDepartmentJournalForwardDeployedNeurologists?ButThat'sWhereTheTroopsAre!LTCRomanBilynsky,MC,USATheroleoftheneurologistinthedeployedmilitaryforcehastypicallybeenlimited.ACombatSupportHospital(CSH)deployedtoatheaterisoftenaugmentedwithaNeuroDetachment.Thisconsistsoftwoneurosurgeonsandaneurologisttoprovideforwardneurosurgicalcare.Theneurologistfunctionstosupportbothpre-andpostoperativeneurosurgicalpatientsifneededandtoprovideprimaryneurologicalconsultation.Idonotproposeanychangestothecurrentconfigurationorutilizationofthisunit.Itisimportanttonotethatallcombatsupporthospitalsdonothavesuchaugmentation.InIraq,thedetachmentiscollocatedwithaCSHelementinBaghdad.Duetohostileconditionsanddistancesinvolved,theactualeffectivesphereofroutineconsultativereferralisrestricted.Neurologistscanprovideimportantconsultativeservicesforthedeployedforce.Theirexpertiseisevaluationand/ortreatmentofSoldierspresentingwithheadaches,migraines,concussions,seizures,syncope,epilepsy,nonsurgicalneckorbackpain,chronicpainsyndromes,andvagueneuropsychiatriccomplaints.SuchexpertiseclosertothelinewouldminimizetherisksoftransportingSoldierstodistantconsultantswithinoroutsidethetheater.ItwouldprioritizeSoldierswithmedicalconditionswhoneedadditionalneurophysiologicaland/orneuroimagingevaluations.Iflocalnationalfacilitiesareavailable,theneurologist'sexpertiseininterpretingneuroimageryofmagneticresonanceimagingorCTcomputerizedtomographyscansofthebrainandspinalcordcanbeeffectivelyutilized.Thiswoulddrasticallyreducetheneedforpatientevacuationforroutineorrule-outstudies.Mostimportantly,locationofneurologistsincloserproximitytocombatunitsobviouslysupportstheArmysoverallgoalofmaintainingcriticalcombatandmanpowerresourcesasfarforwardaspossible.Neurologistscanalsobeinvaluableforconsultationwhenrenderinghumanitarianaid.Basedonmydeploymentexperiencewiththe4thInfantryDivisioninTikrit,Ideterminedthatthereisaclearneedforspecialtyneurologicalconsultationfarbelowtheaterlevel.Isubmitthefollowingimplementationoptionsforconsideration:DivisionLevel.Therehasbeenanemphasisonforwardmentalhealthoverthelast10yearsthathasresultedintheformationofCombatStressControlteamsandprovisionforapsychiatristatdivisionlevelforconsultativeservices.AsimilaremphasisonprovidingforwardneurologicalcarecouldbeinitiatedrelativelysimplybyassigninganeurologisttofilloneoftheProfessionalFillerSystem(PROFIS)slotsattheleveltwomainsupportbattalionordivisionalaidstation.Thiswouldenabletheneurologistinthedivisionsupportarea,visitedbysupportedunitsforlogisticalandotherpurposes,toprovideneurologicalconsultationservicesinaconvenientlocation.BrigadeLevel.TheneurologistcandeployasaPROFISphysicianproviderattheleveltwoforwardsupportbattalionaidstation.Thisisaconvenientlocationbecauselogisticalelementsfromsupportedunitsinthebrigaderegularlytraveltothebrigadesupportareaforsuppliesenablingconvenientaccessforconsultationpurposes.Thedeterminingfactorastowhetherall3or4brigadesorjust1or2brigadesinadivisionneedanassignedneurologistwouldbetheoveralldispositionofthesupportedandadjoiningunits.Thebrigadelocatednearthedivisionsupportareawouldprobablybethebestlocationforasingleprovider.Myexperienceasaneurologistduringdeploymentisbasedonthismodelofstaffing.BattalionLevel.NeurologistscandeployastheprimaryPROFISphysicianprovidinggeneralmedicalofficerlevelonecareatthebattalion(infantry,armor,etc)andconcurrentlybeavailableforneurologicalconsultation.Thistypeofproviderpositioningwouldbeoptimalonlyifcollocatedwithotherunitsorifitisalongamainsupplyroute.Consultationisonlyfeasibleifpatientshaverelativelyeasyaccesstotheconsultant.Iftheproviderislocatedatanontransitpoint,transportationofthepatienttothepointofcarewillobviouslybecostlyintermsofman-hoursandvehicles.

PAGE 29

OctoberDecember200627CORRECTION IntheJulySeptember2006issueoftheAMEDDJournal,CPTDavidAdmire,theauthorofthearticleThumbOppositionRestoration:ACaseStudy,wasincorrectlyidentifiedasaPhysicalTherapist.HeisanOccupationalTherapist.TheJournalregretstheerror. ThecurrenttrendinoperationaldeploymentsandfuturerequirementsofthelargenumbertroopsinIraq(andAfghanistan)makesacompellingargumentformovingneurologicalspecialtycareforward.Manpowershortagesandrequirementstoprovidepersonnelforguardduty,details,convoyduty,andprovisionforrestandrelaxationandmid-tourleavemakethisanecessity.Substitutionofaneurologistforanotherphysicianprovidinglevelonecaredoesnotchangeoveralldeployedmedicalpersonnelstrengthanddoesnotnecessitatechangesintablesoforganization.IraqandAfghanistanarecombattheatersofoperationwithinwhichdeploymentalongtraditionalcombatfrontlinesisnotfeasible.Theyrepresentthenew,modernbattlefield.Travelbetweenforwardoperatingbasesishazardousbecauseofexposuretoattacksfromsmallarmsand/orimprovisedexplosivedevices.Transportationofapatienttoonelocationinalargetheaterofoperationsinvolvesonetoseveralconvoys,helicopters,and/oraircraft.Consequently,routineprioritypatientsandaccompanyingpersonnelareunnecessarilyexposedtoincreasedrisk.LocatingneurologistsatkeytransitpointswouldbeamajorstepinthereductionofthissafetyriskandanadditionalfactorintheArmysgoaltomaximizecareforallofourSoldiers.Forwarddeploymentofneurologistsisforwardthinkingforthedynamic,fluidbattlefieldofthefuture.AUTHOR LTCBilynskyiscurrentlyassignedtothePattersonArmyMedicalClinic,FortMonmouth,NewJersey.

PAGE 30

28ArmyMedicalDepartmentJournalTheaterimmersionisnotanewconceptfortheArmy.FordecadestheArmysCombatTrainingCentershaveemployedthepracticeofplacingleaders,Soldiers,andunitsintoanenvironmentanalogoustowhattheywillencounterincombat.*Thecriticaltenetoftheaterimmersionisthedeliberate,constant,andpracticalstudyofthecontemporaryoperatingenvironment.SuccessfullyreplicatingthecontemporaryoperatingenvironmentrequiresatrainingenvironmentthatisflexibleandadaptabletothecurrentconditionsintowhichourArmysforceswilldeploy.From21Marchto30May2005theSoldiersandleadersofthe344thCombatSupportHospital(TaskForce344Med)trainedinsuchanenvironmentatFortMcCoy,Wisconsin.TheabilityofthetrainingteamatFortMcCoytoreplicatetheoperatingenvironmentintowhichTaskForce344woulddeploywasthecriticalelementinthesuccessfulpreparationforitscomplexmissioninIraq.Withoutquestion,theimmersionofTaskForce344Medinatough,realistic,anddemandingtrainingenvironmentprepareditsSoldierstoexecuteitsmissionessentialtaskstoarigorousstandard.Thistrainingenvironmentalsopreparedthemmentallyforthetoughchallengesthattheywouldfaceduringtheirone-yearmission.ThecombinationofmentaltoughnessandsuperbtaskexecutioncreatedinalltaskforceSoldiersasenseofconfidencethattheydidnothavewhentheyarrivedatFortMcCoyinlateMarch.Thisself-confidencewillgreatlyhelptheSoldiersofTaskForce344Medastheyconductadifficultanddemandingmission,namely,theprovisionofworldclasshealthcaretodetaineesattheAbuGhraibandCampBuccadetentionfacilities.STUDYINGTHEMISSIONENVIRONMENTInlateFebruary2005,theFirstUSArmyandtheUSArmyReserveCommandnotifiedleadersofthe2ndBrigade,85thDivision(TrainingSupport)andtheRegionalTrainingSiteMedical(RTS-Med),FortMcCoy,thatapproximately300Soldiersofthe344thCombatSupportHospitalwouldmobilizeandtrainatFortMcCoy.TheSoldiersofTaskForce344MedwereduetoarriveatFortMcCoyon21MarchandwerescheduledforanearlyJunedeploymenttoIraq.The2ndBrigadeandRTS-MedplanningteamimmediatelyinitiatedastudyoftheTaskForce344missionandtheenvironmentwithinwhichitwouldprovidedetaineehealthcare.Membersof2ndBrigadesuccessfullyestablishedcontactwithkeyleadersandstaffofTaskForce115Med,thehospitalunitfromFortPolk,Louisiana,thatwaspresentlyprovidingdetaineehealthcareatAbuGhraibprisonandtheCampBuccadetentionfacility.2ndBrigadeplannersalsoestablishedcontactwithmembersofTaskForce115MedwhohadrecentlyredeployedtoFortPolk.MissioncriticalinformationsoonbegantoflowintotheFortMcCoytrainingteam(2ndBrigadeandRTS-Med)thatwouldlaythegroundworkforthereplicationofthemissionenvironmentinWisconsin.TheMcCoytrainingteambegantoenvisionandunderstandtheTaskForce344MedtrainingenvironmentthattheteammustestablishatFortTheaterImmersion:TrainingaMedicalTaskForceforOperationsinIraqCOLJamesB.Henderson,USA *LTGRussellLHonoreandCOLDanielLZajac.TheaterImmersion:Post-mobilizationTrainingintheFirstArmy.FirstUSArmyPamphlet;2005.ThepurposeofTheaterImmersionistorapidlybuildcombatreadyformationsledbycompetentandconfidentleaderswhoseefirst,understandfirst,andactfirst,andaremannedbybattleproofedSoldiersinculcatedwiththeWarriorEthos.*

PAGE 31

OctoberDecember200629McCoy.The2ndBrigadeS2servedastheconduitforinformationbetweentheMcCoytrainingteam,TaskForce115Med,and44thMedicalCommand(theforwarddeployedcommandforTaskForce115Med).TaskForce115Medprovided2ndBrigadewithupdatedstandardoperatingproceduresforhospitalanddetaineehealthcareoperations,itsforceprotectionmissions,anditsreportformatsandsubmissionrequirements.MembersoftheTaskForce115staffanswereddozensofrequestsforinformation.TheBrigadeS2harvestedinformationfromclassifiedwebsitesofForwardOperatingBaseAbuGhraibandthetacticalunitsthatoperatedinthevicinityofAbuGhraib.ThetrainingteamstudiedsatelliteimageryoftheAbuGhraibprisoncomplextobetterunderstandtheforwardoperatingbaselayout.Trainersreviewedandwar-gamedrecentinsurgentattackpatternsagainsttheprisonandagainstcoalitionforcesintheareaandmainsupplyroutesadjacenttoAbuGhraib.TheS2andthetrainingteamconductedthesamekindofenvironmentalanalysisforCampBuccaanditssurroundingarea.Thetrainingteamnowhadenoughinformationtoestablishthephysicalandthemission-specifictrainingenvironmentatFortMcCoy.BythesecondweekofMarch,FortMcCoyinstallationworkershadbrokengroundontheTaskForce344MedForwardOperatingBase(FOB)trainingsites,andthetrainingteamwasfullyengagedindevelopingdozensoftrainingscenariostailoredtothetaskforcemission.BUILDINGTHEMISSIONENVIRONMENTItwasnecessaryforthetrainingteamtoleverageexistingFortMcCoytrainingsitesduetothelimitedtimeavailabletopreparethesitesforearly-ApriloccupationbyTaskForce344Med.2ndBrigadeplannersworkedwithRTS-Medandtheinstallationstaffontheconstructionof2basecampsthatwouldsimultaneouslyserveastrainingsitesandlifesupportareas.TheRTS-MedtrainingsiteonFortMcCoywastheobviouslocationforthemainlifesupportareaandtrainingsite.Thissiteofferedadequatespaceforconstructionofatemporarylifesupportarea(LSA)for300Soldiers.TheLSAconsistedof4largecontractedgeneralpurpose(GP)tents,adiningfacilitytrailerforfoodserviceandamesstent,atentthatservedasatrainingsiteforupto100Soldiers,fieldshowerslinkedtoaninstallationwatersourceandsewerline,atrailerhousingtheS4andunitsupplyroom,andamotorpark.InstallationworkersmovedobservationtowersandbunkersfromothertrainingsitesonFortMcCoytotheFOB,andhelped2ndBrigadeSoldierssetupanentrycontrolpointintotheoperatingbase.TheArmy-AirForceExchangeServiceestablishedanexchangeatthesitethatwasopentoSoldiersintheevenings.TheMcCoygymstaffcreatedaworkoutareafortheSoldiers.TheentiresitewasenclosedinprivacyfencingtogivetheSoldiersthecontinuousillusionofbeinginawalledcompound.ThemaintrainingsitealsocontainedanRTS-MedmanagedfieldhospitalthatwouldserveastheTaskForce344MedhospitalatFOBAbuGhraib.TheRTS-MedsiteadministratorscoordinateddeliveryofmedicalequipmentthatwasuniquetotheTaskForce344Medhealthcaremission,orinsomecaseswasinusebyTaskForce115MedinIraq.TheRTS-MedstaffprovidedabuildingadjacenttothehospitalfortheTaskForceTacticalOperationsCenter(TOC).PersonnelfromtheMcCoyDirectorateofInformationManagementlaidmorephonelinesandcomputernetworkcableintothebuilding.ThroughthisefforttheTOCandthehospitalstaffwereabletocommunicate,quicklycoordinateoperations,andsendorreceivemissionspecificreports.TheMcCoytrainingteamalsodevelopedasmaller,moreaustereCampBuccatrainingsiteonthesouthsideofFortMcCoyapproximately5milesfromtheAbuGhraibsite.Thissiteconsistedof3trailersthatservedasworkspaceforabout60SoldiersandthetaskforcesCampBuccastaff,rudimentaryfieldhygienefacilities,andatemporaryfieldhospitalthatRTS-Mederectedatthesite.TheSoldiersworkinginshiftsatCampBuccareturnedtothemainLSAonthenorthsideofFortMcCoyinordertotakeshowersandsleepintheGPtents.ThisproceduresavedtheinstallationmoneyanddidnothingtodetractfromtheSoldierstheaterimmersion.The2ndBrigadetrainingteamneededatrainingsiteatwhichthetaskforcemedicscouldconductdetaineesickcallandwoundcare,andadministerdailydosesofprescribedmedicationtothedetainees.FortMcCoysEnemyPrisonerofWartrainingcompoundservedasaperfectlyanalogoussiteatwhichAbuGhraibandCampBuccamedicteamscouldexecutethesetasks.ThissitewaswithinamileoftheAbuGhraibFOB,andwaslessthana10-minutedrivefromtheCampBuccatrainingsite.Tentsservedasworkareasforthemedicalteams,and2tentsprovidedholdingareasfordetaineeroleplayers.Whilethesitewasnotveryrobust,thefencedcompounddidgivethemedical

PAGE 32

30ArmyMedicalDepartmentJournalteamstheillusionofbeinginsidethewireattheirrespectivedetentionfacility.The2ndBrigadeestablishedanexercisecontrolcenter(ECC)fortheTaskForce344Medcollectivetrainingphases.AsmallcellofSoldiersintheECCreplicatedthe44thMEDCOMstaffandservedastheBaseOperationsCenter(BOC)staffforbothFOBAbuGhraibandCampBucca.RadioandphonecommunicationsystemsprovidedtheprimarymeansofcommandandcontrolbetweenthesenotionalheadquartersandTaskForce344Med.Emailalsoservedasameansbywhichthemedicaltaskforceprovidedroutinereportstotheexercise44thMEDCOMandtheBOCstaffs.AparkinglotadjacenttotheECCservedasthelinkuppointfordailyconvoysthatdepartedFOBAbuGhraiborCampBucca,thesamelinkupprocedureusedatbothsitesinIraq.WhiletheECCstaffprimarilyadministeredcommandandcontroloverallofthetrainingaidsandroleplayersusedtosupportTaskForce344Medcollectivetraining,thecontrolcentersBOC/44thMEDCOMstaffdidasuperbjobofexercisingtheTaskForce344Medreportingandstaffplanningprocesses.TheTaskForce344Medstaffusedthesamereportformatsduringcollectivetrainingthatitwoulduseforreportingto44thMEDCOMandtheBOConcedeployed.Replicatingthecommandandcontrolproceduresandusingtheactualtaskforcereportformatscontributedsignificantlytothetheaterimmersionofthetaskforceanditsstaff.DevelopmentofrealisticandrelevanttrainingexercisescenarioswasalsocriticaltoTaskForce344Medssuccessfultheaterimmersiontraining.InearlyMarch,the2ndBrigadeexerciseplannersassembledhealthcaresubjectmatterexpertsfromtheFirstArmyCommandSurgeonsoffice,theMcCoyRTS-Medstaff,andkeystaffmembersoftheFortMcCoyTroopMedicalClinic.Theirpurposewastodevelopmedicaltrainingscenariostoreplicatethekindofcarethatthemedicaltaskforcewouldperformintheater.TheplanningteamassembledeachweektodevelopandrefinesituationsthatappliedtoTaskForce344Medsuniquemission.Theteamscriptedover120differentmedicalscenariosthataddressedvariousaspectsofdetaineehealthcare,LevelIII/IVcareforcoalitionforces,andemergencycareforlocalIraqicivilianswoundedduringUScombatoperations.Thesescenariosrangedfromroutinecarethatclinicalstaffprovidedeachdayinthehospital,suchasphysicaltherapysessionsforinjureddetainees,toamasscasualtytypeeventof8to12woundeddetaineesorcoalitionforces.Thecomplexityofthiseffortwascompoundedbytheneedfordetaineeswhoreceivedtreatmenttohaveamedicalhistory.Thisrequiredthescenariodevelopmentteamtocraftover150uniquemedicalrecordsthathospitalpersonnelwouldusewhentreatingdetaineepatients.TheplanningteamwasabletoestablishthefrequencyandtypeofmedicalscenariosbystudyingTaskForce115Meddailymedicalsituationreportssubmittedtothe44thMEDCOM.Theexerciseplanningteamthenusedthescenariostodevelopalistofrequiredtrainingaidsandroleplayers,thetimerequiredtoexecutethescenario,andtheneedforanyspecialpreparationsuchasapplicationofmoulagetoacasualtyordetainee.WhiletheMcCoyRTS-Medplannersprovidedsomescenariosthattheyusetotraintraditionalcombatsupporthospitals,theuniquemissionofTaskForce344requireddozensofscriptedevents,presentingtrainingnotroutinelyprovidedtoastandardcombatsupporthospitalatanArmyCombatTrainingCenter.*Themedicalplanningteamwasextremelysuccessfulindevelopingrigorous,realistic,andveryrelevantmedicaltrainingscenariosthatfullysupportedthetheaterimmersionofTaskForce344Med.Aforceprotectiontrainingteamconsistingprimarilyof2ndBrigadeplannersandtrainersworkedinparalleltothemedicalplanningteam.TheteamgatheredandassimilatedinformationthatwasrelevanttothesecurityanddefenseofintheaterFOBAbuGhraibandCampBucca.SomesourcesofinformationincludedFOBperimetertowercrewtranscripts,theTaskForceMedlifesupportareadefenseplans,andTaskForce115Medstaffresponsestovariousrequestsforinformation.Armedwiththisinformation,thebrigadesexerciseplannersandtrainersdevelopedaTaskForceMedBaseDefensePlanthatwassimilartotheplanthattheunitwouldhavetoexecuteonceitdeployed.Theplanreplicatedthesamenumberof *BasedondiscussionsbetweentheauthorandmembersoftheJointReadinessTrainingCenter(JRTC)EchelonAboveCorpsmedicaltrainingteamduringasitevisitatFortPolkinearlyMarch2005.ThedetaineecaretrainingprovidedattheJRTCisnotanalogoustothecarethatTaskForce115or344MedprovidedtodetaineesatAbuGhraibandCampBucca.TheaterImmersion:TrainingaMedicalTaskForceforOperationsinIraq

