Q&A: Carl E. Hendricks
Health IT Advisor
Ensuring Strategic IT Investment for the Military Medical Community
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Carl E. Hendricks
Chief Information Officer
Military Health System
Carl E. Hendricks began serving in August 2005 as the chief information officer for the Military Health System (MHS) and director of the Information Management, Technology and Reengineering Directorate for the TRICARE Management Activity (TMA). He is the principal advisor to Department of Defense medical leaders on all matters related to information management, information technology (IT), information protection, enterprise architecture, IT capital investment and IT strategic planning. He works closely with Army, Navy and Air Force deputy surgeons general, and the executive director of TMA to ensure MHS health IT programs are well-managed, comply with applicable statutes and policies and align with the objectives of the MHS.
Hendricks is a former colonel in the Army Medical Service Corps, serving in a variety of positions spanning 26 years, with a concentration of experience in medical information technology and acquisition management. Most recently, he was the chief information officer for the Arizona Telemedicine Program and, at the same time, through an intergovernmental personnel assignment, he was a special assistant to the director of the Telemedicine and Advanced Technology Research Center, a division of the Medical Research and Materiel Command at Fort Detrick, Md. In his last assignment prior to retiring from the Army, he was appointed by the assistant secretary of defense for health affairs to serve as the program executive officer, Joint Medical Information Systems Office, in August 2000. Prior to that assignment, he served as the chief information officer for the Office of the Army Surgeon General and the assistant chief of staff for information management, U. S. Army Medical Command.
Hendricks has returned to public service in the Department of Defense, having been appointed to the Senior Executive Service. Hendricks graduated with a bachelor’s degree in public administration from the University of Arizona in 1975. In 1989 he received his first master’s degree from Boston University, with a focus on business administration. He earned his second master’s degree in biomedical engineering from Worcester Polytechnic Institute in 1992. In addition, he was awarded full certification by the Army in the functional specialty of program management through the Defense Acquisition University.
He is a member of the Order of Military Medical Merit, the Project Management Institute, the Association for the Advancement of Medical Instrumentation, and the Institute of Electrical and Electronic Engineers.
Interviewed by MMT Editor Jeff McKaughan
Q: Good morning Mr. Hendricks. Could you start by laying out an overview of the Military Health System to give our readers a real understanding of the size and scope of the system?
A: We are responsible for more than 9.2 million beneficiaries across the globe, including active duty military and their families, retirees and their families, reserve and National Guard troops called to active duty, Coast Guard and other uniformed Services—commissioned members of the National Oceanic and Atmospheric Administration and Public Health Service.
Our beneficiary population is more mobile than that of most health care organizations, with many beneficiaries—and employees—routinely relocating every few years.
The Military Health System—MHS—consists of 70 hospitals, more than 800 clinics, and over 132,000 employees.
The MHS is a microcosm of health care in the United States in many ways. We see 1.8 million outpatients every week and some are surprised to learn that we deliver 2,000 babies each week. In an average week, 1.8 million outpatient encounters take place—640,000 direct care; 1.1 million purchased care—there are 18,300 inpatient admissions—5,500 direct care; 13,700 purchased care—104,000 dental procedures—direct care only—and 2.1 million prescriptions filled—includes retail, direct care and mail order.
Q: AHLTA [Armed Forces Health Longitudinal Technology Application] is a system on the move that seems to be a cornerstone of the health IT [HIT] transformation. Can you tell me what this system is doing for military medical IT?
A: DoD continues to build on its long history of transforming health care through the use of information technology. We are leading the health care industry in IT with the creation and deployment of AHLTA. Our advanced electronic health record system was welcomed to national acclaim at its official introduction on November 21, 2005.
AHLTA’s principle purpose is to improve care for military health care beneficiaries. To this end, AHLTA is patient-centric, designed with the safety and welfare of the patient in mind, gathering patient information from our military treatment facilities—MTFs—around the world into a record that accessible to providers at the click of a mouse. This single, secure, complete, legible, and durable record ensures continuity of care for beneficiaries, whether they received care on the battlefield, at their home MTF, or at an MTF hundreds— even thousands—of miles from home. Health care providers have a record that includes all necessary information to make an optimal health care decision.
Frankly, AHLTA is not just important to the military. AHLTA is a part of the foundation that will help assure the nation has uniform and unified EHR standards to facilitate the transfer of health data not just within the MHS, or the MHS and the VA, but from the military, to the VA, to any hospital—and back.
Q: Besides bringing on new users in 2006, will the system see any enhancements or upgrades?
A: 2006 is a watershed year for AHLTA—it marks the year its first phase will be completed. All 63,000 users will be trained, all MTFs will have AHLTA implemented, and MHS beneficiaries’ records—more than 9.2 million individuals—will be supported by AHLTA.