PAGE 33

OctoberDecember200631staticbattlepositionsthatTaskForce344Medwouldoccupyaspartofitsbasedefenseresponsibilities.ItalsorequiredthetaskforcetoformaQuickReactionForcecapableofexecutingthesameforceprotectiondutiesandresponsibilitiesastheTaskForce115QuickReactionForce.TheexerciseplannersandtrainersthenarrayedbunkerpositionsandemplacedobservationtowersintheFOBAbuGhraibtrainingsitethatweresimilartotheactualintheaterlayoutofthosepositionsrelativetothehospitalandtheSoldierslifesupportarea.TheplanningteamsinterviewswithrecentlyredeployedTaskForce115MedSoldiersalsoprovidedkeyinformationonhowthetaskforceplansandexecutesitsmovementoperationsfromFOBAbuGhraibtootherlocations,andtheweeklyrhythmofthesemovements.TheteamthenbuiltscenariosandresourcelistsfromthisinformationthattrainerswouldusetoexecutegroundassaultconvoytrainingforTaskForce344Med.ThetrainingteamhadtodesignateSoldiersandvehiclesthatwouldalsoparticipateinTaskForce344MedconvoysduringsituationaltrainingexercisesandthetaskforceMissionReadinessExercise,sincethemedicaltaskforcealwaysmovesaspartofalargerconvoyintheater.ByprovidingtheseresourcestoTaskForce344Medduringitstraining,the2ndBrigadewasabletoensurethatthetaskforcewouldtrainlikeitwouldoperateoncedeployed.Havingaunittrainlikeitwillfightisthepurposeoftheaterimmersion.TRAININGINTHEMISSIONENVIRONMENTThetheaterimmersiontrainingschemeforTaskForce344MedstartedalmostimmediatelyuponarrivalatFortMcCoy.Individualandleadertrainingestablishedabasisforcollectivetrainingconductedlaterinthetrainingscheme.SoldiersattendedtrainingonImprovisedExplosiveDevicesattheendoftheirfirstweekatMcCoy.AllSoldiersattendedculturalawarenesstraining,andateamofinstructorsfromtheDefenseLanguageInstituteprovidedthemajorityoftheSoldierswhoworkinthehospitalwithseveraldaysoflanguageimmersiontraining.FormerIraqinationalsnowlivingintheUnitedStatesandundercontractatthemobilizationstationasinterpretersduringpost-mobilizationtrainingcontinuedtoworkwithmembersofthehospitalontheirlanguageskills.Theywoulddosothroughouttheremainderofthetaskforcestraining.AMobileTrainingTeamofsubjectmatterexpertsfromtheArmyMilitaryPoliceSchoolandtheArmysDisciplinaryBarracksatFortLeavenworthprovidedsuperbinstructionondetaineeoperations,handling,healthcare,andtheimpactofthesetasksontheSoldierswhowouldexecutethiscriticalandstressfulmission.ThetaskforcemovedintotheFOBon8Aprilandwouldlive,eat,andworkthereforthenext53days.UponarrivalattheFOB,theyreceivedinstructionfrom1stBattalion,338thRegimenttrainersonseveralbattledrillsthatarefundamentaltoalloperationsinIraq:reacttoindirectfire,reacttodirectfire,individualmovementtechniques,andestablishingpersonnelaccountabilityafteranattackontheunit.SelectSoldiersinthetaskforcereceivedtrainingonmanninganobservationpost/tower,operatinganentrycontrolpoint,andQuickReactionForceoperations.The2ndBrigadesgroundassaultconvoy(GAC)trainingteamandGAClivefireteamprovidedsuperbtrainingonthiscriticalmissiontoallmembersofthetaskforce.TrainingscenariosforcedtheSoldierstoexecutetheirGACmissionsusingthesametactics,techniques,andproceduresthattheywoulduseinIraq.Contractedandmilitaryroleplayersportrayedciviliansonthebattlefieldandinsurgentforces,therebymakingtheunitsGACmissionsmuchmorecomplexandrealistic.Opposingforcesattackedtheconvoyswithdirectfireandimprovisedexplosivedevices.TheunithadtotreatandevacuatecasualtiesorSoldierswhowerekilledinaction.Soldiershadtoconducthastyrecoveryofdisabledvehiclesandtowthemtoarallypoint.Roleplayerstriedtointerferewiththeunitsconvoys.Civilianvehiclesattemptedtosharetheroadwiththeconvoyandinfiltrateintotheconvoymarchunit.ThesescenariosforcedtheSoldierstoemployaseriesofactionsandgraduatedresponsesthatarepartoftherulesofengagementtheunitwouldemployinIraq.Thistypeoftrainingistheaterimmersioninfullforce.ByearlyMay,TaskForce344Medwasreadyforaprogressiveseriesofcollectivesituationaltrainingexercises(STX)thatwouldfurthertrainanddemonstratetheunitsproficiencyinitsmedicalandforceprotectionmissions.Duringthe2seriesofmedicalSTX,theunittrainedonalloftheactivitiesitwouldperforminsidethewallsofthehospitalatboththeAbuGhraibandCampBuccasites.Thetaskforce

PAGE 34

32ArmyMedicalDepartmentJournaloperatedatacticaloperationscentertocommandandcontrolitsoperationandtoreporttoitshigherheadquarters,44thMEDCOM,onthedailystatusofmedicaloperations.Insidethehospital,theSoldiersexecutedmedicalscenariosthatcloselyreplicatedtheirfuturemissiontempoandtasksinIraq.TheyprovidedmedicalanddentalsickcallforUSSoldiersaroundtheclock.Theysentmedicalteamsdailytothedetentioncentertoconductin-processingphysicals,sickcall,medicationpass,monthlyhealthassessments,andwoundcarefordetainees.Additionally,theyreceiveddetaineesinthehospitalsdailyforphysicaltherapyandoccupationaltherapy,radiology,anddentalexams,andanyothercarethatthemedicsatthedetentioncampcouldnotperform.NumerousscenariosalsorequiredtheunittoexecutecollectivemissionsitwouldlikelyperforminIraq.Severaltimesthetaskforcehadtoreacttoanincreasedcasualtyloadcausedbydetaineeriots,Soldiersinjuredduetocombatactions,andciviliancasualtiesresultingfromcombatactioninurbanareas.Thetaskforcesuccessfullyaccomplishedthesetasksandthenprogressedintothenextphaseoftraining,theForceProtectionFieldTrainingExercise(FTX).DuringtheForceProtectionFTX,theunittrainedandexecutedalloftheactionsitwouldperformasatenantunitofFOBAbuGhraibandCampBucca.ThisphaseofimmersiontrainingincludedtheunitsresponsibilitiesattheFOBsdifferentReadinessConditionlevels,reportingtothebaseoperationscenter,GACoperationstoBaghdadInternationalAirportandCampBuehring,suckersanitationtruck(SST)movementsecurityoperations,andreactiontodirectandindirectfires.Thisphaseofthetrainingalsoenabledtheunittopracticeitsinternalstandardoperatingprocedures(SOPs),identifystrengthsandweaknesses,andmakeadjustmentsinitsSOPspriortotheMissionReadinessExercise.TheMissionReadinessExercise(MRE)wastheculminatingeventofTaskForce344Meds70daysoftrainingatFortMcCoy.DuringtheMREthetaskforcesimultaneouslyperformeditsmedicaltasksandforceprotectionresponsibilitiesinasplit-baseconfiguration;oneelementatFOBAbuGhraibandanother,smallerelementatCampBucca.Thisphasewas5dayslongandthetaskforceconductedcontinuous,24-houroperationsthroughouttheentireexercise.DuringtheMRE,theunitwasrequiredtosubmitallrequireddailyreportstoitshigherheadquartersandtheBaseOperationsCenterateachFOB,anditconducteddailymedicalandforceprotectionoperationssimilartothosethatitwouldexecuteduringitsupcomingmission.Theunitconductedtacticaloperationscenteranddailystaffoperations,publicaffairsoperationswith3liveinterviews,forceprotectionoperationsatbothFOBs,groundassaultconvoyandSSTescortmissions,anddetaineeandcoalitionforcemedicalsupportoperations.Over100roleplayerssupportedthisphaseoftraining.Roleplayersservedasdetaineesecurityforcesinthehospitals,otherunitsinthedailyGACs,SSTdrivers,detainees,coalitioncasualties,contractedworkersontheFOB,andotherFOBquickreactionandsecurityforces.ContractedformerIraqinationalsservedasinterpretersonthehospitalwards.ThroughouttheMREs5days,TaskForce344Medin-processed80detainees,conductedsickcallfor120detainees,providedmedicationsto250detainees,treatedwoundson80detainees,andconductedamonthlyphysicalassessmentof30detainees.Thecomplexity,tempo,andcontinuousoperationsoftheexercisestressedallofthetaskforcessystemsandmissionareas.Therealismofthemissionscenariosprovidedthetaskforceanindicationofhowwellitwouldoperateunderthemosttryingcircumstances.Thetotaltheaterimmersionofthetaskforceintoitsmissionenvironmentpreparedtheunitwellforitsrigorous,demandingmission.CONCLUSIONTheaterimmersionworksextremelywellinpreparingunitstoconductoperationsintheatersaroundtheglobe.TaskForce344MedwasimmersedinareplicaofitsoperatingenvironmentatFOBAbuGhraibfor53daysoftoughtraining.TheabilityoftheFortMcCoytrainingteamtodevelopareplicaofTaskForce344MedsmissionenvironmentrequiredadeliberateanalysisandstudyofthecontemporaryoperatingenvironmentinIraqatAbuGhraibandCampBucca.EstablishingcontactwithTaskForce115Medandbringingmission-relatedinformationfromIraqtoFortMcCoywascriticaltothedevelopmentoftrainingvenuesandtrainingscenariosforTaskForce344Med.ThesuccessfultrainingofthetaskforcewasduelargelytotheskilloftheFortMcCoytrainingandgarrisonsupportteamandwhatitwasabletodowiththeinformationprovidedbyTaskTheaterImmersion:TrainingaMedicalTaskForceforOperationsinIraq

PAGE 35

OctoberDecember200633Force115Med.TheFortMcCoyteamquicklydevelopedatrainingenvironmentthatwasaphysicalandproceduralimitationofwhattheunitwouldfacewhendeployedinIraq.ThedemandingtrainingenvironmentallowedTaskForce344Medtoconductoperationsacrossthefullspectrumofitshealthcareandforceprotectionmissionset.Theresultofthiskindofdemandingandrigoroustrainingisataskforcethatiswellskilledinitsmissions,mentallytough,andextremelyconfident.Thisresultisthegoalofanytrainingprogram,andtheaterimmersionisthemeanstothatend.AUTHOR COLHenderson,anArmorofficer,wasCommander,2ndBrigade,85thDivision(TrainingSupport),FortMcCoy,Wisconsin,atthetimethisarticlewaswritten. 85thDivision(TrainingSupport)CusterDivision

PAGE 36

34ArmyMedicalDepartmentJournalINTRODUCTIONGeographicinformationsystem(GIS)isatermusedtodescribeasoftwaretechnologythatrelatesvariousdatabasestocommonfeaturegeography.Specifically,aGISiscomposedofanintegratedsystemofcomputersoftwareandhardwarethatallowsuserstorapidlycreatecustomizedmapsandmodelsthatcaptureonlythosefeaturesorobjectsthatmeetparticularselectioncriteria.GIShasalreadymadeapositiveimpactonhealthcareinthepublic,private,andmilitarysectors.Manypublichealthdepartments,bothintheUSandthroughouttheworld,haveappliedGISinvariousways,includingtheidentificationofnearbymedicalfacilitiesforambulanceservices,improvedepidemiologicalresponsefollowingweather-relateddisasters,andhospitalpreparednessforunconventionalcasualtyevents,tonameafew.1-3HealthserviceprofessionalsinmilitaryinstallationshaveusedGIStoimprovetheirunderstandingofhealthissues.Forexample,anepidemiologicalstudyofsexuallytransmitteddiseases(STD)atFortBragg,NorthCarolina,usedGIStotrackoccurrencesofselectedSTDsinspaceandtime,thusallowingPreventiveMedicinepersonneltodevelopinterventionsfortheFortBraggpopulation.4In1993,theUSArmyCenterforHealthPromotionandPreventiveMedicine(CHPPM)usedGIStointegratetheunitlocationregistrydatabasetotrackandmaptrooplocationsrelativetosmokefromoilwellfiresignitedduringthefirstGulfWar.Since1995,CHPPMhasexpandedthissystemtotracktroopexposurestootherpotentialenvironmentalhazardsfromspecificoperationalevents.Futureplanscallformappingexposurestopotentialoperationalhazardssuchasdepleteduranium,ballisticmissileimpacts,andotherdemolitionactivities.5AcurrentmissionoftheDepartmentofPreventiveMedicine(DPM)atWilliamBeaumontArmyMedicalCenter,FortBliss,Texas,istointegrateGIScapabilityintothedifferenthealthandenvironmentalservicesitperforms.Forexample,theEnvironmentalHealthService(EHS)currentlyenterswaterlaboratorydata,WestNilevirusmosquitosamplingresults,monthlydiningfacilityinspectionfindings,hazardousmaterialslocations,andotherinformationintoaGIS(ArcView,registeredtrademarkofEnvironmentalSystemsResearchInstitute,Inc.[ESRI],RedlandsCA,909-793-2853),whichcaninstantlygeneratemapsdisplayingtrendsofthesefeaturesinspaceandtime.Similarly,theIndustrialHygieneServiceusesGISforplottingbiological,chemical,physical,andradiologicaldatathatarecollectedaspartofscheduledsamplingorforemergencyresponse.Inaddition,DPMhasusedGISinsimulationsofhospitalpreparednessforvariousscenariosinvolvingchemical,biological,radiological,nuclear,andexplosive(CBRNE)events,thusprovidingimportantinformationtohospitaldecisionmakers.DISCUSSIONWestNileVirusandGISWestNilevirus(WNV)isarelativelynewyetserioushealthconcernfirstdocumentedinTexasin2002.6StatisticscompiledbyboththeTexasDepartmentofHealthandtheCentersforDiseaseControlandPrevention(CDC)showatotalof58humandeathsinTexasalonesince2002.6,7Thisviruscausesmildtosevereinfectionsinhumans,typicallythroughthebiteofamosquitothathasacquiredthevirusbyfeedingonaninfectedbird.AccordingtotheElPasoCity-CountyHealthandEnvironmentalDistrict,WNVcasestypicallyoccurfromAugusttoOctober,whichApplicationofGeographicInformationSystemTechnologytoPreventiveMedicineInterventionsJoelReyes,BSRoeneNeu,PhDJosefA.Sobieraj,PhDLTCMarkD.Harris,MC,USA

PAGE 37

OctoberDecember200635correlateswithmigratingbirdpopulationsfortheregion.TheincubationperiodforWNVrangesfrom3to14daysandsymptomsgenerallylast3to6days.8ThemildformofWNVinfectionisdescribedasafebrileillnessofsuddenonsetoftenaccompaniedbymalaise,headache,anorexia,myalgia,nausea,rash,vomiting,lymphadenopathy,andeyepain.Approximately1in150WNVinfectionsaresevere,includingfeverandevendeath.TheCDCreportsthatthemostsignificantriskfactorisadvancedage,butthesickandyoungarealsovulnerable.ElPasoCity-CountyhadnumeroushumancasesofWNVinfections,includingfatalities,in2004.Fortunately,in2005,althoughmosquitoesandhumanstestedpositivefortheinfection,nodeathswerereported.InApril2005,CHPPMpublishedspecificguidelineswithregardtohowArmyprogramsshouldgeoreferenceWestNilevirussurveillancedata:DatamustbeinaformatallowingittobeintegratedintoaGIS.GISdatashouldbecombinedwithlocal,state,andnationaldataforamorecomprehensiveassessmentofWNV.AccuratelymaplocalsitesinGIStodevelopoptimalsamplingplansandbestallocationofresources.TheEHSatWBAMCiscurrentlyinfullcompliancewiththisCHPPMguidance,effectivelyusingtheGIStoplotmosquitotraplocationsandassociatedlaboratoryresultsinspaceandtime.Asanexample,Figure1wasgeneratedinGISusing2004FortBlissmosquitotrapinformationtoshowtraplocationswithintheFortBlissgolfcourse(anidentifiedhotspotforWNVmosquitoes9)whichcapturedWNVpositivemosquitoes.Alsohighlightedonthemaparefacilitieswithat-riskpopulationsinthevicinityofthesetraps,suchasanelementaryschoolandayouthcenterinproximitytothegolfcourse.Since2004,theEHShasbeenproducingthesemapstoeffectivelytargetpositiveWNVmosquitolocationswithfoggingintervention,education,andtrainingoftheat-riskpopulations,alongwithothermeasures.AnagreementwasrecentlyestablishedbetweentheElPasoCity-CountyEnvironmentalandHealthDistrictandPreventiveMedicineatWBAMCtoprovidetimelyexchangeofWNVinformation,includingexactlocationsofmosquitotrapsandlaboratoryresults,andthepresentationofthisdataonacountymap.Beforethisagreementwasformalized,theseentitiesdidnotshareinformationregardingmosquitotraplocations,laboratoryresults,orsamplingstrategies.Figure2isaGIS-generatedmapshowinglocationsofmosquitotrapswhichcapturedpositiveWNVmosquitoesin2004usingdataderivedfromthecombinedElPasoCity-CountyandFortBlissdatabases.ImplementingaGIS-BasedEmergencySystemNumerousemergencyservicesagencies(police,fire,medicalfacilities,emergencyshelters)intheUSandabroadhavealreadyestablishedGIS-basedemergencysystemsaspartofreadinessprogramsforrespondingtonaturalandnon-naturaldisasters.GISwasanimportanttoolintheresponse,rescue,andrecoveryeffortsintheattacksofbothSeptember11,2001(9/11)inNewYorkCity,andtheLondonbombingsinJuly2005.10-12AGISapplicationcanplotthelocationofallmobileandlandlinecallersonadigitalmap,givingfirstresponderstheabilitytofindthesite,routesinvolvingshortestdistances,andshortesttraveltimesforambulances,thusreducingemergencyresponsetimebyacritical2minutes.12Hospitalsandhealthsystemshaveatremendousstakeinacommunity'spreparednessforanymasscasualtyscenariorelatedtoaCBRNEattack.Since9/11,manyhospitalshavedraftedplansforresponsestosucheventsandothermassterrorattacks.13Whilehospitalsarefairlyadeptatscalingupforapredictableevent,mosthospitalsarenotwellpreparedtorespondtoanunexpectedlarge-scaleeventsuchasanepidemic,thereleaseofabiologicalagent,oraterroristattack.14Forhospitalstorespondpromptlytotheseevents,itiscrucialtohaveinformationofpersonnelandpatientsinamedicalfacilityreadilyavailablewithinminutes.TheLomaLindaUniversityMedicalCenterinLomaLinda,California,hasintegratedGISinthemanagementofcarenetworksandforhospitalstrategicplanning,toincludemasscasualtyevents.TheyhavemergedGISwithdigitalfloorplansofthehospital,real-timepatientdata,physicianin-careofaspecificpatientrelationships,andoccupiedandemptybedinformation.UsingthisintegratedGISdatabase,newpatientscanbeeasilyallocatedtosuitablebedswithmatchingroommatesbasedontheirconditionandtheattendingphysician.15Thesystemcanalsobequeriedforpatientsbeingtreatedbyoneparticulardoctor,andprovideadoctorwithafloorplanmaptoallhisorherpatients.

PAGE 38

36ArmyMedicalDepartmentJournalThecapabilitytopredictdamageandanalyzeconsequencesfromaCBRNEattackisanincreasinglyimportantresponsibilityoftheWBAMCDepartmentofPreventiveMedicine(DPM),whichisdevelopingaGIS-basedmodelthatpredictshospitalcapabilitiesandreadinessintheeventofaCBRNEeventintheproximityoftheFortBlissmilitarybase.Forthismodel,completehospitalfloorplanshavealreadybeenincorporatedintoGIS.DPMhasgeneratedmapsshowingexactbedlocationsforthehospitalduringnormalcapacity,expansionofhospitalcapacityundertheemergencymanagementandexcesssurgecapacityplans,andhasevenmodeledbedlocationswithhypotheticalconditionsofhavingincreasedisolationwardsforinfectiouspatientsoracontagiousdiseaseoutbreakfacility(Figure3).Bytakingintoaccountbaselinepatientbedoccupancyandstaffinglevels,DPMhasmodeledscenariosinwhichhospitalresourcesareeitheradequateandinadequateinspaceandtimeforpatientarrivalsurgesfromaCBRNEevent.Amongotherimportantinformation,thesemodelsevenrevealwhereprocessbottlenecksarelikelytooccurduringthetriageprocess.Thisinformationmayassisthospitaldecisionmakersand Figure1.MapofFortBlissGolfCourseandmosquitotraplocationsgeneratedbyGIS(Note:SomeGISlayersprovidedbytheFortBlissDirectorateofEnvironmentthroughafile-sharingagreementwiththeDepartmentofPreventiveMedicine) ApplicationofGeographicInformationSystemTechnologytoPreventiveMedicineInterventions

PAGE 39

OctoberDecember200637reducesomeofthedisorderlikelytooccurduringaCBRNEevent.CONCLUSIONTheDepartmentofPreventiveMedicineatWBAMChasestablishedaGISplatformwithmanybeneficialcapabilities.MapsgeneratedbyGISusingintegrateddatabasesshowingmosquitosamplinglocationsandlabresultsforWNV,aswellasthestartofaGIScollaborationbetweentheElPasoCity-CountyandFortBlisscommunities,havealreadyhelpedmitigatethehealthrisksfromWNVbyallowingmorefocusedinterventionsagainstthevirus.Additionaldata-sharingapplicationsbetweenElPasoCity-CountyandFortBlissarebeingevaluated.DPMisintheearlystagesofusingGIStoplanforaCBRNEattackaswellaspreparebasicvulnerabilityassessments.ByintegratingaGIS-basedemergencysystemintoahospitalreadinessprogramandtheEmergencyOperationsCenter,WBAMCmayhaveamorerapidresponseallowingtheimmediateandeffectiveuseofpersonnel,ambulance,andequipmentresourcestosavelivesduringaCBRNEattack.Insuchsituations,evenafewminutescanmakethedifferencebetweenlifeanddeath.GISinformationmayprovidethoseminutes. Figure2.PositiveWNVmosquitolocationsin2004generatedbyGISfrommergeddatabasesbetweenFortBlissandtheElPasoCity-County.

PAGE 40

38ArmyMedicalDepartmentJournal Figure3.GISmapoftheWBAMC4thfloorIntensiveCareUnit(ICU)and7thfloorsurgicalwardshowingpatientbedlocationsundernormalcapacity(Capacity),emergencymanagementplan(EMP)capacity,aswellasnegativepressureisolationroomsandretrofittedisolationrooms.ApplicationofGeographicInformationSystemTechnologytoPreventiveMedicineInterventions

PAGE 41

OctoberDecember200639REFERENCES1.PelegK,PliskinJS.AgeographicinformationsystemsimulationmodelofEMS:reducingambulanceresponsetime.AmJEmergMed.2004;22;No.3:164-170.2.WaringSC,Zakos-FelibertiA,PadgettPM,StoneM.,WoodR.Theutilityofgeographicinformationsystems(GIS)inrapidepidemiologicalassessmentsfollowingweather-relateddisasters:methodologicalissuesbasedontheTropicalStormAllisonexperience.IntJHygEnvironHealth.2005;208:109-116.3.SchreiberS,YoeliN,PazG,BarbashGI,VarssanoD,FertelN,HassnerA,DroryM,HalpernP.Hospitalpreparednessforpossiblenonconventionalcasualties:anIsraeliexperience.GenHospPsychiatry.2004;26;No.5:359-366.4.ZenilmanJM,GlassG,ShieldsT,JenkinsPR,BaydosJC,McKeeKT.Geographicepidemiologyofgonorrheoeaandchlamydiaonalargemilitaryinstallation:applicationofaGISsystem.SexTransmInfect.2002;78:40-44.5.BrameL.CurrentstatusofArmyspositiononevidenceofexposuretochemicalagentsintheGulfWar:evidenceofexposuretochemicalagentsintheGulfWar.DesertStormVeteransAssociation.1997.Availableat:http://www.desertstormvets.org/health/index.cfm.6.StateHealthExpertsUrgePersonalProtectionAgainstWestNileVirus.[VideoNewsRelease].Austin,TX:TexasDepartmentofHealth;May,2003.Availableat:http://www.tdh.state.tx.us/news/wnv_script.htm.7.CentersforDiseaseControlandPrevention.WestNilevirushomepage.Availableat:http://www.cdc.gov/ncidod/dvbid/westnile/index.htm.8.CentersforDiseaseControlandPrevention.WestNilevirusinfection:informationforclinicians.Availableat:http://www.cdc.gov/ncidod/dvbid/westnile/resources/fact_sheet_clinician.htm.9.ReyesJ,NeuR,BellL,LeyvaE,EverettMA,MagaaJC,SobierajJA,HarrisMD.PreventingWestNilevirusinElPasousinggeographicinformationsystemsmodelsforElPasoCountyandFortBlisscommunities.ElPasoPhysicianJ.Inpress.10.KevanyMJ.GISintheWorldTradeCenterattack-trialbyfire.ComputEnvironUrban.2003;27;No.6:571-583.11.LockeyDJ,MacKenzieR,RedheadJ,WiseD,HarrisT,WeaverA,HinesK,DaviesGE.LondonbombingsJuly2005:theimmediatepre-hospitalmedicalresponse.Resuscitation.2005;66:9-12.12.LondonAmbulanceService-GISexperience:geographicalinformationsystems-casestudies.BusComputWorld.February1998:50-5413.MorseA.Bioterrorismpreparednessforlocalhealthdepartments.JCommunHealthNurs.2002;19:203-209.14.DavenhallW.Preparingforlarge-scaleevents.ArcUser[online].OctoberDecember2003.Availableat:http://www.esri.com/news/arcuser/1003/largescale1of2.html.15.CityUniversityLondon,SchoolforInformatics.OverviewofGISforhealthorganizations.HealthGeomatics[online].December,2000.Availableat:http://www.geog.ubc.ca/courses/geog471/notes/health/Overview_GIS_Health.htm.AUTHORS JoelReyesisacontractedGISspecialistintheDepartmentofPreventiveMedicineattheWilliamBeaumontArmyMedicalCenter,FortBliss,Texas.RoeneNeuisacontractedGISspecialistintheDepartmentofPreventiveMedicineattheWilliamBeaumontArmyMedicalCenter,FortBliss,Texas.JosefSobierajisChief,IndustrialHygieneService,WilliamBeaumontArmyMedicalCenter,FortBliss,Texas.LTCHarrisisChief,DeptofPreventiveMedicine,WilliamBeaumontArmyMedicalCenter,FortBliss,Texas. WilliamBeaumontArmyMedicalCenter

PAGE 42

40ArmyMedicalDepartmentJournalThemilitaryhealthsystemrecentlychangedthenameofitselectronicmedicalrecordtoAHLTA.Thenamechangeismorethanjustasymbolicgesture.Itreflectsanunderstandingandemphasisonthecompositionandintendedutilityofthemilitaryhealthsystemsglobalelectronicmedicalrecord(EMR).Thenamechangeisalsopartofagreaterefforttospeedintegrationofallthesubcomponentsofthesystem.ManypeoplethinkofAHLTAasthecomputerintheirofficeorexamroom.WhileacknowledgingtherecordiskeptinalargedatabaseinMontgomery,Alabama,theglobalnatureandthemultiplesystemsthatcomposeAHLTAwerenotreflectedinthenameCompositeHealthcareSystem(CHCS)II.AsportrayedintheFigure,AHLTAincludesCHCS,CHCSII,CHCSII-T,andclinicaldataminingcapabilities.AHLTAalsoincludesinterfaceswithandinformationfromtheUSDepartmentofVeteransAffairsEMR(VeteransHealthInformationSystemsandTechnologyArchitecture)aswellasothergrowingnetworkinterfacessuchasthePharmacyDataTransactionSystem(PDTS).Theotherreasonforthenamechangeisanacknowledgementthatmanagementofthesesubcomponentsandinterfacesmustbecollaborativeandinunison.Changestoordelaysinanypartimpacttheutilityoftheothercomponents.ThecomplexityofthelargestEMRintheworldandtheneedtocontinuallyenhanceitdemandsgreatcoordinationatalllevels,fromtheclinictotheenterprisemanagementoffice.ThenamechangedidnotsignalabeliefthatAHLTAwasacompletedproduct.Throughoutitsdeployment,ithasbeenclearthatuseofAHLTArequiredchangesintheclinicalworkprocess.Itisequallytruethatnecessarychangeswereidentifiedbyclinicalteamsusingthesystem.Thishascreatedacontinualcycleofevolutionandimprovementbaseduponrealclinicalcare.NoEMRwilleverbeperfectedinthelab;itrequiresreal-worlduseandfeedback.Duringthefirst2yearsoffulldeployment,usersrecommendedmanychangestoAHLTAwhichhavebeenfunded.Thelistofimpendingimprovementsisimpressive.ThechangeswillrequirethecontinuedculturalandclinicalbusinesschangesintheArmyMedicalDepartment(AMEDD).Theprovidedcapabilitiesoffermanyimprovementsinclinicalcare,decisionsupport,andefficiency.TheAMEDDrealizesthateventheseimprovementswillnotcompletetheEMR.Greatinnovationsandrecommendationsforimprovementareoccurringeverywhere.Toharnessthisenergyandentrepreneurialeffort,theAMEDDhasdevelopedaprocesstohelpcapture,develop,andshareideasandbestpractices.SYSTEMCHANGEREQUESTANDBESTPRACTICESIndividualsandgroupscansubmitsystemchangerequeststotheAMEDDAHLTAProgramOfficeortotheirregionalrepresentativesontheAMEDDEMRCollaborationandCommunicationBoard(CCB).TheAMEDDAHLTAsystemchangerequestformisavailableattheAHLTAwebsite.ThepersonorgroupTheNewNameoftheMilitaryElectronicMedicalRecordLTCRonMoody,MC,USADavidFreemanAHLTAGlobalView*CBDMClinicalBusinessDataMartCDWClinicalDataWarehouse

PAGE 43

OctoberDecember200641submittingtherequestisaskedtoclearlydefinetheoutcomethatthesuggestedchangewillallow.ThiswillhelptheAMEDDstaffdeveloptheideawiththesubmitter.Moreoftenthannot,theAMEDDstaffisabletolettherequestorknowthestatusonanearliersimilarrequest.TheCCB,whichmeetstwicemonthly,consistsofrepresentativesfromeachregionalmedicalcommandandotherareas.ItwascharteredasacommitteeoftheAMEDDInformationManagementGuidanceCounciltofacilitatecollectionandreviewofinformationfromthefieldforimprovingAHLTA.ThegroupwasalsocharteredtohelpimprovethesharingofbestpracticesanduseofAHLTA.Inaddition,theCCBdevelopsstandardizedreportssothateverymilitarymedicaltreatmentfacilitydoesnotreinventthewheel.UsersareencouragedtocontacttheirCCBrepresentatives.CCBrepresentativescommunicatechangesandsolicitfeedbackonimprovingtheAMEDDselectronicmedicalrecord,AHLTA.MEDCINTERMSThestructuredlanguagethatisthenotewriterinAHLTAisMEDCIN,acommercialproductdevelopedbyMedicompSystems,Inc.(14500AvionParkway,Chantilly,VA,703-803-8080)whichisinuseinmanycivilianEMRs.IndividualsandgroupscanrequestadditionsandchangestotheMEDCINvocabularythroughtheAMEDDAHLTAwebsite.AspreadsheettocapturetherequestedchangestoMEDCINandinstructionsonsubmittingchangesareavailableonthatwebsite.TherequestedchangesarecompiledandsubmittedtoMedicomp.Ofcoursethereisnoguaranteethatthechangeswillbeaccepted.However,itisguaranteedthatchangeswillnotoccurifrequestsarenotmade.Ingeneral,ittakesabout6monthsforanacceptedtermtobereleasedinAHLTA.TheAMEDDhashadgreatsuccessingettingclinical,readiness,andadministrativetermsadded.TheconsultantsintheOfficeofTheSurgeonGeneral(Army)areaskedtoreviewandconsolidaterequestedchangestoMEDCINvocabularyfortheirareas.TheconsultantscanalsoassistinconsolidatingfeedbacktoforwardtotheAMEDDAHLTAprogramofficeassystemchangerequests.SUSTAINMENTTRAINERSTheAMEDDAHLTAprogramofficehasanetworkofsustainmenttrainerstohelpwithongoingtraining,thecollectionanddisseminationofbestpractices,andtroubleshootingAHLTAissues.Thiscollaborativenetworkallowsthequickidentificationandresolutionoftrainingissues.Italsohashelpeddevelopandevolvesystemchangerequestsintobetterideas.Thesustainmenttrainerskeepthemedicaltreatmentfacilitiesinformedofchangesthroughnewslettersandagrowinglistoftrainingdocumentsandfrequentlyaskedquestions.AlistofthesetrainingdocumentscanbefoundontheAHLTAwebsite.TheAMEDDAHLTAwebsiteisaccessiblethroughthe ArmyKnowledgeOnline(AKO)system(authorizedusersonly).EntertheAKOhomepage,selectGroups,enterAHLTA,selectHomepage.Or,fromtheAKOhomepage,enterhttps://www.us.army.mil/suite/page/406. AUTHORSLTCMoodyistheProgramManagerforAMEDDAHLTAImplementationandClinicalIntegration,EisenhowerArmyMedicalCenter,FortGordon,Georgia.DavidFreemanistheSeniorAnalystintheAMEDDAHLTAImplementationandClinicalIntegrationOfficeandAdvisortotheProgramManager.

PAGE 44

42ArmyMedicalDepartmentJournalAlthoughfulldeploymentofAHLTAwasapprovedinJanuary2004,*themilitaryhealthsystem(MHS)hasbeendeployinganelectronicmedicalrecordsinceearly1980.ThedeploymentanduseoftheCompositeHealthCareSystem(CHCS)helpedovercomemanyissues.Forexample,computerizedphysicianorderentry(CPOE)continuestobeastumblingblockfororganizationstryingtoimplementanelectronicmedicalrecord.Theresistancetothischangehaspersistedforover20yearsdespitetheevidencethatCPOEimprovespatientsafetybypreventingmedicalerrors.Indeed,physicianresistancetoorderingmedicationandlabsthroughcomputerswaspresentwithintheArmyMedicalDepartment(AMEDD).However,overtimemanyusersgrewdependentontheCPOEcapabilitiesofCHCS.Whatwecallprogressistheexchangeof onenuisanceforanothernuisance.HavelockEllis TheearlyyearsofCHCSdeploymentandusewerenotwithoutproblemsandcontroversy.ThekeycomplaintsaboutCHCSwerethatitwasslow,notuser-friendly,resultedinlostproductivity,andinterferedwithphysician-patientinteraction.ThecomplaintsarevirtuallyidenticaltothoseheardaboutAHLTA.Someoftheseissuessurfacedbecauseeachofthesesystemspushedthetechnologyenvelopeoftheirtime.Theissuesalsooccurredbecausethesystemsweredesignedforglobaluseandwerenotcustomizedtoanysinglelocationorpracticepattern.However,mostoftheissuesarecloselyrelatedtotheimpactthattheelectronicmedicalrecordhasonthecultureofmedicine.LikeCHCSbeforeit,AHLTAhascreatedafundamentalneedtochangeclinical-businesspracticeswhilenotchangingthehigh-qualityofcarethatisprovided.TheswitchtothenextgenerationofTRICAREcontractshasalsocreatedtheneedtochangepractices.Agreatmovehasoccurredfromcountingvisitstorelativevalueunits.Theacceptanceofchangeintechnologyfollowsapredictablepattern.Gartner1definedthenewtechnologyimplementationcycle:TechnologyTrigger.Abreakthrough,publicdemonstration,productlaunch,orothereventthatgeneratessignificantpressandindustryinterest.PeakofInflatedExpectations.Duringthisphaseofover-enthusiasmandunrealisticprojections,aflurryofwellpublicizedactivitybytechnologyleadersresultsinsomesuccesses,butmorefailures,asthetechnologyispushedtoitslimits.Theonlyenterprisesmakingmoneyareconferenceorganizersandmagazinepublishers.TroughofDisillusionment.Becausethetechnologydoesnotmeetitsover-inflatedexpectations,itrapidlybecomesunfashionable.Mediainterestwanes,exceptforafewcautionarytales.SlopeofEnlightenment.Focusedexperimentationandsolidhardworkbyanincreasinglydiverserangeoforganizationsleadstoatrueunderstandingofthetechnologysapplicability,risks,andbenefits.commercialoff-the-shelfmethodologiesandtoolseasethedevelopmentprocess.PlateauofProductivity.Thereal-worldbenefitsofthetechnologyaredemonstratedandaccepted.Toolsandmethodologiesareincreasinglystableastheyentertheirsecondandthirdgenerations.Agoodplanexecutedtodayisbetterthana perfectplanexecutedatsomeindefinitepointinthefuture.GeneralGeorgeS.Patton,Jr Ithasbeenshownthatsuccessinatimeofculturalchangerequiresaclearvisionandcommitmenttoachievestatedgoals.TheAMEDDdeploymentofAGlobalElectronicMedicalRecord,TodaysRealityLTCRonMoody,MC,USADavidBlair,MD *Seerelatedarticleonpage40.

PAGE 45

OctoberDecember200643AHLTAhasbeenfocusedonthegoalsofimprovingboththehealthofbeneficiariesandthehealthcaresystems.In2001,anInstituteofMedicinestudy2detailedasignificantissuewiththeUShealthcaresystem.Thefollowingstatementfromthestudysummarizestheissue:Initscurrentform,habits,andenvironment,Americanhealthcareisincapableofprovidingthepublicwiththequalityofhealthcareitexpectsanddeserves.InamorerecentstudybytheRANDCorporation,itwasestimatedthatimplementationofhealthinformationtechnologyandelectronicmedicalrecordswouldimproveclinicalcareandoperationalefficiency.Thestudyrevealedthatproperlyimplementedhealthinformationtechnologywouldsavemoneyandsignificantlyimprovequality.Thetotalannualsavingswasestimatedtobeashighas$162billion.Savingswouldcomefromincreasedefficiency($77billion),reducedoccurrenceofadversedrugevents($4billion),andimprovedconditionmanagementandpreventivecare($81billion).TheAMEDDssuccesswithAHLTAimplementationhasoccurredbecausedeploymentcontinueddespitechallenges.Byfocusingonthevisionofimprovedhealthcare,AMEDDhelpedfieldandcreatesolutionstothosechallenges.ThepastandfuturesuccessesofAHLTArequireacontinuedefforttolearnhowtouseandteachtheusesoftheapplication.Successalsorequiresbothaplanandtheevolutionofthatplanthroughcontinuedlearning.Othereffortsatlarge-scaleEMRimplementationhavemetwithsimilarchallenges.TheUnitedKingdomsefforttoimplementanationalEMRhasbeenhinderedbydelayeddeliveryofcriticalsoftware.Thesedelayshaveincreasedcost.InpreparingforbattleIhavealwaysfound thatplansareuseless,butplanningisindispensable.DwightD.Eisenhower TheAMEDDstrategyforimplementingAHLTAcanbestberepresentedin5phases:Phase1DeployAHLTAtoallsitessothereisacommonEMRavailableBlock1Medical(February2004toJuly2006)Block2DentalandSpectacleRequestTransitionSystemII(August2006tofinish)Phase2IncreaseutilizationbyallsitesanddeployAHLTAtoallmedicalarealocations(theater,battalionaidstations,Soldierreadinessprocessingsites,communitybasedhealthcareorganizations)(January2005toDecember2006)BettertrainingandtoolsPreventiveHealthRemindersClinicalDataMartInitialdeploymentSharedSolutionsfromthefieldPhase3ImprovetheQualityofCarebygatheringandutilizingEvidence-BasedCareandBestPractices(January2006tofinish)DeployClinicalDecisionSupport/AutomationofClinicalPracticeGuideline/Registry/OutcometoolEnhancedClinicalDataManagerandeventualClinicalDataWarehouseRegulationandPolicyChangesPhase4Improveoutcomeswhiledecreasingcostsasaconsequenceoftheaboveactionsbeingsuccessfullyaccomplished(July2006tofinish)Phase5Prepareforinpatientsuccess(July2006tofinish)Althoughdepictedasphases,theactivitiesareoccurringinparallelwithgreatoverlap.Completingeachphasewillprovidethebaseandinfrastructuretomorerapidlyachievethenextphase.PresentlytheAMEDDAHLTAProgramofficeismanagingnewimplementationandlifecycleequipmentmanagementbasedonanestablishedprogrammanagementplan.ThisplancontinuestoevolvefromlessonslearnedandfeedbackfromusersasillustratedintheFigure.Victorybelongstothemostpersevering. NapoleonBonaparte Finally,successwasnoteasy.AsofJuly2006,allAMEDDmedicaltreatmentfacilitieshaveaccesstothesamepatientrecord.Thiswasaccomplishedwithhardworkandeffortfromeveryoneinvolved.AHLTAhascreatedadditionalstressineveryonesdayastheAMEDDgoesthroughitspresenttransformationandtheculturalchangeofmovingfromapaper-based