Over the next few years, AHLTA will be enhanced with new, advanced functions. These enhancements will be rolled out in phases or blocks. The next block will integrate comprehensive dental documentation and optometry orders management capabilities. My goal is to have this block close to completion within two years.
After that, we’ll work to modernize legacy systems’ ancillary order entry and results retrieval, improve inpatient documentation, and enhance data exchange with other information support systems.
Q: There is obviously a tremendous amount of R&D going on in the IT private sector. What can you do to harness that innovation and combine it with your own directed R&D to ensure the most bang for the buck and the least duplication of efforts?
A: Our goal is to bring the best and appropriate technologies to our patients. We continue to reach forward to identify and test new medical technologies and concepts.
We continue to research, test and incorporate innovative, best of breed commercial products that meet our needs. These commercial tools jump-start or accelerate our development. Sometimes adaptations or enhancements to products that are made by our commercial partners to meet our specific requirements are judged to be of value in the commercial marketplace and incorporated into commercial releases.
A perfect example of this is the success we have had with AHLTA. It is composed of an integrated suite of commercial products. One of its components is a sophisticated medical vocabulary contributed by the commercial product MEDCIN that is used for our clinical notes. In collaboration with our commercial partner we further developed the vocabulary. Our product enhancements were added to the commercial release. An added benefit of its integrated multiproduct design is the ability to keep pace with advancing technology without having to reinvent the entire system to upgrade a subset of capabilities. Because AHLTA was constructed as an integrated system of commercial-off-the-shelf technologies, there is no reason why it can’t be replicated for use in the civilian sector.
We need to continue to engage with our commercial partners in this two-way collaborative effort. In other words, we work with companies to fully meet our needs by enhancing their core commercial products. As a result, our expertise, lessons learned and investment are available to the nation, indeed the world, because we have extended and enhanced the products already available commercially, preventing duplication and in effect accelerating industry.
Q: In talking to various people, it seems that some locations developed their own IT solutions for data management and storage difficulties. While these solutions may work, it obviously creates commonality problems and other interoperability issues. How do you walk the line between having common solutions wherever possible and stifling creativity with the clinicians and administrators that are working hands-on with the information?
A: Interoperability is not dependent on the type of technology solution chosen or the limitation of creative design. Rather, it relies on the development of our ability to translate information across systems regardless of type. Adoption of universal standards is, of course, beneficial for promoting interoperability, but it is not the whole story. The achievement of the president’s goal to standup a nationwide, interoperable HIT infrastructure is achievable but requires a shift in focus from standards application alone to the translation of information.
Over the last 15 years, most players in the HIT world have seen the lack of a single comprehensive clinical concept terminology set as the biggest impediment to broad adoption of information technology in health care. Most large vendors tried to produce huge comprehensive IT systems that could do everything, and these systems have proven incredibly expensive and inflexible. A few commercial organizations tried to produce clinical lexicons to permit best-of-breed systems to interoperate, but each vendor wanted to build a dominant business based on their specialized views and interests and none really succeeded. The only working system incorporating dynamic interoperability of best of breed systems—of which I am aware—is the military’s AHLTA environment. We have developed a novel approach to assure close interoperability between systems produced by 3M, PKC, MEDCIN and Northrop Grumman.
For the Military Health System, achieving semantic interoperability overcomes differences in terminology or meaning so that our interpretation is the same across and between organizations. As an example, the meaning of cold can be different depending on the context of use. It can be a diagnosis—I have a cold—or a physical state—I am cold. Electronic health systems need to overcome this complexity. Our approach was to establish a terminology service bureau. The TSB approach is fundamentally different. Rather than try to build a monolithic terminology set, capable of representing every concept required for every area of medicine, the TSB is creating a dynamic system for linking many different specialty terminology sets together with a sophisticated mapping process. This allows the TSB to leverage the work of many different specialists. The TSB is designed to be completely open source. In order for any organization to have their terms included in the TSB mapped lexicon, they must place their concepts and codes into the public domain and they must pledge to continue that practice as they develop new concepts.
Our approach of creating a reliable translation layer holds great promise as a critical step forward in the evolution of health information technology. Semantic interoperability must exist in order to build a truly nationwide HIT network. This is the model for the future of HIT.
Q: Taking that in a similar direction, how can you make sure that efforts between various other federal agencies and you are not wasted on the same research and duplicated solutions?