PAGE 46

44ArmyMedicalDepartmentJournalsystemtoafullyelectronicmedicalrecord.Thestressonthesystemhasbeenandwillcontinuetobeforthesingulargoalofimprovinghealthcarequality.TheculturaltransformationisnotoverandAHLTAwillcontinuetoevolveastheclinicalcareteamfindsbetterwaystousethistoolanddemandsmoreofit.CORPORATESUCCESSSTRATEGYSuccessinthecontinuedpursuitofimprovinghealthcarerequiresacorporatevision,strategy,andleadership.Organizationaswellaslocalsuccessdemandscommitmenttoandpublicsupportofthestrategyinallleadershipactions.ThesuccessoftheAMEDDinthisendeavorhasbeenacceleratedbytheactionofseniorAMEDDleadershipandongoingreviewofstrategyandgoals.TheAMEDDheld3electronicmedicalrecordsummitsattendedbyallofitsseniorleadershiptoensurethesuccessfuldeploymentofAHLTA.Thefocusoffuturesummitsisnolongertheelectronicmedicalrecord,buttheimprovementofhealthcarenowthatauniversalsystemisinplace.Thefollowingarekeystepsforcorporatesuccess:Establishaclearvisionandgoalsforuseoftheelectronicmedicalrecord.Developstrategyforinformationmanagementandtechnologytosupportthevision.Acknowledgethedifficultyofmedicalchangewithoutcompromisingthevision.Developandcommunicateanimplementationstrategy.Revise,donotabandon,theimplementationstrategy.Acceptanceofnewtechnologynormallyrequires12to18months.Dontletperfectbetheenemyofgood.Remember:electronicmedicalrecordsarenotperfectedinthelaboratory.AGlobalElectronicMedicalRecord,TodaysReality Trainingcompleted Sustainmenttrainerarrives TrainingdateAMEDDphysicianonsiteProviderrolloverNewbuildreleasePre-implementationImplementationIntegrationSustainmentHospitalLeadershipTechnicalsupportforsitepreparation MTFleadersnamedLocalguidedeveloped ContinuedcommandsupportforCHCSII IM/IT*SitesurveysHardwaredelivery Implementation supportNewusersupportDeploynewequipment UserTrainingUNISYStrainersarriveTrainingnewusersTrainingnewcapabilities ClinicalPostingofAMEDDspecialtyspecifictemplates Provideradjustmenttodocumentationchanges ProviderandnurseadjustmentstochangesinbusinessprocessLearningnewcapabilities AdministrativeClinicscheduleadjustments Codingimpacts Commandbrief&developmentofmedicaltreatmentfacilityimplementationguideEquipmentlifecycle Sitenotified*Informationmanagement/InformationtechnologyPeriodrequiringcriticalattentiontoCHCSIItoensuresuccess TheArmyMedicalDepartmentStrategicPlanOverviewforAHLTAImplementation

PAGE 47

OctoberDecember200645Establishwell-definedfeedbackloopswithdevelopersandgiveusersareasonableexpectationofwhatmodificationsarepossible.Usermustprovideanobjectiveevaluationofclinicalandbusinessoutcomesofanychangesdesired.Donotdesignthesystemtoperpetuatenon-evidence-basedactions.Avoidlettingpersonalpreferencesdictatecorporatepreferences.Finally,rememberthatLeadersmustLEAD.FINALTHOUGHTSSuccessremainsanattitude.ThatattitudehastheAMEDDpushingforanacceleratedimplementationofaninpatientelectronicmedicalrecord.ItalsohasAMEDDpolicyincreasingfocusingonoutcomes.Thisincludeschangesinpointofcareinformationfeedback,performance-basedrewardforimprovements,andincreasingeffortstocentralizemedicalmonitoringtoallowmedicaltreatmentfacilitiestofocusonoutcomes.REFERENCES 1.Gartner,Incorporated,56TopGallantRoad,Stamford,Connecticut06902-7700203-964-0096.2.InstituteofMedicineoftheNationalAcademies.CrossingtheQualityChasm:ANewHealthSystemforthe21stCentury.2001.Availableat:http://www.iom.edu/CMS/8089/5432.aspx.3.RANDCorporation.Healthinformationtechnology:canHITlowercostsandimprovequality?2005.Availableat:http://www.rand.org/pubs/research_briefs/RB9136/index1.html.AUTHORS LTCMoodyistheProgramManagerforAMEDDAHLTAImplementationandClinicalIntegration,EisenhowerArmyMedicalCenter,FortGordon,Georgia.DrBlairisafamilyphysicianattheBloomerMedicalCenterinBloomer,Wisconsin.TheFocusMustBeOnHealthcareImprovement,NotElectronicMedicalRecordImplementation.

PAGE 48

46ArmyMedicalDepartmentJournalDEPLOYMENTREVIEWAHLTA,themilitaryhealthsystems(MHS)enterpriseelectronicmedicalrecord(EMR),wasapprovedforworldwidedeploymentinJanuary2004.*AllUSArmyMedicalDepartment(AMEDD)medicaltreatmentfacilities(MTFs)completedBlock1(outpatientEMRdeployment)inAugust2006.Duringthatshort,32-monthtimeframe,thesystemwasdeployedacrosstheglobeandisnowusedforover80%ofallAMEDDoutpatientvisits.ItisthelargestemploymentofanyEMRintheworld.TheAMEDDroleinthesuccessofAHLTAisundisputed.ThelasttwoArmySurgeonsGeneralsettheAMEDDscourseforsuccessfulAHLTAdeploymentanduse.However,theAMEDDhelditsfirstEMRsummittoconsolidateitsvisionandstrategyonlyrelativelyrecentlyinMarch2005.ItwasatthisinitialsummitwherethevisionofAHLTAasthesingleenterpriseEMRwasclearlyestablished.AttheAMEDDssecondEMRsummitinNovember2005,theinterrelatednatureofCHCS(CompositeHealthCareSystem),AHLTA,CHCSII-TandtheClinicalDataMart/Warehousewasdiscussed.ThefactthattheMHSEMRisdependentontheaggregationofthesesystemsispartofwhatmotivatedthenamechangefromCHCSIItoAHLTA.ThethirdAMEDDEMRsummit,heldinApril2006,wasattendedbytheArmySurgeonGeneral,theDeputySurgeonGeneral,andallRegionalMedicalCommanders,alongwithotherAMEDDgeneralofficers.ThesummitproducedtheplantohaveallfuturesummitsfocusnotjustontheEMR,butonHealthcareImprovement,whichisthefundamentalbasisfordeploymentoftheEMR.AsummaryofthiseventisavailableontheAMEDDAHLTAwebsite.TheAMEDDsuccessatdeployingAHLTAnotwithstanding,itisclearthatAHLTAisnotperfect.Nocomputerorinformationsystemis,particularlynotoneasnewandcomplexasAHLTA.TheSurgeonGeneralsdirectivewastofieldthesystem,useit,andimproveit.Ithadbecomeclearthatthesystemwouldnotbeperfectedinthelaboratory.ThestrategywassuccessfulastheAMEDDanditsendusershaveguidedmuchofthesystemsevolutionsincedeployment.Thishasincludedimprovementsinspeed,stability,vocabulary,andfunctionality.Processlessonshavealsobeenlearned.Forexample,intheearlydays,sometimesthepreferenceofasingleusersubmittedasaSystemChangeRequest(SCR)andincorporatedintothesystemwouldsubsequentlyrequireremoval,andthesystemreturnedtotheoriginalstate(orathirdstate)oncefurtherfeedbackwasreceived.SCRsarenowprocessedusingbroaderuserinputandincreasedvetting,andadditionalroutessuchastheAMEDD-uniqueSCRprocesshavebeenputintoplace.TheAMEDDAHLTAOfficeandtheAMEDDInformationManagementOfficewillcontinuetointeractwiththeTricareManagementActivityintri-serviceprioritizationandexecution,andcontinuetoemphasizeAMEDD-definedpriorities.TheAMEDDhasplacedanemphasisonfieldingcriticalfunctionalityattheearliestpracticalopportunity.TheseprocessesmaximizetheAMEDDsabilitytoselect,refine,support,and/orfundsystemimprovementsthatdelivermaximumbenefittoall,especiallythepatient.AHLTA,whilenecessitatingsomechangesinhowcareisdelivered,doessupportoutpatientspecialtyuseinitscurrentform.However,therearespecialtiesforAHLTADeploymentStatusandDevelopmentStrategyLTCRonMoody,MC,USAMAJJacobAaronson,MC,USACarlBuising,MDCOL(Ret)DougBarton,MS,USA *Seerelatedarticleonpage40.AccessiblethroughtheArmyKnowledgeOnline(AKO)system(authorizedusersonly).EntertheAKOhomepage,selectGroups,enterAHLTA,selectHomepage.Or,fromtheAKOhomepage,enterhttps://www.us.army.mil/suite/page/406.

PAGE 49

OctoberDecember200647whichclearshortcomingsexist.PlannedimprovementstoAHLTAwillbenefitmost,ifnotall,specialties.Whatisoftendebatedisthefastest,mosteconomical,andbestoverallapproachtodeliveringspecialty-specificfunctionality.Acommonlysuggestedapproachisthepurchaseandintegrationofexistingcommercialoff-the-shelf(COTS)intoAHLTA.ThefollowingdiscussionexplainstheMHSandAMEDDapproachtoAHLTAenhancements.COTSSOFTWAREThereisconsiderableoverlapinneededandrequestedfunctionalityforAHLTAamongsubspecialties,andintherequestsofsubspecialtiesascomparedwththoseofprimarycarespecialties.ThereturnoninvestmentthattheAMEDDandMHSareseekingisnotinanygivenspecialty,butacrosstheclinicalspectrumorthepatient,availabletoallsystemusersinastandardizedformat.Theoverarchinggoalisimprovementintheuseandreuseofpatientdataacrossthecontinuumofcare.Themainbeneficiaryisthepatient,whowillhaveaunified,comprehensivemedicalrecord,allowingimprovedoutcomesandmoreeffectiveclinicalmanagement.Forexample,theEmergencyDepartmentneedsaflowsheetcapability,asdoesobstetrics/gynecology(OB/GYN).IfaCOTSelectronicmedicalrecordfortheemergencydepartmentisintegratedwithallitscostsforinterfacesanddataintegrity,purchaseoftheflowsheetcapabilityforOB/GYNwouldstillbenecessary.Further,pulmonary,urology,physicaltherapy,andotherscanalsobenefitfromaflowsheet.Ifaseparateapplicationwereboughtforeacharea,itwouldbetooexpensivetomapdataacrossthesystems.Eachareawouldbeleftwithitsownsiloofinformationtoview.ThiswouldbesimilartoonepatientsafetyissuepresentwithCHCSapatientsallergiesandmedicationscouldnotbeviewedbyotherMTFs.Thepatientrecordwouldbedifficulttokeepcomplete.Thechoicefacingthemilitaryhealthsystem:buildacorecapabilitythatisrobustenoughtomeetenterpriseneeds,orbuymultipleEMRsspecificforeveryspecialtyareaandthenattempttokeepthemintegrated.Unfortunately,thecommercialEMRindustrylimitsstandardsindesignandarchitecture.Therefore,notonlyistheuseofmultipleCOTSproductsamorecostlyinitialapproach,butthelong-termcostishigheraseachnewCOTSchangewouldrequirechangestoallintegratedsystems.WhileagivenCOTSproductmayinitiallyprovidesomewhatsmootherfunctionalityforoneclinicalareathananapplicationdevelopedwiththeoverarchinggoalsinmind,theadditionalcostandefforttointegratesuchproductswiththeexistingbackboneisconsiderable.Ifspecialtyproductswerepurchasedforeveryclinicalarea,theredundancyincapabilitywouldbehuge.Further,atthispointfulldataintegrationwouldessentiallybeunaffordable.Itisimportanttoappreciatethatcurrentlytheseapplicationsarenotplugandplay.Althoughsalesprofessionalsoftenrepresentotherwise,trueintegrationremainschallengingandveryexpensive.AHLTAcommonlyfacesintegrationchallengesnow,justwiththevariousCOTSproductsalreadyinvolvedinAHLTA,includingthosefromMicrosoft,SecuredServices,Oracle,3M,SAIC,andothers.Theshort-termcostofCOTSapplicationsandintegrationisinitiallyhigherbecausemanyofthepurchasedcapabilitiesareredundant.AllEMRproductshavebasicfunctions,suchasdemographics,check-in,testdisplay,andencounterdocumentation,aswellasnumerousoverlappingspecialtyfunctions.Alloftheseareasmustbemappedacrossallapplicationssothatdatacanbeshared.Theonlyalternativeisasystemthatdoesnotcross-referenceitsowndata.Considerasystemthatdoesnotuseacommondemographicidentifierforpatients,allowingoverlappingand/orredundantrecordsonthesamepatient.Infact,asthelegacyCHCShostdataisrolledintotheAHLTAcentraldatarepository,weseeexactlythisscenarioasmultiplelocalrecordsonasingleindividualfromvarioushostsareaggregatedintothecommondatabase,necessitatingcomplexpatientmergeprocesses.Imaginethatthisnecessitywasanongoing,acceptedprocessaclinicianwouldnotevenknowthelocationofthepatientsdata.Thisproblemcanbeextrapolatedtoincludeanyotherdataelement,andisofparticularconcernwhenthelossofclinicalmeaningisconsidered.Systemsthatstoreinformationofanencounternoteinapictureformatarenottrulyintegrated.AsystembasedonthisapproachwouldturnAHLTAintoaveryexpensivefilingcabinet,astepbackwardintheevolutionofourEMR.Suchsharingofnoteimagesonlyaffordstheconvenienceofavailabilityofthechartforhumanreviewandinterpretationofcontent.Itfailstocapitalizeontheinherentdataprocessingpowerofinformationtechnologies.ThispreventsthehealthcaresystemfromtakingadvantageoftheautomatedtoolsthattheInstituteofMedicinehasreportedwillimprovehealthcare.

PAGE 50

48ArmyMedicalDepartmentJournalPOTENTIALFORERRORSAsthecomplexityofsystemintegrationrises,theriskoferrorsalsoincreases.Interfaceandintegrationworkisrequiredforeachofthedisparatesubsystems,ratherthantothemasterapplication.Mappingandintegrationofpulseoximeterdata,forexample,isrequiredfornotonlytheCOTSemergencydepartmentproduct,butalsotothepulmonary,pediatrics,familypractice,andothersubapplications.Failuretocompletethisworkwouldlikelyresultinthepresentationoferroneousdatatothehealthcareteam.Thebottomline:COTSsoftwaremaysatisfyusersinagivenspecialty,butitisnotthebestchoiceforthepatient,norisitthebestchoiceforthemilitaryhealthsystemandAMEDDsusersasawhole.TheTricareManagementActivityseffortshavebeendirectedtowardsfieldinganEMRthatservestheentirespectrumofpatienthealthcare,withtheneededfunctionalityprovidedwithinnotexternalto,orpartiallyintegratedintoAHLTA.Giventime,theneedsofallspecialtieswillbemetthroughiterativedevelopment.STATUSOFCURRENTENHANCEMENTSAsdiscussedabove,thecurrentstrategyistouseincremental,stepwiseimprovementsinexistingfunctionality,basedoncurrentapplicationsandarchitecture.Thefollowingisasummaryofmajorcurrentefforts,especiallywithregardtotheemergencydepartmentandophthalmology.Thesesubspecialtieshaverequestedmanycapabilitiesthataredesiredbyothers.EmergencyDepartmentFrontEnd(GraphicalUserInterface/GUI)vs.Application.Overthepast5yearstheTricareManagementActivity(TMA)hasheldatleast3requirementssessionswithemergencydepartment(ED)consultantsfromall3militaryservicesineffortstodefinethefunctionalcapabilitiesneededfortheED.Thesecapabilitiesaresometimescollectivelycalledamodule,butthisisamisnomer.ThecapabilitiesneededintheEDoverlapwithmuchofwhatthecurrentAHLTAsystemdoes,aswellaswhatisneededbyotherclinicalareas.AseparateEDmodulemightbenefittheED,butwouldlikelybeduplicativeinsomeareasoffunctionality,aswellaslimitingavailabilityofsomeofthatfunctionalitytootherclinicalareaswhichsharetheneeds.EveniftheMHSmovestotheuseofanEDelectronicmedicalrecordmodulethatispartofaninpatientEMR,theworkdoneaspartoftheEMRwillbenefitotherareas.Additionally,inthiscase,liketheinpatientmodule,theEDmodulewouldessentiallybecomepartofAHLTA.Thetri-serviceEDcapabilitieslistwascreatedtoallowvendorstobidontheinpatientcapabilitiescontractwithEDfunctionalityincluded.Thisfunctionalitygoeswellbeyondawhiteboardandaflowsheet,andTMAscurrentacquisitiontimelineisfor2010orbeyond.TheArmySurgeonGeneralhasaskedTMAtoevaluatewaystoaccelerateinpatientEMRdeployment.AHLTAdevelopmentworkiscurrentlyunderwaytodeliveressentialEDcapability,includingapatienttrackingwhiteboardfunctionwhichcouldbeusedbyallclinics.Italsoincludesimprovementsforflowsheetuse.OphthalmologyMEDCINVocabulary.Duetodirectfeedbackfromeyespecialists,over170neweyetermshavebeenaddedtoMEDCIN,anditsdeveloper,MedicompSystems,Inc.(14500AvionParkway,Chantilly,VA,703-803-8080),ispreparedtoaddmore.ThisvendorhasalsoconsidereduserfeedbackandAMEDDrequestsinthedesignofimprovementstotheirCOTSproduct.AcommoncomplaintisthatMEDCINdoesnotadequatelysupportthestandardophthalmologyclinicaldocumentationprocess.ThatconcernandotherfeedbackhasbeenprovidedtoMedicompwhichisevaluatinghowtorefinetheproductforthisspecialtyrequirement.AsolidfunctionalrelationshiphasbeendevelopedwiththiscompanywhichisofgreatassistanceinmeetingAMEDDsneeds.Gettingcompletesubjectmatterexpertagreementonwhatvocabularyistrulyneededandcorrectisverydifficult.Theuseoffreetextwillremainasanavenuebywhichtomodifystructuredtermstoprovideclarityanddetail.DrawingTool.Acapabilityrequestedbymanyareas,theinitialAHLTAdrawingtoolconsistsofbasicimages,theabilitytoimportimagesofchoicefromyourdesktop,andtheabilitytoimportpicturesfromelsewhere.Theuserwillbeabletowritefreehandontheseimagesincolor.Thebasicimagescanbecopyforwardedintothepatientsnextvisitforupdate.ThetoolwillprovideseveralfeaturesusefultoallAHLTADeploymentStatusandDevelopmentStrategy

PAGE 51

OctoberDecember200649specialties.Theimageswillnowbestructured,allowingastructurednotetobecomposedwhiledrawingonthepicture.Thedrawingcanalsobeachartofresultssothatapaper-likeinputandoutputchartofnumberscanbeenteredandthenoteswillprintlookinglikethechart.Thepotentialofthistoolistremendous.Theassistanceofprovidersinallspecialtiesisneededtocreateanexpandedlibraryofmappedimagestomeetclinicalneeds.TheintegrationoftheadvanceddrawingtoolintoAHLTAwillprobablybegininlate2006.NoteWritingChoices.Currently,anotecanbeenteredbyuseoftemplatesandAlternateInputMethod(AIM)forms.Thiscapabilitywillsoonbeaugmented,firstbytheAdvancedAIM(A3)formandthenwiththedrawingtooldiscussedabove.Templateshavetheadvantageoflocaldevelopmenttoindividualpreferences.AIMformshavetheadvantagethatdeveloperscanincorporatedecisionsupportcapabilitiesintothem.Thisisafeaturethatisjustbeginningtobeused.TheAIMformsaremorelikepaperandaredesignedbyspecialistsinthoseareas.Directfeedbackcanbegiventothedesignerbyclickingonthe?onthelasttaboftheAIMformforyourspecialtyarea.Theadditionofthebasicdrawingtool,theA3form,andtheadvanceddrawingtoolwillprovidemorechoicestomeettheindividualdesiresofthousandsofAMEDDhealthcareprofessionals.TabletPCsandEquipmentChanges.TheAMEDDhasalsochangedthedeploymentconceptofoperationsforcomputers.Tabletpersonalcomputersarenowpartofthehardwarepackagedeployedforproviders.Thiswillpermiteasierdrawing,theuseofhandwritingrecognitionforfreetextcomments,andfacilitatethemovetowirelessatsomepointinthefuture.Drawpadsandscannersarealsobeingfieldedtoallsitesasaresultoffieldinput.EquipmentIntegration/Interface.Interfacingsimpleexternaldevicessuchasvitalsmachinesisnotdifficult;thechallengeisthatthereislittleuniformityofequipmentacrosstheAMEDDandourMTFs,andinterfacingeachandeverypieceofequipmentisnotfeasible.Thatsaid,workisproceedingontheinitialdeviceinterfaces,andanoverarchingplanhasbecomeoneofthetop10end-of-yearitems.Again,thegoalistoimportmappeddata,asopposedtorelativelymeaningless,purelytextdocumentationthatmustbeinterpretedbyhumanreview.Thegenericinterfacecurrentlyunderdesignwillallowtheprovidertoseetheinformationatthetimeofthevisit,andfurtherallowthatinformationtobedigestedintostructureddataforlateruse.Document/LetterWritingCapabilityandStandardFormCompletion.AMEDDhasfundedprojectstoenableboththeproductionofstandardforms(SF,DD,DA)andtheabilitytocreatelettersanddocuments.Again,theseformswillbemappedandintelligent,asopposedtosimpletextfields.Fieldingisexpectedin2006.TheSFtoolwillbecapableofgeneratinganyStandardForm(thoughmappingwillbenecessaryforcreation),andthedocumentcapabilitywillallowcreationofanyformthatthepatientneeds,forsignature,anoteforwork,oranoverprintofinformationforminoreditsinthepreparationofaletter.Aswehavedonewiththeobstetricsummarysheet,pertinentpatientdatacanbepulledintoadefinednoteforasummaryletterorspecialtyreferralletters.PointofCareDecisionSupport.OneofthekeyadvantagesofaglobalEMRwithacommondatasetisthatdecisionsupportisavailableatthepointofcare.Withoutthestandardizeddataset,suchdecisionsupportisnotpossiblebecausethesystemdoesnotknowhowtointerpretitsdataelements.InitiallythecapabilitywillbecomeavailableinAHLTAastheUSPSTF*/individualreminders,andwillbegreatlyexpandedinthepatientregistryandoutcometool,oftencalledtheACPGproject.Thistoolwillallowpatient-centricdatatobedisplayedatthepointofcareasdefinedbythemedicalconditions,status,medications,labresults,andtheclinicprovidingthecare.RefractiveSurgeryInformationSystem(RSIS).TheAMEDDRSISwasrecentlyreviewedbytheArmySurgeonGeneralsChiefInformationOfficerandtheAMEDDAHLTAImplementationandClinicalIntegrationOffice.ItwasdeterminedthattheRSISduplicatesfunctionalityprovidedinAHLTA,withtheexceptionofspecializeddecisionsupport.AmethodtoachievethatfunctioninAHLTAhasbeendefinedandwillbeaccomplishedasanAMEDDinitiative.The *UnitedStatesPreventiveServicesTaskForceAutomationofClinicalPracticeGuideline