A: The federal government is a major investor in health IT and understands the importance of achieving interoperability and eliminating duplicative efforts. The MHS and other federal leaders are actively engaged in strategic partnerships in both the public and private sectors to advance health care informatics and to promote and define standards for systems interoperability. Under the Federal Health Architecture [FHA] umbrella we have worked to improve coordination and collaboration on national health IT solutions. DoD fully supports FHA’s goal to create a consistent federal framework to improve health data sharing and maximize federal health IT investments. The FHA links business processes to IT solutions, demonstrating improvements in health outcomes. It enables the utilization of existing systems to meet health care delivery requirements while providing clear rules for the development of new tools.
Today, a myriad of existing and overlapping standards are used in health care systems, implementation is inconsistent and the guidance needed to make these systems communicate is lacking. Harmonization of these standards relative to data, technology, security and communications is one of the key foundations for interoperability. The MHS and the Department of Veterans Affairs are engaged in a joint evolutionary journey to full interoperability and have made tremendous progress in our abilities to share health information to support the quality and continuity of health care for American veterans. Through the Consolidated Health Informatics Phase II initiatives, DoD serves as a lead partner with the VA in the federalwide adoption of a portfolio of health information interoperability standards which will enable federal agencies to speak the same language with common enterprisewide business and information technology architectures.
Q: Can you tell me about the National Coordinator for Health IT and how that interacts with your office?
A: The current administration began a push toward infusing the American health care system with technology in January 2004 with the State of the Union address, which [the president] reemphasized during this year’s address.
The president followed his initial address with an announcement of his technology agenda and executive order, placing health IT in a new prominence on the national stage. He established the Office of the National Coordinator for Health Information Technology and appointed Dr. David Brailer as national coordinator. The relationship between the national coordinator and the MHS began almost immediately after the office’s establishment.
Because of the tremendous progress DoD has made advancing health care informatics through our large-scale adoption and deployment of electronic health records, we have been thrust into a unique leadership role on the national level. The DoD and the VA were asked to report on our respective contributions to the advancement of the adoption of health information technology. The information we provided was used by Dr. Brailer to frame the strategic approach to the accomplishment of the President’s HIT mandates. Our contributions helped provide the basis for a report they called, “The Decade of Health information Technology: Delivering Consumer-centric and Information Health Care—Framework for Strategic Action.”
So from the beginning, we’ve joined with Health and Human Services through the Office of the National Coordinator, to develop a strategy that will meet each of the President's HIT goals. In October, Dr. [William] Winkenwerder [assistant secretary of defense for health affairs] joined the rest of the public and private sector health care leaders recruited as members of the American Health Information Community. The community has been charged with developing the strategy that will lead America’s health care providers down the path toward a nationwide, secure health information technology network. We are uniquely positioned, within this larger forum, to share our lessons learned and lead the nation toward the realization of the president’s goal of making electronic health records available to a majority of Americans within 10 years. The MHS is the only subset of the American health care sector that is meeting his intent right now.
Q: What were some of the key lessons learned from the Military Health System’s response and reaction capability to the problems caused by the hurricanes last summer? Has your office implemented any major changes as a result?
A: Shortly after Hurricane Katrina struck I toured some of the areas which had been absolutely devastated. I learned, first hand, of the plight of thousands of retirees whose paper health records had been completely destroyed and I saw the difficulties the medical community faced trying to cope with the medical needs of displaced persons in the absence of medical information. Hurricane Katrina exposed the glaring need in this country for a national network of electronic health records.
Any MTF, regardless of location, that has activated AHLTA has access to beneficiary health data resident in the Clinical Data Repository [CDR]. The largest MTF in the affected geographical area was Keesler Air Force Base [AFB] Medical Center. Prior to Hurricane Katrina, the data from the medical center had been imported into the CDR. The strength of the electronic health record and centralized CDR was immediately apparent when displaced patients from Keesler AFB, Biloxi, Miss., continued to receive care when they were displaced to Lackland AFB, Texas, where their providers were able to access their records in the CDR through AHLTA.
Similarly, a number of displaced patients from the Gulf region had been undergoing treatment for cancer. Their records were available through AHLTA at other MTFs, and their continuity of care was largely unimpeded by the hurricane’s wrath. One of these patients arrived at Naval Medical Center Portsmouth, Va., and health care providers were able to access her records through AHLTA and provide her next chemotherapy exactly as scheduled.
Another system in use in the MHS since 2001 is the Pharmacy Data Transaction Service [PDTS] which contains a significant portion of the information that comprises an electronic prescription. The information in PDTS includes not only patient prescription information from our MTFs, but also from our mail order and retail contracts. PDTS continued to support drug-drug and drug-allergy checking for displaced beneficiaries regardless of their locations following Hurricane Katrina.