PAGE 52

50ArmyMedicalDepartmentJournaldevelopmenteffortwillprovidedecisionsupportbykeepingallthepatientinformationinasinglelongitudinalandsearchabledatabase.FUTUREPLANSTheSurgeonGeneralsdirectivefromtheAMEDDEMRsummitshasbeentouseAHLTAforalloutpatientencountersoncetrainingiscomplete.Likeanysystem,AHLTAisnotperfect,nordoesitprovideexactlywhateveryclinicianorspecialtywantstoday.Forexample,AHLTAstartedworldwidedeploymentwithoutapediatricgrowthchart,butthefactisthatcurrentlythesystemiswidelyusedinboththepediatricandfamilymedicinespecialtiesdespitethisglaringdeficiency.Growthchartswillbeavailableinthenextfewmonths,and,astimepasses,allofourclinicalneedswillbemet.AHLTAusebytheAMEDDhashelpedimprovethesystem,andcreatedbetterunderstandingofhowtheclinicalbusinessprocessesmustchange.Despiteitsproblems,theexistingsystemisusableinalmosteveryoutpatientspecialty.ThecurrentmetricforAHLTAutilizationis95%ofallencountersatamedicaltreatmentfacility.EPILOGUEManyclinicalareasforwardrequeststotheAMEDDAHLTAprogramofficeforthereviewofspecialty-specificCOTSproducts.Basedontheprecedingdiscussion,severalimportantquestionsarealwayspertinent:WherewouldtheintegrationofspecialtyEMRproductsstop?WhodecidesthatanareaissomuchmoreuniquethanotherareasthatitdeservesacustomEMR,penalizingthesafetyandfurtherdevelopmentofthetotalsystemforallusersduetothelong-termrequirementsofintegrationofthatcustomproduct?Mostimportantly,fromthepatients(nottheproviders)perspective,whatisthebestcourseofactiontotake?Finally,itisagiventhatconsensusonwhatconstitutesthebestsystemishardtoachieve.Thisisparticularlytrueinviewoftheglobalandtri-servicenatureofourEMR.Evenwithallthemoney,effort,andsubjectmatterexperttimethatwerespentonotherinterimapplicationsfieldedbytheAMEDD,nonewerecompletelyacceptedbyallusers.ItisthehopeofAMEDDleadershipthatalluserscanworksynergisticallyforrapidimprovementinAHLTA.SuchcooperativeandcollegialeffortwillspeedimprovementsothatwedonotwastelimitedresourcesinpursuitsthatareduplicativecausedelayineffectivedeploymentandutilizationofanEMR.AUTHORS LTCMoodyistheProgramManagerforAMEDDAHLTAImplementationandClinicalIntegrationattheEisenhowerArmyMedicalCenter,FortGordon,Georgia.MAJAaronsonistheAHLTAFunctionalRequirementsandIntegrationofficer.HeisassignedtotheOfficeoftheChiefInformationOfficer,OfficeofTheSurgeonGeneral,AMEDD,FallsChurch,Virginia.DrBuisingistheClinicalInformaticsOfficerintheInformationManagementDirectorate,OfficeofTheSurgeonGeneral,AMEDD,FallsChurch,Virginia.COL(Ret)BartonistheSeniorAdvisortotheAMEDDAHLTAImplementationandClinicalIntegrationOffice.HeisaHealthCarePolicyAnalystattheWalterReedArmyMedicalCenterinWashington,DC. AHLTADeploymentStatusandDevelopmentStrategy

PAGE 53

OctoberDecember200651AREWEMEASURINGTHECORRECTMETRICS?TheArmyMedicalDepartment(AMEDD)andotherhealthcareorganizationsexpendmuchtimeandeffortoncoding.Thisinvestmentofpersonnel,time,andmoneyincludessignificanteffortstomonitorcoding.Often,thestatedgoaloftheseeffortsistoimprovecodingaccuracy.Unfortunately,aswithmanyotherhealthcareorganizations,theAMEDDhasnotshowncontinuedimprovementincodingaccuracy,despitesubstantialinvestmentinpersonnel,time,education,andmonitoringofthismetric.Thehealthcareteammayhavelittleunderstandingoftherelationshipbetweencodingaccuracyandoutcome,ormayquestionifsucharelationshipevenexists.Therefore,thefollowingquestionsmustbeasked:Arewemonitoringthecorrectcodingmetrics?Whatisthedesiredoutcomeofmonitoringthesemetrics?Canmonitoringthesemetricsimprovethedesiredoutcomes?ArecurrentmetricsadequateformonitoringLeanSixSigmabusinessimprovementprocessescurrentlyemphasizedbyAMEDDleadership?Inordertoaddressthesequestions,itisimportanttobeawareofthehistoryofmedicalcoding.CODINGCLASSIFICATIONHISTORYTheInternationalClassificationofDiseases(ICD)wasdesignedtopromoteinternationalcomparabilityinthecollection,processing,classification,andpresentationofmorbidityandmortalitystatistics.1Thenameandhistoryofthemoderndaycodingsystemindicatethatthesystemwasdesignedtodowhatcomputerizedmedicalrecorddatabasescannowdotoevengreaterlevels.In1893,aFrenchphysician,JacquesBertillon,introducedtheBertillonClassificationofCausesofDeathattheInternationalStatisticalInstituteinChicago.AnumberofcountriesadoptedDrBertillonssystem,andin1898,theAmericanPublicHealthAssociation(APHA)recommendedthattheregistrarsofCanada,Mexico,andtheUnitedStatesalsoadoptit.TheAPHAalsorecommendedrevisingthesystemevery10yearstoensurethesystemremainedcurrentwithmedicalpracticeadvances.Asaresult,thefirstinternationalconferencetorevisetheInternationalClassificationofCausesofDeathconvenedin1900,withrecurringsessionsevery10yearsthereafter.Atthattimetheclassificationsystemwascontainedinonebookwhichincludedanalphabeticindexandatabularlist.Indeed,thebookwassmallcomparedwithcurrentclassificationtexts.Therevisionsthatfollowedcontainedminorchanges,untilthesixthrevisionoftheclassificationsystem.Withthesixthrevision,theclassificationsystemexpandedto2volumes.Thesixthrevisionincludedmorbidityandmortalityconditions,anditstitlewasmodifiedtoreflectthechanges:ManualofInternationalStatisticalClassificationofDiseases,InjuriesandCausesofDeath(ICD).In1948,theWorldHealthOrganization(WHO)becametheorganizationresponsiblefordevelopingandpublishingrevisionstotheICD.Inthiscapacity,theWHOrevisedandpublishedtheseventhandeighthrevisionsin1957and1968,respectively.TheninthrevisionoftheICD(ICD-9)waspublishedin1978.TheUSPublicHealthServicemademodificationstomeettheneedsofAmericanhospitalsandcalleditInternationalClassificationofDiseases,NinthRevision,ClinicalModification(ICD-9-CM).ThisremainstheeditionusedforoutpatientcareintheUnitedStates.WorkbeganonICD-10in1983andwascompletedin1992.ICD-10expandsthenumberofclassificationsto10timesthatfoundinICD-9.Thisexpansionofclassificationhasoccurredfarmorerapidlythantheexpansionofmedicaldiagnosis.ICD-10,althoughreportedtosimplifycoding,notonlyincreasesthenumberofclassificationcodes,butalsothenumberofalphanumericcodesneededtoreportElectronicMedicalRecords,MedicalCoding,andOutcomeImprovementLTCRonMoody,MC,USA

PAGE 54

52ArmyMedicalDepartmentJournalthem.TheRandCorporationhasestimatedthatthecostintheUStoswitchtoICD-10couldbeashighas$1.2billion.2TheconstantchangesnecessaryinthehealthcaresystemtomeetthecontinuingchangestotheICDclassificationsystemrepresentsanotherhiddenhealthcarecost.AdoptionofICD-10classificationwasrelativelyswiftinmostoftheworld,butnotintheUnitedStates.Since1988,USlawrequiresuseofICD-9-CMcodesforMedicareandMedicaidclaims.Withthepassageofthislegalrequirement,mostoftherestoftheAmericanmedicalindustryfollowedsuit.Despiteanextensiveliteraturesearch,nodetailedinformationcouldbefoundoneithertheportionofhealthcareexpensesrelatedtomedicalcodingorthetotalcostofcodingintheUSfrom1980-2000.Thereviewwasundertakentocomparetheimpactofthe1988mandatetouseICD-9codesformedicalbillingonhealthcarecost.ICDcodingisadiseaseclassificationsystemthathasbecometiedtomedicalreimbursementasaresultoflegislativeactions.Thisdiseaseclassificationsystemisnotalwayssynonymouswithclinicaldiagnosis.Aspresentlyconducted,codingaddstotheadministrativecostofprovidingmedicalcare.Thoughinitiatedasaclassificationsystemthroughwhichtorecordandanalyzediseaseprevalenceandoutcome,thesystemhasgrownincomplexityandcost.Theutilizationofelectronicmedicalrecordswhichusestructureddataentryandcontinuallyupdatedcodingtablesandalgorithmsmayalloweasierandlessexpensivedatasourcestoanalyzediseaseprevalenceandoutcome.Therelationaldatabasesoftheelectronicmedicalrecordwilllikelyprovidegreateropportunitiestodeterminecausation.Unfortunately,thecontinuedcomplexityandexpansionofICD-10willprobablyresultincontinuedissueswithcomplianceandaccuracy,withoutimprovingoutcomes.CODINGMETRICSAspreviouslydiscussed,oneoftheprimarymetricsusedtoassesscodingisoftentermedaccuracy.AccuracyisdefinedbyWebstersasfreedomfrommistakeorerror;conformitytotruthortoastandardormodel;degreeofconformityofameasuretoastandardoratruevalue.Themilitaryhealthcaresystemalsomonitorscomplianceorcompletionbytimelinessandadherencetoregulationandguidance.Codingaccuracyisoftendefinedasareproducibleconclusionbasedontheclinicalinformation.Anevaluationandmanagement(E&M)codeisconsideredtobeaccurateiftheE&Mlevelchosenbytheperson(orcomputer)isthesameastheonetheauditorwouldselect.Theauditormayhavemorecodingknowledgebutisapplyingthesamesetofrules.Studiesofcodingaccuracyusingthismethodhaveshownpoorcodingbyprovidersandpooragreementbetweencodingagencies.3,4Reportsofhighercodingaccuracylikelyindicatehigherintercoderreliabilityorconsistency,whichmayormaynotreflectgreateraccuracy.Therefore,thereproducibilityofcodingisreallywhatismeasured,ratherthanaccuracy.Studiescomparingelectronicmedicalrecord(EMR)codingaccuracytohumancodingaccuracyhaveshownpromise.5AnEMRthatinvolvescreationofanencounternotebyusingstructureddataallowsthedirectcaptureandreportingoftheworkperformed.Thehealthcareperformedcanbeprocessedusingsoftwarealgorithmstodirectlyrecordproceduresandtodeduceanevaluationandmanagementcodeforthevisit.Thecomputer-basedalgorithmprovidesahighlyreproduciblecode.ApotentiallymoreusefulmetricformonitoringE&Mlevelusageisappropriatenessandtheuseofstatisticallyrelevantmeasurementsofvariation.ThemetricofappropriatenessevaluateswhetheraproperE&Mcodelevelwasselected.Thisdependsonpatientstatus,typeofservice,andlevelofcareprovided.Variationlooksatthepatternofcodingtoindicatepossibletrendsindicatingup-ordown-coding.Calculatedresultscanbeeasilyrepresentedgraphically,withE&Mcodedistributionsdisplayedbyclinicandindividual.Thisresultcanbecomparedtonationalnorms.Ifastandarddistributionispresent,thenE&Maccuracyislikelypresent.Also,anauditcouldsimplyanalyzethevariationofcodebetweenoriginallydocumentedcodesandtheauditedcodestodeterminethenumberofencounterscodedonelevelhigherandlower.Thestandarddeviationcouldbereportedusingstatisticalmethods,allowingthedeterminationofanyvariationthatmaybestatisticallysignificant.TheE&Mcodeisinfluencedbymultiplefactors,themostcommonbeingpatientstatus,settingofcare,servicetype,andexamtype.TheselectionoftheappropriategroupcansignificantlyalterreimbursementasdemonstratedintheTable.EMRsElectronicMedicalRecords,MedicalCoding,andOutcomeImprovement

PAGE 55

OctoberDecember200653canquicklyreconfigurecodinginformationusingtheseparametersbaseduponuseractionorautomaticallybaseduponspecificcriteria.ThereportingofappropriatenessallowsforprocessimprovementtooccuronspecificE&Mcodingbehaviors.Forexample,thetypicalwell-womanexamorwell-childvisitshouldbecodedwithpreventivemedicineE&Mcodes.Ifthisisnotoccurring,theevaluationofcodingappropriatenesswouldsuggestthatprocessimprovementmeasuresarenecessarytoevaluateandcorrecttheclinicorhealthcareteamprocess.AsecondaspectofevaluatingcodingistheuseofCurrentProceduralTerminology(CPT)andHealthCareFinancingAdministrationCommonProcedureCodingSystem(HCPCS)codes.Thesecodesimpactrelativevalueunitsandreimbursement.ReportsontheuseofCPTandHCPCScodesarealsooftenreportedbasedonaccuracy.Accuracydoesnotindicatethenatureorcauseofanyinaccuracy.Potentialalternativemetricstohelpimprovecodingwouldbereportsonthefollowingdata,whichspecifiesbehaviorthatcanbemonitoredandcorrected:PercentofallchartswithfailuretodocumentCPTcodePercentofallchartswiththewrongCPTcodePercentofallchartswithfailuretodocumentHCPCScodePercentofallchartswiththewrongHCPCScodeAfinalaspectofcodingthatisoftenaddressedundertherubricofaccuracycansimplybelabeledasother.Thisisthebodyofrulesthatmakecodinganart.Theserulesaredetailedinthe1995and1997CPTManuals.Theexistenceof2setsofrulesthatcandefineaccuracyfurthercomplicatesmedicalcoding.Regulationscovermanyaspectsofhowcodesareassigned,suchasthecorrectprioritizationoflistedICD-9codes,theassociationofCPT/ICD-9,andotherrulesthatimpacttheselectionoftheclassificationtermwhichdoesnotimpactthemedicaldiagnosis.Thelattergroupispertinenttothisdiscussion.Currentcodingguidelinesstatethatafifth-levelcodeshouldbeutilizedTheguidelinesfurtherstatethatrarelyshoulda3-digitcodebeutilized.Thereasoncitedistogiveamoreaccuratediagnosis.Thisisafalseassertionbecause,aspreviouslystated,ICD-9isaclassificationsystemandnotadiagnosticsystem.Thecodingofmanyencountersislistedasinaccurate,eventhoughthecorrectdiagnosisislisted.TheinaccuracyisbasedontheneedtomeetICD-9classificationsystemguidelines,notdiagnosticaccuracy.Itisunclearifamoredetailedreportingofclassificationhasresultedinbetterpopulationhealthcareoutcomesorlowertotalhealthcarecost.ThisisanotherareawhereEMRsprovideapowerfuladvantage.Theuseofclassificationsystemsarosepriortothecreationofstructureddatabases.AnEMRusingastructureddatabaseallowsthepatientsconditiontobedocumentedandstratifiedingreaterdetailbaseduponsymptoms,physicalfindings,diagnostictestresults,Relativevalueunitsfortypesofservice,illustratingtheimpactofserviceclassificationonreimbursement.E&M*CodeDescriptionRelativeValueUnit 99201NewPatientFocusedProblem0.45 99202NewPatientExpandedProblem0.88 99203NewPatientDetailedProblem1.34 99204NewPatientComprehensiveProblem2.00 99205NewPatientComprehensiveHighProblem2.67 99211EstablishedPatientFocusedProblem0.17 99212EstablishedPatientExpandedProblem0.45 99213EstablishedPatientDetailedProblem0.67 99214EstablishedPatientComprehensiveProblem1.11 99215NewPatientComprehensiveHighProblem1.17 99241ConsultationPatientFocusedProblem0.64 99242ConsultationPatientExpandedProblem1.29 99243ConsultationPatientDetailedProblem1.72 99244ConsultationPatientComprehensiveProblem2.58 99245ConsultationPatientComprehensiveHighProblem3.42 *Evaluationandmanagement

PAGE 56

54ArmyMedicalDepartmentJournalandothercoexistentdiseaseprocesses.EMRscanfacilitatetrulystandardizedreportingofclinicalandbusinessdata.Theuseofstructureddataanddatabasesallowstheautomaticcreationofregistriesalongwithdirectmonitoringofoutcomes.StructurednotesalsopermitthebillingofE&Mlevelsbasedonrecordedinterventionsandactionsinawaythatismeasurableandreproducible.EMRS,CODING,ANDTHEBUSINESSOFMEDICINEWithsuchpotentialbenefitstoimprovemedicalcareandbusinessmanagementalongwithpotentiallyreducingspiralinghealthcarecosts,itseemsoddthatEMRsarenotrapidlybeingadopted.ThisisparticularlytruewhentheadvocacyforEMRuseisreviewed.PresidentBushhascalledforuniversalutilizationofEMRsby2014.ArecentRANDCorporationreportestimatesthat$182billioncouldbesavedannuallyfrommedicalITadoption.2Althoughfinancialsavingsareimportant,theimprovementofhealthoutcomesisthetruecorebusinessofmedicine.In1999,theInstituteofMedicine(IOM)releasedastudytitledToErrisHuman.6Thereportemphasizesthatthehealthcaresystemshouldbesafe,timely,efficient,effective,patient-centered,andequitable.Subsequently,in2001theIOMreleasedCrossingtheQualityChasm,7whichconcludesthat:Initscurrentform,habits,andenvironment,Americanhealthcareisincapableofprovidingthepublicwiththequalityofhealthcareitexpectsanddeserves.Neitherstudystatesthattheindividualsonthehealthcareteamareincapableofdeliveringbetterormorecost-effectivecare.Thereportsalsodonotindicatethatahighervolumeofcareiswhatisneeded.Theissueisclearlyoneofeffectivenessofhealthcareandnotproductivity,asmeasuredbynumberofencounters.Thisiswhyitiscriticaltoestablishanaccurateandreproduciblemethodforreportingthevalueofhealthcaredelivered(measuredbyrelativevalueunits)astheUnitedStatesmovestowardthepossibilityofperformance-basedpaymentsystems.DespitetheevidencesupportingtheroleoftheEMRinhelpingtoimprovehealthcareoutcomes,thecostofautomationisoftenstatedasabarriertoimplementation.ChangestobusinesspracticemustoccurwithuseofanEMRforfullfinancialbenefit.8,9Tofacilitatearapidmovetobetterhealthcareoutcomesanddecreasedhealthcarecosts,clinical-businessreorganizationshouldalignchangesinbilling/reimbursementwiththeuseofEMRs.RECOMMENDATIONS1.Focuscodingmonitoringonmetricsthatprovideactionabledata:a.E&Mcodingvariationfromcoder/auditorreview:i.Percentofcodesconsistentwithcoder.ii.Percentofcodesonelevelhigher.iii.Percentofcodesonelevellower.iv.Percentofcodes2ormorelevelshigher.v.Percentofcodes2ormorelevelslower.b.IncorrectE&Mclassbaseduponinappropriateuseofservicetype,patientstatus,locationofcare,ortypeofexamlisted.Metric:NumberofrecordswithwrongE&Mclass/totalrecordsreviewed.c.Modifier(s)requiredbutnotused.Metric:Numberofchartsrequiringmodifier/totalchartsreviewed.d.Diagnosiscodes:i.ICD-9use:WrongICD-9codeassignedforthediagnosisenteredonthechart(codeanddescriptionmismatch).Metric:PercentageofICD-9codesthatmatchbetweenthewrittenrecordandrecordofbillingforallrecordsreviewed.ii.Vcodes:FailuretouseVcodeswhenappropriate.Metric:NumberofrecordswithfailuretouseVcodes/totalAHLTA*-codedrecords.iii.SequencingofICD-9codes.Metric:Percentofincorrectsequencing/totalrecordsreviewed.e.ProcedureCodes:i.FailuretoincludeCPTcodewhenactionwasdocumented.Metric:PercentofrecordsmissingCPTcode.ElectronicMedicalRecords,MedicalCoding,andOutcomeImprovement *Seerelatedarticleonpage40.