The utility of electronic health records in coping with the medical needs of displaced persons in the aftermath of disasters such as Katrina is now undisputed. We recognize that HIT tools are also needed by the community of first responders and disaster relief workers to deal with the immediate health care needs and movement of disaster victims in areas where communication is absent or spotty at best. As a consequence of lessons learned during Katrina, FEMA is evaluating components of our Theater Medical Information Program—the BMIST-T handheld device, our theater version of AHLTA, and JMeWs our medical command and control system—to fill the gap in limited communication environments.
Q: With all of the energy going into making personal health records accessible by clinicians anywhere the patient is, what is the goal of having each patient have access to their own records? Is it a goal to be able to have patients have their records at the click of a mouse?
A: Our goal is to involve our patients more deeply in managing their own medical care. One of the best ways to empower patients to take charge of their health care needs is to give patients ownership of key aspects of the health care experience. TRICARE Online.com [TOL] is the MHS enterprise eHealth portal. It provides instantaneous, secure, worldwide role-based access to health care information and services customized to each participant in the health care experience— patients, providers and clinic managers.
TOL provides a Web environment for eHealth collaboration. It gives patients the ability to create a personal health record, make their own appointments with their doctors and provides them with a wealth of trusted health care information, on demand, wherever and whenever they choose to access it.
These Web-based capabilities will be significantly expanded in the future to include an augmented personal health record, pharmacy refill and renewal, appointment reminders, an ability to request routine tests and structured provider to patient messaging. TOL will provide both beneficiaries and doctors with interactive online questionnaires and surveys which capture and document clinical data into the EHR through the use of problem knowledge couplers. This technology will allow patients to take responsibility for their health care needs and will make patients and providers interactive partners in the health care encounter.
Dr. Winkenwerder, as a member of the American Health Information Community, has asked us to share our experiences and lessons learned to support the efforts of the Community’s Consumer Empowerment Working Group charged with making recommendations for gaining widespread adoption of personal health records that are easy-to-use, portable, longitudinal, affordable, and consumer-centered. If large scale adoption becomes a reality, Web-based e-health technologies have the potential to transform the way Americans regard their health, the way they participate in health care and the relationships they establish with their health care providers.
Q: Is security technology keeping ahead of the security concerns of having these records out there in cyberspace?
A: Any security program is only as strong as its weakest link. Maintaining the privacy and security of our information systems and the patient health information they contain, is our highest priority and our greatest concern. In addition to safeguarding our patient’s health information, we have the added responsibility of ensuring that our systems and networks do not compromise the integrity of DoD’s overarching IT systems and security framework. As a consequence of this need to protect DoD’s national security mission, our security requirements and risk mitigation activities are much more stringent than those of private sector health care organizations. Our systems, databases, interfaces and facilities must comply with DoD’s overall Defense in Depth strategy. To this end, our information assurance program has three major components; physical security, electronic security and personnel security.
Physical security measures include such things as access control procedures and equipment to prevent entry of unauthorized persons into the facilities where system hardware and software physically reside. We also ensure that facilities that house IT systems have the necessary structural features to provide favorable environmental conditions and fire suppression capability to prevent loss from physical damage.
Regarding electronic security, first, we have a formal process for evaluating and certifying that each of our IT products meets all DoD security criteria before we field them. Second, the MHS uses a broad variety of security technologies to protect sensitive patient information in storage, during processing, and in transport to providers who have authorized access and a need to know. Our information systems reside within secure enclaves, which are protected with firewalls, intrusion detection and digital security certificates. Information in transport between systems and users is protected using certified technology for information encryption via a virtual private network enclave.
On the personal security side, we perform background checks on personnel before they are granted access to our systems. We control the level of access that is authorized for individual users. At our MTFs, role-based rules are extensively used and selectively applied to grant appropriate levels of user access to the HIT system and the patient health information within. DoD is implementing Public Key Infrastructure technology for DoD military personnel, civilians and contractors to use for identity when accessing DoD networks and systems. External business partners who need access to our systems are required to have the same level of certification and assurance as our own systems and personnel. We have solid auditing capabilities that can tell us what users saw, what they did, and what they are allowed to do. Finally, for those personnel who work in information assurance we require a nationally recognized certification of skills and we have extensive role-based training programs for system users.
Although DoD uses extensive procedures to encrypt information and keep it private, as well as role-based rules to grant appropriate user access, technological solutions alone can not guarantee information safety. All systems are potentially vulnerable to highly skilled, industrious, technology experts with malicious intent. We continuously assess the vulnerabilities of our systems and collaborate with other federal agencies and commercial partners to identify new threats, develop and apply appropriate counter measures. We will continue to explore new technical and procedural solutions to augment our three aspects of defense and strike the balance—safeguarding our beneficiaries’ health information without compromising the benefits derived from global access by our worldwide health care delivery team. ♦