PAGE 57

OctoberDecember200655ii.WrongCPTcodechosenforproceduredocumented.Metric:PercentageofrecordswithincorrectCPTcode.iii.FailuretouseHCPCSLevelIIcodeswhenappropriate.Metric:PercentageofencountersmissingHCPCScodewhendocumentationsupportstheiruse.2.Establishprocessimprovementmeasurestousetheabovemetricstoimprovethesystem.3.EvaluatetheroleofcoderswithuseoftheEMR.ThewideadoptionoftheEMRwillresultinchangesintheroleofcoders.Humancodingskillsmaybeneededmoreinthehighlycomplexandprocedure-orientedclinicalareas.Theremayalsobeatransitiontotherolesofauditor,processimprovement,andconsultantstotheclinicalteam.4.LegislativeChanges:LegislativechangesshouldbeconsideredthatallowdirectelectronicMedicarebillingwheninvoicesaresentfromapprovedEMRsthatusestructured-textentry.ThiswillgivedirectfinancialincentivetoadoptuseofEMRsbynegatingthehealthcarepractitionerscurrentfinancialburdenofcontinuingtofundcodinginfrastructurewithEMRimplementation.Theswitchtostructured-entry-basedEMRsshouldprovideamorereliableandconsistentreportofactualhealthcarework.Thetransitionwillbefacilitatedinthesamemannerthatthe1987legislativeactionmovedtheUnitedStateshealthcaresystemtotheuseofICDcodesforreimbursement.CONCLUSIONThetransitiontoanduseofEMRsthatusestructured-dataentrywillhelptoimprovehealthcareoutcomesanddecreasecost.Thetransitionmustbecoupledtoclinicalandbusinessprocesschanges,suchascoding/billingtoexpeditenationalEMRintegrationandusage.Thistransition,whichcouldbeaidedbylegislativechanges,couldalsohelpachievetheoriginalintentofICDusemorereliablereportingofdiseaseclassificationandmorestandardizedbillingpractices.REFERENCES1.HistoryofICD.WorldHealthOrganization.Avaliableat:http://www.who.int/classifications/icd/en/HistoryOfICD.pdf.2.LibickiM,BrahmakuiamI.ThecostsandbenefitsofmovingtotheICD-10codesets.TR-132-DHHS.RANDCorporation.March2004.Availableat:http://www.rand.org/pubs/technical_reports/2004/RAND_TR132.pdf.3.KingMS,SharpL,LipskyMS.AccuracyofCPTevaluationandmanagementcodingbyfamilyphysicians.JAmBoardFamPract.2001;14:184-192.4.BentleyP,WilsonA,DerwinM,ScodellaroR,JacksonR.Reliabilityofassigningcurrentproceduralterminology-4E/Mcodes.AnnEmergMed.2002;40(3):269-274.5.MorrisW,etal.AssessingtheAccuracyofAutomatedCodingSystemsinEmergencyMedicine.ProceedingsoftheAMIA2000AnnualSymposium.November2000.AmericanMedicalInformaticsAssociation.Availableat:http://www.alifemedical.com/documents/LifeCodeEMPerformanceAMIA2000.pdf.6.InstituteofMedicineoftheNationalAcademies.ToErrisHuman.1999.Availableat:http://www.iom.edu/CMS/8089/5575.aspx.7.InstituteofMedicineoftheNationalAcademies.CrossingtheQualityChasm:Anewhealthsystemforthe21stcentury.2001.Availableat:http://www.iom.edu/CMS/8089/5432.aspx.8.WongS,etal.Acost-benefitanalysisofelectronicmedicalrecordsinprimarycare.AmJMed.April2003;14(5):397-403.9.EbellM.Integratinginformationtechnologyintoclinicalpractice.ClinicsinFamMed.December2003:5(4):1027.AUTHOR LTCMoodyistheProgramManagerforAMEDDAHLTAImplementationandClinicalIntegrationattheEisenhowerArmyMedicalCenter,FortGordon,Georgia.

PAGE 58

56ArmyMedicalDepartmentJournalINTRODUCTIONAsanationatwarwemustleverageinformationforvictory.Armytransformationisbringinginformationintoaction.Healthtransformationinvolvesreducingcostandimprovingcarebyoptimizingthepotentialusesofmedicalinformationsystems.Armymedicinehasmadesignificantprogressintransformationofmanyareasofinformationmanagement,frommedicalreadinesstocontinuityofcare.FortLewis,withitstransformingunitsandhighlydigitizedmedicalcenter,isaconvergenceoftheoverallArmystransformationwithArmymedicaltransformation.Anobjectiveintegratedsystem,however,remainsadistantgoal.Thisreportdescribesthetacticalrequirements,theprogressoftheStrykerBrigadeCombatTeams(SBCTs),andtheprocessandsystemsinvolvedinachievingafunctionaltacticalelectronicmedicalrecord.MEDICALREADINESSTheDepartmentofDefense(DoD)definesmedicalreadinessastheabilitytomobilize,deploy,andsustainfieldmedicalservicesandsupportforanyoperationrequiringmilitaryservices;tomaintainandprojectthecontinuumofhealthcareresourcesrequiredtoprovideforthehealthoftheforce;andtooperateinconjunctionwithbeneficiaryhealthcare.1MedicalreadinesscanbefurtherbrokendownintoSoldierhealthreadiness,individualmedicaltraining,unitlevelmedicaltraining,medicalequipmentmaintenanceandlogistics,andtheSoldiersfamilyhealthreadiness.SoldierhealthreadinesstracksmeasuresoftheindividualSoldiershealth.Somemeasures,suchasdentalreadiness,arerequiredfordeployment.Othermeasuresmustbemetpriortoattendingschools,suchastheperiodicphysical.Inrecentyears,cardiovascularhealth,combatstressinjuryprevention,andphysicalinjurypreventionhavebeenrecognizedasimportantmeasuresforscreeningaSoldiershealthreadiness.Anidealhealthreadinesssystemwouldbeintegratedwiththetacticalelectronicmedicalrecordsothatmedicalscreenings,diagnostics,andinterventionswouldbeenteredastheyareperformed.SuchasystemwouldallowthemedicalhistoriestobeeasilyaccessiblebyamedicaladvisorwhocouldanalyzeandpresentdatatoensurethatthecommandknowsthecurrenthealthstatusoftheirSoldiers.Awell-trainedforcehasbeenrecognizedascriticaltothesuccessofanarmysincethewarsofthePrussianking,FredricktheGreat(17401778).TheUSArmyrecognizestheimportanceofawell-trainedmedicalforceandcontinuestoimproveitstraining.Commandsurgeonsmusttrackandsuperviseallmedicaltrainingintheirunit.Foranoperationalunitthisincludesthe91W(medic)transitionandsustainmenttraining,CombatLifeSaverProgram,FieldSanitationTeamtraining,trainingforlowdensitymilitaryoccupationalspecialtieslikelabandradiologytechnicians,physicianassistants,andProfessionalFillerSystemphysiciantraining.Anintegratedinformationsystemallowstrackingofthatandanyadditionaltrainingaunitmaymandate,suchastacticaltraumatraining.Medicalunittrainingisalsoimportant,ensuringthatmedicalplatoons,medicalcompanies,andechelonabovebrigadeunitsaretrainedtostandardsoutlinedintheirArmyTrainingPlans.Thattrainingmustalsobetrackedandmonitored.Therealtimesustainmentofmedicalforcesisveryimportantformedicalreadiness.Anintegratedinformationmanagementsystemshouldprovidevisualizationofcurrentdataandenhancecoordinationfortacticalmedicalcare.Plannersatalllevelsmustknownotonlythestatusofindividualpatients,butthestatusofevacuationassets,cot/bedstatus,medicalequipmentoperability,classVIII,andblood.Anintegratedsystemshouldallowsupplyrequeststobegeneratedautomaticallyassuppliesareusedorpartsareneeded.TheTacticalElectronicMedicalRecord:TheKeytoMedicalTransformationLTCEdwardMichaud,MC,USACPTMichaelMcClendon,MS,USALTCKeithSalzman,MC,USA

PAGE 59

OctoberDecember200657ThehealthofaSoldiersfamilyisalsoacriticalpieceofourArmysoverallmedicalreadiness.WorldclasshealthcareprovidedtoourSoldiersspouse,children,andotherdependentsallowsourSoldierstoexecutetheirmission,assuredthattheirfamiliesarewellcaredforintheMilitaryHealthSystem.Familyadvocacyeffortsareimportant,notjustbecausecaringforourSoldiersfamiliesistherightthingtodo,italsomakestheArmyfamilystronger.Anobjectivesystemwouldallowaunitscommandsurgeontotrackfamilyhealthissuesandadvisehiscommanderofidentifiedneeds,therebyimprovingtheunitsmedicalreadiness.CONTINUITYOFCAREElectronicaccesstopatientmedicalinformationclearlyimprovestheoverallqualityofcare.Militaryhealthprovidersappreciatetheimportanceofmedicalrecorddocumentation.However,thecurrentmethodofrecordingandstoringonpaperthemedicalrecordinformationofourSoldiers,civilians,contractors,anddetaineesisinadequateinthatdocumentationisrarelyavailableforreviewatthepointofcare.TheGovernmentAccountingOfficereportsthatthestateofcurrentmedicaldocumentationwithintheDoD,althoughvariable,isgenerallyverypoor.2Providersneeddocumentationofpriorencounterstoproperlycareforapatient.Informationsuchasthedifferentialdiagnosis,treatmentplan,proceduresperformed,andpatientexposuresareexamplesofcriticalinformationthat,whenabsent,canadverselyaffectqualitycare.OftenSoldiersneglecttotellthecaregiversignificantaspectsoftheirpastmedicalhistory.Thetreatingprovidermusthavetheabilitytoobtaininformationfrompastencounters,suchaslaboratoryresults,x-rays,andotherrelevantclinicalinformation.Tobeeffective,theelectronicmedicalrecordmustprovidethathistoricalclinicaldocumentationforreviewbythecaregiverwhereverandwheneverrequired.TheavailabilityofinformationwithinthedirectsequenceofaSoldiersmilitarycaregiversisnottheonlycapabilityoftheelectronicmedicalrecord.AspartoftheconceptofhealthinformationexchangeadvocatedbytheInstituteofMedicine,clinicalcareinformationmustalsomoveacrosstraditionalbusinessboundaries.3Tothatend,ourobjectivesystemmustnotonlyacceptinformationfromavarietyofdifferentsources,butalsobeaccessibletoavarietyofdifferentorganizations,eg,civilianfacilitiestowhichaSoldiermaybereferredorpresentforemergencycare.Asystemthatdoesnotallowsuchcapabilityisnotacceptable.CONFIDENTIALVSSECRETWhenconsideringthemosteffectiveuseofelectronicinformationincombatsituations,itisimportanttoconsidertheconfidentialityofpatientinformationandtheoperationalsecurityoftacticalinformation.PatientconfidentialitywasformalizedintheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA)4whichcodifiedconfidentialityrequirementsformedicalpractice.HIPAAcreatedtheimpetusformanyphysicianstoadopttheelectronicmedicalrecordtosimplifycompliancewiththeconfidentialityrequirementsforbillingandothermedicallyrelatedrecords.Intodayscombatunits,mostinformationistransmittedonsecretnetworks.Attemptshavebeenmadetousesuchnetworksfortheexchangeofdigitizedmedicalinformation.Themajorimpedimenttothisisthatmedicalinformationisclassifiedasconfidential,notsecret.Mostproviderscannotaccesssecretnetworks,somedicalpersonnelcanneitherenterthedata,norretrieveitfromthenetwork.Further,ifdeployedprovidersweregrantedaccesstosecretnetworksforexchangingmedicaldata,providersinUSfixedfacilitieswouldstillnothaveaccesstothatdata.ContinuityofcarewouldthereforebecompromisedasaSoldiersphysicianintheUSwouldhavelimitedornoaccesstoinformationenteredintothesystemduringdeployment.Tacticalelectronicmedicalinformationobviouslyhasthegreatestutilityandvaluewhenallprovidershaveaccesstoit.Therefore,medicalinformationmustbeenteredintoasystemwhichisaccessiblebyhealthcareproviderswhoneeditquicklyatdifferentlocations.Aweb-basedsystemseemstobethemostlogicalvehicleasproviderspotentiallycouldaccessitfrombothaidstationsandhospitalsintheUS.However,operationalsecurityrequirementsdictatethatinformationwhichmaybeofvaluetotheenemymustbesafeguardedwithrestrictedaccess.Certainlythereareinstancesinwhichcertainaggregatemedicalsummariesshouldbeclassifiedassecret,eg,casualtiesfromagivenunitorlocationonagivendate,ortheamountofclassVIIIrequirementsfromaunit.Accesstothistypeofdatamustbelimitedandmadeavailableonlyonthesecretinternet.

PAGE 60

58ArmyMedicalDepartmentJournalMEDICALSURVEILLANCEANDHEALTHOUTCOMESMedicalsurveillanceisimportantformaintenanceofthehealthofanypopulation.Inthemilitary,aunitcommanderhasspecialresponsibilityforthehealthofhisSoldiers.Themilitaryalsohasseveraluniqueadvantagesinmaintainingandimprovingpopulationhealth.Thoseadvantagesincludeapopulationwhichisnormallylocalizedandmotivatedforimprovedhealth,andprescribedperiodicopportunitiestoeffectchangeinindividualandgrouphealth,suchasregularphysicalexaminations,mandatorybriefs,andSoldierReadinessProcessingevents.Asthecommandersadvisorandhisinstrumentforpopulationhealthmanagement,theunitsurgeonmusthavetheabilitytotrackinjuriesanddiseasestoidentifyandanalyzetrends,andadvisethecommanderontheoptimumapproachtokeephisforcehealthy.Theunitsurgeonwillthentaketheleadinimplementingthoseefforts.Healthoutcomes(benefitsperformancemetrics)isamuchsoughtafterfeatureoftheelectronicmedicalrecord.5Practiceimprovementsintheoperationalenvironment(traininganddeployed)wouldgreatlyexpandwithacomprehensivetacticalelectronicmedicalrecord.Suchimprovementswouldextendasfarforwardashealthcareisdeliveredanddocumented.Asscientists,wehavetheresponsibilitytodemonstratethatoureffortstoeffectchangeinpopulationhealthare,infact,effective.TheidealelectronicrecordwouldbeabletotrackICD-9diagnoses,labresultsincludingabnormalcultures,x-rays,andmedications.Easilyaccessiblecommoninformationwouldallowthesurgeonssectiontotrackinjuries,infections,combatstress,andmanyothermetrics.EarlydetectionoftrendscouldallowearlyinterventionandavoidanceofsimilarproblemsforotherSoldiers.Outcomesofthoseinterventionscouldthemselvesbetrackedtomeasuretheireffectiveness.MEDICALREGULATIONMedics,commanders,andSoldiersfamiliesareallconcernedabouttrackingSoldiersonthebattlefield.AnidealsystemwouldallowthetrackingofSoldiersthroughoutthemedicalsystemasoutpatients,inpatients,andduringevacuationanywhereintheworld.Forexample,FederalExpressandUnitedParcelServicecantrackpackagesintheircustodyanywhereintheworld.Incontrast,moreoftenthannotwehavedifficultyrespondingtoaFirstSergeantsinquiryaboutwhetherornotaSoldierwasseenatsickcallonagivenmorning.Anidealsystemwouldallowanymedicalproviderorsupportstafftoquicklydeterminewhere,when,andbywhomaSoldierwasseen.Itshouldalsobeabletotrackthedispositionateachlevelofcare,ie,returnedtoduty,keptforobservation,orevacuated,andnotethetimeofdisposition.Itshouldalsotrackpatientsastheypassthroughvariousmilitaryhospitalsaroundtheworld,andgiveaccuratemedicalstatusandprognosticinformation.Doctrinally,evacuatedSoldiersarenolongertheresponsibilityoftheirunit.This,ofcourse,makesnosensetothefamilymemberatFortLewiswhoattemptstoobtaininformationabouttheirSoldiersconditionfromareardetachmentcommander,whoisdependentoninformationfromthemainbodyofhisunit,primarilythesurgeonssection.TheUSTransportationCommandimplementedtheRegulationandCommand&ControlEvacuationSystem,aseparateweb-basedsystemusedtotrackpatientsonmedicaltransportationflightsfromdeparturetodestination.Althoughthissystemisagoodtool,butitdoesnottrackintratheatermovementofpatientsnoronwardmovementfromthepatientsdestinationfacility.ItalsodoesnotprovidespecificinformationtoaSoldiersunitastohistreatmentandprognosis.VERTICALANDHORIZONTALMOVEMENTOFINFORMATIONTheinformationavailableinthetacticalelectronicmedicalrecordsystemshouldincludeaunitsmedicalreadinessstatistics,medicalsurveillance,medicalregulation,andhealthcarelogisticsinformationandneedstobesharedbothverticallyandhorizontally.Individualsandunitsdowntothelowestlevelinthechainofcommandshouldreceivecertaininformationbutalsohaveaccesstoadditionalsourcesasneeded.Higherechelonsshouldhaveaccesstodetailedinformationfromsubordinateunitsinremotelocations.Highercommandsmayhavearequirementtocollectdatafromlargesegmentsofapopulationtoconducttheater-widepopulationhealthresearchorsyndromicsurveillance.Horizontalsharingofinformationbetweenbattlefieldoperatingsystemsisimportant.Medicalandpersonnelstaffmusthavetheabilitytocomparenoteswithregardtocasualties,andmustshareinformationonphysicalexams,dentalTheTacticalElectronicMedicalRecord:TheKeytoMedicalTransformation

PAGE 61

OctoberDecember200659exams,andpermanentprofilerestrictions.Fartoolittleinformationiscurrentlysharedbetweenmedicalandpersonnelsections.FlowofpertinentnonconfidentialinformationtotheElectronicMilitaryPersonnelOfficeisimportant.Militarymedicalorganizationsmustdesignasystemtoshareinformationeffectivelyandefficiently.Medicalinformationmustalsobesharedamongtheservices,withDoD,theVeteransAdministration,andsomeothergovernmentandciviliansystemstoadequatelycareforSoldiersandtosupportcommanders.TRAINASYOUFIGHTTherearemanychallengesinvolvedintheadoptionofsystemswhichareusedonlyduringdeployment.ThebiggestchallengeisensuringthatSoldiersmaintainalevelofproficiencyonsuchasystemwhileingarrison.Systemmaintenanceisanothermajorconcern.Thesystemmustworkwhenneeded.Therefore,anidealsystemforthemilitaryenvironmentwouldbeusedbothingarrisonandinthefieldforthecareofourpatients.Suchasystemwillsupportthesamedailybusinessataidstations,TroopMedicalClinics(TMCs),andhospitalclinics,andrequirethesametrainingforallenvironments.Bothgarrisonandfieldcarewouldbedocumentedintoandretrievablefromthesamesystem.CONNECTIVITYISKEYTherearemanyavailableoff-the-shelfmedicalprogramsthatcouldbeadaptedtomeetthetacticalneedsofourmedicsandproviders.Thekeyisnottheprogram,butconnectivity.Ifinternetconnectivityisavailable,atacticalelectronicmedicalrecordshouldbeavailableforuse.Althoughthesystemshouldbeflexibleenoughforuseonastandalonebasisforthosetimeswhenconnectivityisnotavailable,planningforregularandreliableconnectivityiscritical.Earlyplanning,supportingdoctrine,andinclusionofpersonnelandequipmentassetsintheModifiedTableofEquipmenttosupportmedicalinformationsystemswillensureavailabilityofconnectivityandfunctionalitywhereveraunitmaybedeployed.ADDITIONALBENEFITSOFMEDICALCONNECTIVITYThereiscurrentlyahighlevelofcommunicationscapabilitiesexistingwithinthemedicalchainofconcern.ContactwithCONUSformedicalconsultationisavailableattheBattalionAidStationLevel.Thismaybeassimpleasane-mailorapicturetoaspecialistattheprovidersmedicalcenterofchoice,orassophisticatedasavideo-teleconference.Thosemedicalreportswhicharenotclassifiedsecret,eg,MedicalSurveillanceReports(theweeklyDiseaseNon-BattleInjurystatusofaunit),MedicalRegulation(thestatusofindividualpatientswherevertheyareintheworld),mostClassVIIIrequisitionandmaintenancerequests,etc.,cannowbemovedupanddownthemedicalchainofconcernviatheArmyKnowledgeOnlinesystem.Accesstocontinuityrecordsandweb-basedmedicalresourcesarejusttwoofmanypossibilitiesavailablethroughconnectivitywithinthetacticalhealthcaresystemdowntotheaidstationlevel.Asasidebenefit,internetaccessisanundeniable,nocostmoraleboostforourpatientsandmedicsduringperiodsoflowvolumeuse.HISTORICALSYSTEMSHistorically,Armymedicaldocumentationsystemshavebeencomparabletociviliancounterparts,specificallyblackinkonStandardForm(SF)600s.InthefieldwealsousetheSF600formostdocumentation.Theserecordsareusuallykeptinthefiledrawerofafielddesk.InanidealworldtheserecordsaresenttoCONUSorredeployedwithaunitandfiledintheSoldierspermanentmedicalrecordonredeployment.Inpractice,theserecordsarerarelyjoinedwithapatientspermanentrecord.Therearemanyexplanationsforthisdiscrepancy.Soldiersreceivingcarecomefrommanydifferentunitsandareexaminedindifferentclinicsaroundthebattlefield.Soldiersoftenredeployatdifferenttimesortopostsdifferentfromtheirsupportingmedicalunits.Fortheseandavarietyofothercombinationsofcircumstancesandoccurrences,therearesimplytoomanyopportunitiestolosefieldrecords,despitetheverybestintentionsandefforts.TheelectronictransferofmedicaldatamadeitsdebutinBosnia.Telemedicinewasusedthereonalimitedbasis.TeleradiologywasmoresuccessfullyemployedinBosniawherex-raysimagedinTuslawereroutinelyreadbyradiologistsatLandstuhlRegionalMedicalCenterinGermany.Althoughthiswaseffectiveandveryexciting,itwasalsoaverylimitedcapability.Veryfewsitescouldsendorreceiveelectronicx-rays.

PAGE 62

60ArmyMedicalDepartmentJournalComputerscarcityandbandwidthconstraintsimposedlimitationsonbothavailabilityandspeed.Fortunatelythishaschanged.Currently,plainfilms,CTscans,andultrasoundsarestoredandreadwithin24hoursbytheradiologistcoveringBosniaandKosovofromoneofthethreeArmyHospitalsinEurope,Landstuhl,Heidelberg,orWurzburg.MEDICALCOMMUNICATIONSFORCOMBATCASUALTYCAREIntheStrykerBrigadeswepioneeredtheearlyMedicalCommunicationsforCombatCasualtyCare(MC4)systemsin2001-2002.TheMC4hardwareincludedhandheldcomputers(PDAs)usedbymedicstoenterpatientcareinformation,andlaptopsusedbyphysicianassistants(PAs)andphysicianstoexpandthemedicsnotesandcompletepatientdocumentation.ThesoftwarefortheMC4systemincludedearlyversionsprovidedbytheTheaterMedicalInformationProgram.TheseprogramsincludedMobileMedicalDatathatwasusedbythemedicsontheirPDAs,andCHCS2-T(CompositeHealthComputerSystemIITactical)usedbythePAsandphysiciansonlaptopcomputers.ThepatientrecordenteredintothePDAsusingMobileMedicalDatacouldbesynchronizedusingaphysicalinterfacewiththeproviderslaptopforcontinueduse.Notesandotherpatientinformationcouldeitherbeprintedorwrittentoremovablestoragefortransportationwiththepatienttothebrigadesurgeon,orthenextlevelofcare.Thisfirstattempttoelectronicallyfacilitatepatientdocumentationwasveryawkwardandhadmanylimitations.Afterupgradesandextensivetraining,thesystemwasfinallyusedsuccessfullyduringthemedicalplatoonexerciseandevaluationinthefallof2002.Notesforsimulatedpatientsweregenerated,documentingpatientcarefrompointofinjurythroughtheBattalionAidStation.However,thelimitationstothesystemwereobvious.Asmentionedearlier,theelectronicrecordhadtobeeitherprintedorwrittentoadiskandthentransportedacrossthebattlefieldwiththepatienttohisnextechelonofcare.Inaddition,aseparatecopyoftherecordhadtobetransportedtothebrigadesurgeonformedicalsurveillanceandconsolidationofrecords.TheinformationusedbyalloftheotherbattlefieldfunctionalareaswasmovedaroundthebattlefieldandexchangedwithCONUSelectronically.BATTLEFIELDMEDICALINFORMATIONSYSTEMTACTICALInthespringof2003weattemptedseveralinnovationsforthemovementofmedicalinformationaroundthebattlefieldinatrainingenvironmentatFortLewis.WeusednewequipmentfromtheArmyMedicalDepartment,whichincludedthePersonalInformationCarrier(PIC)andanewprogramforhandheldcomputerscalledtheBattlefieldMedicalInformationSystemTactical(BMIS-T).BothwereprovidedtotheStrykerBrigadesbytheTelemedicineandAdvancedTechnologyResearchCenteratFortDetrick,Maryland.6Thesoftwareonthehandheldcomputerspresentedamoreuser-friendlyinterfaceforourmedics,andthePICisadevicetokeeptheSoldierselectronicmedicalinformationwithhisdogtagstomovewithhimacrossthebattlefield.OurmedicsenteredpatientdatausingtheBMIS-TprogramsandTheTacticalElectronicMedicalRecord:TheKeytoMedicalTransformationACASEINPOINTWhiletrainingatJRTCacommandsergeantmajorsufferedacuteabdominalpainwhichinduceddiaphoresisandtookhimtohisknees.HewastakentotheemergencyroomoftheBaynes-JonesArmyCommunityHospitalwherehisdauntinghistoryofachainofabdominalsurgeriesandcomplicationsmadehisdiagnosisandmanagementextremelychallenging.Initialevaluation,includingaCTscanoftheabdomen,revealedamildtransaminitisbutwasotherwiseunremarkable.Theemergencyroomphysiciansandconsultedinternistwerehavingdifficultydevelopingadiagnosisanddispositionforthiscomplexpatient.Fortunately,wewereabletoaccesspastsurgicalnotes,CTscans,laboratoryresults,etc,intheIntegratedClinicalDataBaseattheMadiganArmyMedicalCenterfromtheBaynes-JonesHospitalemergencyroom.ThismadeinitialandsubsequentmanagementmucheasierandeliminatedtherequirementtoevacuatethisSoldier.Thediagnosisofacutepancreatitisbecameclearonthefollowingday.Hewasmanagedconservativelyandimprovedquickly.HewasabletocompletehistrainingandleadhisunitsdeploymenttoIraq.Itshouldbenotedthatthephysicaltherapynoteforhislowbackpainwhichbadbeenentered2weeksprioratJRTCwasretrievableduringhisadmission.ItwasincludedintheinformationstoredintheMadigandatabaseatFortLewis,Washington.

PAGE 63

OctoberDecember200661transferredthedatatothePICs.ThePICswerethenusedtotransferdatatoalaptopandfromwhichitwasdownloadedintoCHCS2-T.Weattemptedtousetheuppertacticalinternetasabackboneformovingmedicalinformationaroundthebattlefield.Theuppertacticalinternetconsistedofaneartermdigitalradio(NTDR)thatmovedplanningandtrackinginformationbetweentacticaloperationcenters(TOCs)onthebattlefield.OurattempttomoveinformationfromoneTOCtoanothermetwithsomesuccess,butonlybasicinformationwastransferred,nottheentiremedicalnote.Notonlywasthisextremelyawkwardbuttherewereotherlimitations.AccesstoanNTDR,typicallyatabattalionTOC,isrequired.ThesendermusthavethespecifictechnicalexpertisetousetheNTDRandnegotiatetheinterface.Further,datatransmittedthroughtheNTDRentersthenetworksatthesecretlevelofclassification.Medicalinformationisnotsecret,soNTDRtransmissionneedlesslyplacesthedatainahighersecurityenvironment,addingasignificantlevelofcomplexitytotheprocess.Withconsiderableassistanceofthesignalcorpsandthemissionsupporttrainingfacility,weexploreduseofaTacticalLocalAreaNetwork(TACLAN)toscrambletheinformationtransmittedbytheNTDRanddescrambleitusinganotherTACLANuponreception.TheTACLANisusedbylogisticianswhoalsoworkwithsensitive(notsecret)informationsentovertheuppertacticalnetwork.Unfortunately,personnelwereunabletoobtainadequatetrainingontheequipment,interfaces,andprotocols,sothebrigadesunfamiliarityprovedasignificantlimitationtoconductingavalidtestofconcept.UseofBMIS-TtomoveconfidentialpatientinformationintoandoutofthePICandintoCHCS2-Tisaprovencapabilitywhichisthekeystoneintoexpandingthecapabilitiesofelectronicmedicalrecordsinthetacticalenvironment.6Atthepresenttime,eventhelimitedcapabilityofferedbythatapproachisthebestwaytomovemedicalinformationaroundthebattlefield,giventhecomplexityoftransmissionsystems,limitationsofaccessibilitytothosesystemsbyproviders,andthetechnicalexpertiserequiredtousethem.HEALTH-E-FORCES/INTEGRATEDCLINICALDATABASEWhiletheinnovativeworkdescribedabovewasongoing,theMadiganArmyMedicalCenter(MAMC)atFortLewismadethesuccessfultransitiontotheelectronicmedicalrecord.SinceCHCSIIwasnotdeployable,in2002MAMCimplementedtheIntegratedClinicalDataBase(ICDB).ICDBwasinitiallydevelopedbytheAirForceasaframeworkbuiltonCHCSwhichintegratedinformationfromCHCSandotherprogramstoenablerapidaccesstoclinicalinformation.ICDBwasadaptedfortheArmyattheWalterReedArmyMedicalCenter(WRAMC)andimplementedin2002atMAMCandWRAMC.TheStrykerBrigadeswerebroughtonlinebyMAMC,receivingnewcomputersandinformationmanagementsupporttoensureadequatebandwidthinallofourtroopmedicalclinicsandaidstations.MAMCfurtherprovidedinformaticssupport,rapidlymakingchangestothesysteminresponsetoourfeedback.TheelectronicmedicalrecordwasfullyimplementedatFortLewisby2003.ThesystemhassignificantlyaugmentedmedicalcareforourSoldierssinceallpatientnotesenteredattheaidstationsandtroopmedicalclinicsareaccessiblebyspecialistsatMAMC,andnotesfromspecialistsareaccessiblebyproviderswithinthebrigades.Duringthistime,MEDBASEIIwasbeingdevelopedbytheGreatPlainsRegionalMedicalCommandatFortSamHouston,Texas.Itspredecessor,MEDBASEI,wasaverysuccessfulmedicalreadinessprogramwhichprovidedunitsatFortLewisahighlyfunctional,web-based,operationallyorienteddatabaseformedicalreadinessneeds.MEDBASEIIpresentedthepotentialtonotonlytrackallmedicalreadiness,butalsoSoldiersprofiles(theactualelectronicprofilesthemselves)andelectronicmedicalrecordswithautomaticInternationalClassificationofDiseases,NinthRevision,diagnosiscoding.Withourfeedback,theyincludedthecapabilitytotrackfieldsanitationandcombatlifesavertrainingaswell.Intheinterestofmovingtowardasinglesystem,theCentral,Western,Southeast,andNorthAtlanticRegionalMedicalCommandsagreedtounifythesystems.ThenewHealth-E-ForcessystemisstillrecognizabletotheusersoftheICDBbutincludeslinksandfeaturesfromothersystems.

PAGE 64

62ArmyMedicalDepartmentJournalThefirstfullscaleimplementationofthissystemwasaccomplishedinthespringof2004attheJointRegionalTrainingCenter(JRTC)atFortPolk,Louisiana.Duringthereception,staging,onwardmovement,andintegrationphaseofthe1stBrigade,25thInfantryDivisionStrykerBrigadeCombatTeams(1/25thSBCT)deploymenttoJRTC,healthcarewasprovidedasusualfromTroopMedicalClinic4onNorthFortPolk.Fortunately,the62ndMedicalBrigadefromFortLewiswasdeployedinsupportalongwiththeirprovidersfromMAMC.WeusedourlimitedinternetaccesstoinitiatecommunicationofpatientcarenotesviaMAMCswebsitedirectlyfromthetroopmedicalclinic.Thisincludednotonlysickcallvisitsbutalsophysicaltherapyandmentalhealthcare.WeestablishedinternetconnectivityforourbattalionaidstationsscatteredthroughoutJRTC,firstatourbrigadeTOC,andthenatthebattalionTOCs.ThiswasaccomplishedaseachbattalionTOCsetuptheircommunicationslinks.WethenworkedwitheachbattalionS6toestablishalink,eitherintheformofrunningalandlineorestablishingatacticalwirelessinternet,toconnecttheBrigadeSupportBattalionTOCtotheTreatmentandHoldingtentswhichwerelocatedmorethanakilometeraway.Oncethelinkswereestablished,wewereabletoaccessSoldierselectronicmedicalrecordsfromMAMC,andenterournotesfromsickcall,ourphysicaltherapytreatments,andthebrigadepsychologist.CURRENTVERSIONSOFTHETACTICALELECTRONICMEDICALRECORDThecurrenttacticalelectronicmedicalrecordinusebythe1/25thSBCTinIraqistheHealth-e-Forces/ICDBsystem.ItsuseinIraqwaspioneeredby3rdBrigade,2ndInfantryDivisionSBCT(3/2ndSBCT)whichusedICDBtodocumentpatientcareinIraq.Unfortunately,itsusewasnotwidespreadbecauseofthelimitedavailabilityofinternetconnectivityfortheproviders.Accesstotheinternethascontinuedtobeadifficultproblem.Thisdifficultyisnotbecauseofanystructuralfaultinprogrammingordesign,butprimarilyduetounreliableconnectivityandNIPRNET*access.Thelackofasystemsolelydedicatedtothemedicalcommunityrendersaccesstointernetcommunicationstenuousatbest.Currently,medicalconnectivitycompeteswithunitoperationsandmorale,welfare,andrecreationneeds.Asaresult,NIPRNETaccessisextremelyslow,andfiletransferisextremelydifficult.ThelackofaconstantinternetprotocoladdresshindersaccesstoMAMCandconsumesasignificantamountoftimeinsetup.Also,useofhandheldcomputersbylinemedicshasproventobeverydifficult,primarilyduetotheaustereenvironmentandpaceofoperations.Inspiteofthesecomplications,itisobviousthattheArmyisontherighttrackindevelopingdigitalsystemsforthemedicalcommunity.Forexample,the1stBattalion,5thInfantryhasbeenextremelysuccessfulindocumentingpatientcareonthehandhelddevice,startingwithcareduringgroundevacuationandcompletionofthedigitalrecordbyaprovideratthebattalionaidstation.Whiledeployed,the3/2ndSBCTstoredover800noteswhichhavesincebeenmergedwithpermanentmedicalrecordsatMAMC.The1/25thSBCThadadvantagesinmanyaspectsofmedicaloperationsbyusingtheexcellentlessonslearnedfrom3/2ndSBCT.The1/25thSBCTalsohadtheadvantageofthepreviouslydiscussedtrainingintheuseofthetacticalelectronicmedicalrecordingarrisonandforfieldtrainingexercises.When1/25thSBCTdeployed,theirmedics,PAs,andphysicianswereaccustomedtousingthesesystemsingarrison,andhadtrainedonthesesystemsatFortLewisandlateratJRTC.AsofMarch2005,theyhadfiledover3,200clinicalnotesfromIraq.Unquestionably,accesstomedicalinformationandcontactwithspecialtyprovidersatMAMChasbeeninvaluable.AgoodexampleisthatofaSoldierwhowassomehowdeployedshortlyafterbeingdiagnosedwithanewonsetofepilepticseizures.Hewasdeployedshortlyafterbeingprescribednewepilepticmedications.AccesstohismedicalhistoricalrecordsandcommunicationswiththephysicianthattreatedhimallowedadequatecareofthisSoldierinanenvironmentthat,untilrecently,wouldhavenecessitatedhisimmediatereturn.Thisisjustoneofmanyexamplesoftheextremelyhighcontributiontoreadinessrepresentedbycontinued,realtimeaccesstomedicalinformationofallSoldiers.TheFortLewismedicalcommunitycouldnothaverealizedthesessuccessesonitsown.Thesignalsectiontrainedandpreparedwithus.Theyandthecommandof1/25thSBCTunderstoodtheimportanceTheTacticalElectronicMedicalRecord:TheKeytoMedicalTransformation *NonclassifiedInternetProtocolRouterNetwork

PAGE 65

OctoberDecember200663oftheelectronicmedicalrecordandsupporteditsuse.Dedicatedmedicalconnectivityforeachaidstationwouldbeamajorsteptowardensuringourpatientsreceivethebestinmedicalcare.Suchacapabilitywouldmakethedifferencebetweenasystemwhichcanwork,andasystemthatdoeswork.FUTURESYSTEMSTheDepartmentofDefensehaschosenCHCSIIastheobjectivesystemtowhichallDoDmedicalsystemswillmigrate.Thesystemhasbeenunderdevelopmentforalongtimeandpromisesmuchofwhatisrequiredinanobjectivetacticalelectronicmedicalrecord.Unfortunately,thecurrent,cumbersomeacquisitionprocessisnotresponsiveenoughtokeeppacewiththerapidlygrowingfieldofmedicalinformaticsandisinlargemeasureresponsibleforthedelayeddeploymentofCHCSII.7Agilityandresponsivenessmustbeincorporatedintosoftwaredevelopmentandacquisitioninordertoleveragetechnicalsolutionsforenduserrequirementsinatimelymanner.Enterprisesolutionswillbemosteffectivewhencoreapplicationsareshapedbylocaldevelopmentthatisiterativeinnature,anddeliverstimelyresultstoendusers.Thosesolutionsmustbescalableforlocal,regional,andservicespecificuse,aswellasapplicabilityacrosstheentiremilitaryhealthsystem.CHCSIIholdspromisetobeaworldwide,web-basedelectronicmedicalrecorddatamanagementsystemwhichmeetstherequirementsofproviders,hospitaladministrators,andtacticalmedicalproviders.TheVeteransAdministration(VA)ComputerizedPatientRecordSystemisanotherenviableapproachtomedicalinformationmanagement.TheVAchoseadifferentpathfromDoDfortheircongressionallymandatedelectronicmedicalrecord.TheybuiltontheirVeteransHealthInformationSystemsandTechnologyArchitectureandcreatedanintegratedweb-basedsystemfortheirmedicalproviderswhichhasbeenusedveryeffectivelyforseveralyearsnow.8SincetheVAcentrallymanagesandsupportsthissystemthroughouttheirstructureoflocationsandproviders,theyhavemadetremendousstridesinreactingtodirectfeedbackfromprovidersandmoldingasystemwhichliterallymakespatientinformationavailablewiththetouchofafingerbytheproviderwhoneedsit.TheoptionstillexistsfortheArmytoadaptthissuperiorsystemtoourneeds,rapidly,andataverymodestprice.Thiswouldofcoursehavetheaddedadvantageofimprovedcontinuityofcareformanypatientswhomoveamongthemilitary,VA,andcivilianhealthcaresystems.Anotheroptionistheincorporationoffreeinformationflowbetweensystems,whichisactivelyunderdevelopmentinanongoingDoD/VAprojectinvolvingtheMAMCandthePugetSoundVAsystem.9CONCLUSIONAnidealsystemisresponsivetotheneedsofitsinternalandexternalcustomers,withafocusonpatientsandproviders.Asystemmaybeabletogeneratebeautifulspreadsheets,butifitisnotuserfriendly,noamountofcommandinfluencewillmakeitsuccessful.Thesystemmustshareinformationbetweenplanners,providers,logisticians,andadministrators.Thesystemmustprovidehealthprovidersaccesstothefullspectrumofmedicalinformationfromanyhealthcaresystem.Thekeyrequirementforatacticalelectronicmedicalrecordistheability,atthepointofcare,toaccessacomprehensivemedicalrecordandtodocumentobservations,treatment,andcare.ImplementationofatacticalelectronicmedicalrecordwillfacilitateimprovedcarethroughoutaSoldierscareerandintoretirementcareinanymedicalsystem.Useofthesamesystemingarrisonandthefieldensureseaseofuse,continuityofcare,andaforcetrainedandequippedtodocumentcareandretrievedocumentationinallsituationsandenvironments.Onecomplexomnifunctionalsystemwould,ofcourse,beamajorimprovement,butitmaynotbetheidealsolution.Amodularconceptofseamlesslyintegratedmultiplesystemstomeettherequirementscouldbepreferable,becauseoftheinnateflexibilityandmaintainabilitysuchanapproachoffers.WearetrulyanArmyintransformationtomeettherequirementsofanationatwar.Asanintegralpartofthateffort,ArmyMedicinemustmakeatransformationaswell,and,aspartofthateffort,taketheleadintransformingmilitarymedicalinformationmanagement.REFERENCES 1.DoDMedicalReadinessStrategicPlan,19952001.Washington,DC:USDeptofDefense,OfficeoftheAssistantSecretaryofDefenseforHealthAffairs;20March1995.2.CurtinNP.DefenseHealthCare,DoDNeedstoImproveForceHealthProtectionandSurveillanceProcesses.Washington,DC:USGeneralAccountingOffice;October16,2003.PublicationGAO-04-158-T.

PAGE 66

64ArmyMedicalDepartmentJournal3.HershW.Healthcareinformationtechnology.JAMA.2004;292(18):2273-2274.4.PublicLaw104-191HealthInsurancePortabilityandAccountabilityActof1996.Aug21,1996:Availableat:http://aspe.hhs.gov/admnsimp/pl104191.htm.5.RandellCL,BeroCN,WeidmanL.Benefitsofworldwidegovernmentcomputer-basedpatientrecordframework.JHealthCareInforManage.1998;12(4):39-51.6.OnleyDS.Electronicmedicalrecordsgointocombat.GovtComputNews[online].Nov22,2004.Availableat:http://www.gcn.com/print/23_33/27923-1.html.7.RileyDL.Businessmodelsforcosteffectiveuseofhealthinformationtechnologies:lessonslearnedintheCHCSIIproject.StudHealthTechnolInform.2003;92:157-165.8.FletcherRD,DayhoffRE,WuCM,GravesA,JonesRE.ComputerizedmedicalrecordsintheDepartmentofVeteransAffairs.Cancer.2001;91:1603-1606.9.McKaughanJ.Computer-basedpatientrecords.MilMedTech[online]August1,2004;8(5):Availableat:http://www.military-medical-technology.com/article.cfm?DocID=562.AUTHORS LTCMichaudisassignedtotheAMEDDCenter&School,FortSamHouston,Texas.Previously,hewastheCivilMedicalAffairsDirectorforCombinedJointTaskForce76inAfghanistan,andearlierwastheBrigadeSurgeonforthe1stBattalion,25thInfantryDivisionStrikerBrigadeCombatTeam.CPTMcClendonisassignedtotheMadiganArmyMedicalCenter,FortLewis,Washington.Previously,hewastheBattalionPhysicianAssistantforthe1stBattalion,5thInfantryinIraq.LTCSalzmanisChiefofInformatics,MadiganArmyMedicalCenter,FortLewis,Washington.PreviouslyhewastheBrigadeSurgeonforthe3rdBattalion,2ndInfantryDivisionStrikerBrigadeCombatTeam. TheTacticalElectronicMedicalRecord:TheKeytoMedicalTransformation

PAGE 67

OctoberDecember200665In1999,congressmandatedthattheDepartmentofDefense(DoD)developacomputerizedmeanstocollect,store,andtabulatemedicaldataforallservicepersonnelintoanelectronicmedicalrecord(EMR).RecentadvancesincomputertechnologyhaveenabledtheDoDtocreatetheEMRcurrentlyusedinmostfixedfacilitieswithintheUnitedStates,commonlycalledtheCompositeHealthCareSystemII(CHCS2).*Beginningin2003,asimilarversionofthatmilitaryEMR,commonlyreferredtoasCHCS2-T(Theater),wasintroducedintothebattlefieldsofOperationsEnduringFreedomandIraqiFreedom.ModerncombatoperationsexposeSoldierstomanypotentialenvironmentalhealthhazards,aswellasthepossibilityofweaponizedchemical,biological,ornuclearhazards.Theeffectsofexposureduringcombatoperationsmaynotbeimmediatelyapparent,asevidencedbyAgentOrangeexposureduringtheVietnamWarorthemanycomplaintsattributedtoGulfWarSyndrome.Historyhastaughtusthatcomprehensivehealthsurveillanceisnecessarytomitigatethelossofcombateffectivenessduetononbattleinjuriesorillness.QualityassurancestudiesdemonstratethatSoldierswhoaretreatedinforwardlocationsutilizinghandwrittenrecordsrarelyhavetheirpermanentrecordsupdatedtoreflectthecarerendered.ThegoalofCHCS2-TistoprovidethemedicalsurveillanceandmonitoringneededbycommanderstoevaluatetheirForceHealthProtectionneeds.ThearrivalofCHCS2-Tonthebattlefieldprovidesacomprehensive,historical,durablemedicalrecordencompassingallmedicalencountersforeachwarfighter.TheEMRfieldedbytheUSArmywasincludedinasystemcalledtheTheaterMedicalInformationProgram(TMIP).TheTMIPisnotasinglesystem,rather,itencompassesseveralcomputerizedmodelsdesignedtocreateanEMRandtransferpertinentmedicaltreatmentinformationfromthepointofinjuryonthebattlefieldtotheservicememberspermanenthealthrecord.Startingin2003duringOperationsEnduringFreedomandIraqiFreedom,TMIPwasfieldedatvariouslevelsofthecombattheater.Thispaperoutlinesmyunitsexperience(asanewlydeployedtransformation-basedsustainmentbrigade)withtheTMIPsystemintegrationduringOperationIraqFreedomIV,20052006.The4keycomponentsoftheTMIPsystemarediscussedandfeedbackregardingeachcomponentispresented.OverallimprovementofbothForceHealthProtectionandreal-timehealthsurveillanceliesatthecoreofTMIPdevelopment.SuccessoftheArmysEMRisparamounttoreachingtheendstateofaseamless,durableelectronichealthrecordforeachwarfighterthataccuratelycaptures,tabulates,andmonitorshealthcarethroughoutamilitarycareer.TMIPisthemilitarysanswertoprovideafullycomputerizedmedicalhealthrecordforallservicemembersthatiscomprehensiveandeasilytransferablefrompeacetimetocombatoperations.COMPONENTSOFTHETHEATERMEDICALINFORMATIONPROGRAMTheprimarygoalofTMIPisthecaptureofaservicemembersmedicalhistoryinauseabledatabaseformat.Whencapturedinadatabase,themedicalinformationcanbeanalyzedtodeterminetrendsandidentifypotentialhazardsforallpersonnelallowingpreemptiveactionssuchasimmunizationsandprophylaxistreatments.TMIP,whenfullyimplemented,integrates4coredatasystemsfromarewriteabledatacardwornonSoldiersdogtagstoamainframecomputerserverinordertocaptureandstoremedicalinformation.ItishelpfulwhendiscussingthevarioussystemstolinkthemtotheechelonofcareforwhicheachisusedasshownintheTable.ImplementationoftheTheaterMedicalInformationProgramDuringOperationIraqiFreedomIVMAJMarkL.Higdon,MC,USA *NowknownasAHLTA.Seerelatedarticleonpage40.

PAGE 68

66ArmyMedicalDepartmentJournalAsshownintheillustration,thevariouscomputersystemsofTMIParedesignedtoseamlesslycommunicatewithoneanother.Thebasicsystemincludesarewriteableelectronicinformationcarrier(EIC)alsoknownasthepersonalinformationcarrierinadurablecarddesignedtobewornonthedogtagchainofeachSoldier.PersonalhistoricalandadministrativemedicaldataispreloadedontotheEICandcarriedatalltimes.WhenaSoldieristreatedineithergarrisonorcombatoperations,theEICisscannedtoloadapatientsmedicalhistoryandadministrativedataintotheprocessingsystem.ThescanningdevicecommonlyusedtoextractdatafromtheEICisthemedicshandheld,wirelesscomputerknownastheBattlefieldMedicalInformationSystem-Telemedicine(BMIS-T).ScanningtheEICwiththeBMIS-TeliminatesthetimespententeringadministrativedataforeachSoldier.ThemedicusestheBMIS-Tdevicetoenterdataduringsickcallvisitsandtodocumentinformationthatwouldroutinelybeenteredontoafieldmedicalcard.DatafromthehandheldsdownloadstothenextTMIPstep,alaptopcomputersystemoftenreferredtoastheMedicalCareforCombatCasualtyCare(MC4)computer.ThisdatatransfermostoftenoccursatthebattalionaidstationusingtheHotSync(PalmInc,950WestMaudeAvenue,Sunnyvale,CA)functioncommontomosthandhelds.TheMC4computerthentransmitsmedicalinformationtotheJointPatientTrackingApplication(JPTA)databaseacrossastandardNIPRNET(nonsecureinternetprotocolrouternetwork)connection.Ifpossible,alocalnetworkofaunitsCHCS2-TMC4computersisestablishedwithinabattalionaidstationtoallowinformationsharing.Ifnetworkingisnotpossible,informationissimplystoredonthelaptoporhandhelduntilconditionsallowtransferofdatatotheJPTAdatabase.TheJPTAisaweb-basedtrackingandinformationmanagementtoolthatreportsdataoncompiledJPTAdatacanbeaccessedbyanyonewithaNIPRNETImplementationoftheTheaterMedicalInformationProgramDuringOperationIraqiFreedomIV ElectronicInformationCard(EIC) BMIS-THandheldComputer MC4CHCS2-TLaptop JPTADatabase PermanentMilitaryRecord BasicflowofaSoldiersmedicalinformationthroughthevarioussystemscomprisingtheTheaterMedicalInformationProgram. ThefourcoredatahandlingsystemsoftheTheaterMedicalInformationProgram,thedeviceinvolvedforeach,andtheechelonofmedicalcareatwhicheachsystemisused.TMIPSystemDataProcessingDeviceMedicalEchelon Electronic/PersonalInformationCarrierDogtagcardwithdatachipEchelons1,2BattlefieldMedicalInformationSystem-TelemedicineiPAQPocketPC*Echelons1,2MedicalCommunicationsforCombatCasualtyCareSystemLaptopcomputerEchelons1,3JointPatientTrackingApplicationCentralizedserversEchelon4*ProductoftheHewlett-PackardCompany3000HanoverStreet,PaloAlto,CA

PAGE 69

OctoberDecember200667accountandanassignedpassword,allowingaccessfortreatmentofSoldiersinforwardoperatingareas.PasswordsfortheJPTAdatabasecanbeobtainedviaanonlineregistrationform(normal48-hourresponsetimefollowingpasswordrequest).Commanders,physicians,andotherhealthcareproviderscanusetheJPTAdatainthedesignandapplicationofforcehealthprotectionmeasures.Ultimately,themedicaldatacapturedbybothBMIS-TandCHCS2-TisappliedtoupdatetheSoldierspermanentmedicalrecord.Thiscapabilityeliminatestheproblemoflostrecordsandsavesthattimespententeringpurelyadministrativedataontomultiplehandwrittendocuments,withacorrespondingimprovementinaccuracyandreliabilityofthedata.ThecompileddatainJPTAenhancestheabilityoffieldsurgeonstotrackpatientsduringthecasualtyevacuationprocessandtoreviewtabulationsofDNBI(disease,nonbattleinjury)datatohelpidentifypossibletrendsofillnessorexposure.ThepowerfulJPTAdatabasealsoimprovesresponsetimesforcommandinquiriesregardingthehealthstatusofinjuredorevacuatedwarfighters.TMIPcapturesallinformationrelatedtoaservicemembershealthcareandeventuallyinsertsthatdataintotheirpermanentrecord.Redundancyisbuiltintothesystembyhavingmultiplelevelsofinformationcapturethatcouldbeusedtoupdateanyofthelowertiersofmedicaldatacollection.Increasinguseofthesystembyallunitswillgreatlyenhanceresearchactivitiesanddevelopmentofpreventivemedicinetechniques.Army-wideimplementationoftheTMIPisnowplannedforcompletionpriorto2007.4THSUSTAINMENTBRIGADEIMPLEMENTATIONOFTMIPDURINGOPERATIONIRAQIFREEDOMIVThe4thSustainmentBrigadedeployedinsupportofOperationIraqiFreedomIVinSeptember2005.WiththeexceptionofEICs,allmajorcomponentsoftheTMIPsystemwerereceivedpriortodeployment.Unfortunately,thelackofEICspreventedoptimaluseofthehandheldasareplacementforthefieldmedicalcard.Allinitialechelon1treatmentnotes(ifcompletedinforwardlocations)werehandwrittenusingthefieldmedicalcard.AbigchallengefortheBMIS-Tisitsinabilitytowirelesslytransmitdatatothelaptop(MC4)computersduetothenonsecurenatureoftheBluetooth(BluetoothSIG,Inc,500108thAvenueNE,Suite250,Bellevue,WA)technology.Currently,datatransferfromthehandheldtootherTMIPsystemsrequiresacableconnectionusingHotSync.Atechelon1,mostmedicsdidnotfullyusethefeaturesavailablewithBMIS-T;mostsimplyusedtheirhandheldstofollowtreatmentalgorithmsduringsickcall.Asecure,wirelessBluetoothcapabilityisrequiredbeforemedicscanuseBMIS-Tasauniversalreplacementforthestandardfieldmedicalcard.BasicallytheMC4computersfunctionedasdesigned,albeitpainfullyslowduetolimitedmemory.TheAlternateInputMethod(AIM)formscapability,fullyavailableintheCHCS2softwareusedintheUnitedStates,isnotincludedintheCHCS2-Tsoftware.AIMformsprovideafamiliarformatforenteringmedicalnotesthatissimilartothetraditionalpaperchart.Thetemplate-basedentrymethodusedbytheCHCS2-Tsoftwareisdifficulttolearnandtimeconsumingtouse.AIMformshelpstandardizetreatmentforcommonillnesses,allowingmorerapiddocumentation.Giventheinherenttrainingdifficultiesthataccompanyfieldinganewproduct,werecommendthatfutureupgradesoftheCHCS2-TsoftwareincludetheAIMformcapability,assoonapossible.Also,increasedinternalmemoryforeachlaptop(MC4)computerwillimproveprocessingspeeds.Openexpansionslotsareavailableoneachlaptopcurrentlyinuse.Althoughalsoanextremelyslowprocess,transferofmedicaldatafromtheMC4laptopstotheJPTAdatabasepresentednootherproblems.IttookseveralhoursforacompletednotetoappearontheJPTAwebsite,buttheinformationwasaccurateandcomplete.Mostoften,thedelayinupdatinganotetotheJPTAserver(>3hours)resultedinthefieldsurgeonscallingvariousmedicalfacilitiestoobtainreal-timecasualtyinformation.RECOMMENDATIONS1.ThecapabilitytoorganizecasualtydataforeachunitontheJPTAsite,includingasummaryscreenpresentingasnapshotofinformationconcerningthestatusofSoldiersforcommanders,wouldgreatlyenhancethesystem.Thesummaryscreenshouldbecustomizableforeachunit.

PAGE 70

68ArmyMedicalDepartmentJournal2.Avirtualprivatenetwork*(VPN)couldincreasethedepthofreviewavailablewithJPTA.CurrentlyJPTAdataislimitedtothetheaterofoperations.ByusingaVPN,homestationmedicaldatabasescouldbeaccessed,providingimportantmedicalinformation,suchasmedicalprofileinformationandhistoricalradiologicstudies,toforwardstations.3.AmedicalreadinessmoduletotrackmedicalprofilesinbothgarrisonandcombatenvironmentswouldeliminatetheneedforSoldierstopossessacopyoftheirprofile.Additionally,fieldsurgeonsandcommanderscouldmoreaccuratelytrackandreviewmedicalprofilesasthedatawouldinstantlybeavailabletoanyonehavingNIPRNETaccesstotheJPTA.4.TMIPtechnicalsupportwasavailabletothe4thSustainmentBrigadeslocationonForwardOperatingBaseTaji,butitusuallytookseveraldaysforthetechniciantoarriveandtroubleshootnetworkingproblems.Successofanynewsystemisdirectlyrelatedtofullfunctionality.SeveralofthedelaysexperiencedwithTMIPcouldhavebeeneliminatedwithincreasedavailabilityoftechnicalsupport.CONCLUSIONFullintegrationoftheTMIPsystemiscriticalforthecontinuedsuccessesArmymedicinehasexperiencedinthedecreaseofcombatmortality.ExpeditiousfieldingofcompleteTMIPsystemsandcontinuedsoftwareenhancementsarenecessarytomeettherequirementsinsupportofthemodernSoldier,before,during,andafterdeployment.Theabilitytocompileaccuratemedicaldataquicklyandefficientlyisnecessaryforallcommanderstomaximizecombateffectiveness.The4thSustainmentBrigadesmedicsandhealthcareprovidersquicklybecamereliantuponthedatamanagementprovidedbytheelectronichealthrecord(CHCS2-T).Overall,TMIPisanoutstandingconceptthatwilleliminatethepreviousinconsistencyandfragmenteddatacommonwithhandwrittenrecords.ContinuedeffortsshouldbefocusedonseamlessintegrationofbothinpatientandoutpatientdataintoandwithintheTMIPsystem.Army-wideimplementationoftheelectronichealthrecordbothinthegarrisonenvironmentandduringcombatoperationsoffersthemobilitynecessarytosubstantiallyenhanceforcehealthprotection.Theelectronichealthrecordisvitaltothecommandersfullmedicalsituationalawarenessandoffersamyriadofreportingandtrackingcapabilitiesconcerninghealthsurveillance.The1999congressionalmandatewasonlytheimpetusandthebeginning.ContinuedrefinementofthedurableelectronichealthrecordandTMIPisessentialtothesupportoftodayswarfighters.AUTHOR MAJHigdoniscurrentlyassignedtotheDepartmentofFamilyandCommunityMedicineatMartinArmyCommunityHospital,FortBenning,GA.Atthetimethisarticlewaswritten,hewastheBrigadeSurgeonforthe4thSustainmentBrigade,deployedtoIRAQinsupportofOIF05-07. *Avirtualprivatenetwork(VPN)isaprivatenetworkthatusesapublicnetwork(usuallytheinternet)toconnectremotesites(localnetworks)oruserstogether.Insteadofusingadedicated,realworldconnectionsuchasadirectcableorleasedline,aVPNusesvirtualconnectionsroutedthroughtheinternetamongthevariousisolatedlocalnetworksandfurtherintocentralservers.AVPNinvolvesparts:theprotectedor"inside"networkthatprovidesphysicalsecurityandadministrativesecuritysufficienttoprotecttransmission,andalesstrustworthyor"outside"networkorsegment(eg,internet).SecureVPNsusecryptographictunnelingprotocolstoprovidethenecessaryconfidentiality,senderauthentication,andmessageintegritytoachievethesecurityrequired.Whenproperlychosen,implemented,andused,suchtechniquescanprovidesecurecommunicationsoverunsecurednetworks. ImplementationoftheTheaterMedicalInformationProgramDuringOperationIraqiFreedomIV

PAGE 71

SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewe d print medium to encourage dialogue concerni ng health care issues and initiatives. REVIEW POLICY All manuscripts will be reviewed by the AMEDD Journal s Editorial Review Board and, if re quired, forwarded to the appropriate subject matter expert for further review and assessment. IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST 1. Related to individual authors commitments: Each author is responsible for the full disclosure of all financial and personal relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state explicitly whether potential conflicts do or do not exist. Auth ors should do so in the manuscript on a conflict-of-interest notification section on the title page, pr oviding additional detail, if necessary, in a cover letter that accompanies the manuscript. 2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this assistance, if any. 3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done so in the manuscript. 4. Related to project support: Authors should describe the role of the study sponso r, if any, in study design; collection, analysis, and interpretation of data; writing the repo rt; and the decision to submit the report for publication. If the supporting source had no such involvement, the authors should so state. PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH When reporting experiments on human subjects, authors must indi cate whether the procedures follo wed were in accordance with the ethical standards of the responsible co mmittee on human experimentation (institution al and national) and with the Helsinki Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must explain the rationale for their approach and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether t he institutional and national guide for the care and use of laboratory animals was followed. GUIDELINES FOR MANUSCRIPT SUBMISSIONS 1. Articles should be submitted in digi tal format, preferably an MS Word docume nt, either as an email attachment (with illustrations, etc), or by mail on CD or floppy disk accomp anied by one printed copy of the manuscript. Ideally, a manuscript should be no longer than 24 double-spaced pages. However, exce ptions will always be considered on a case-by-case basis. In general, 4 double-spaced MS Word pages produc e a single page of 2 column text in the AMEDD Journal production format. 2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles should conform to those guidelines as cl osely as possible. Abbreviati ons/acronyms should be limited as much as possible. Inclusion of a list of article acronyms an d abbreviations can be very helpful in the review process and is strongly encouraged. 3. A complete list of refere nces cited in the article must be provided with the manuscript. The following is a synopsis of the American Medical Associ ation reference format: Reference citations of published articles must include the auth ors surnames and initials, arti cle title, publication title, year of publication, volume, and page numbers. Reference citations of books must includ e the authors surnames and initials, b ook title, volume and/or edition if appropriate, place of publ ication, publisher, year of copyright, and specific page numbers if cited. Reference citations for presentations, unp ublished papers, conferences, symposia, etc, must include as much identifying information as possible (l ocation, dates, presente rs, sponsors, titles). 4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproduction quality, but please avoid excessive use of multiple colors and shading. Digital graph ic formats (JPG, GIF, BMP) and MS Word photo files are preferred. Prints of phot ographs are acceptable. Please do not send photos embedded in PowerPoint. Images submitted on slides, negatives, or copies of X-ray film wi ll not be published. For clarit y, please mark the top of each photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript. 5. The authors names, ranks or academic/certification credenti als, titles or positions, current unit of assignment, and contac t information must be included on the title page of the manuscript. 6. Submit manuscripts to: EDITOR, AMEDD JOURNAL ATTN MCCS DT 2419 HOOD ST STE C FORT SAM HOUSTON, TX 78234-7584 DSN 471-6301 Comm 210-221-6301 Email: amedd.journal@amedd.army.mil