Innovations in Military Medical Surveillance
TAKING CARE OF THE FIGHTING FORCE.
In the 15 years since the Persian Gulf War, the DoD has made significant progress in its ability to monitor the health of the servicemember and identify health hazards that could impact the medical readiness of deployed servicemembers.
After the Gulf War, many concerns were raised regarding the origins for the unexplained illnesses of Gulf War veterans. In coordination with President Clinton’s Presidential Advisory Committee on Gulf War Veterans’ Illnesses, DoD established a task force to investigate incidents and circumstances during the war that might be related to veterans’ symptoms. The Office of the Special Assistant for Gulf War Illnesses—now known as the Deployment Health Support Directorate—was tasked with conducting the investigations and reporting its findings to the president. The Deployment Health Support Directorate continues to gather information on medical issues relevant to the troops who served during the Persian Gulf War and troops serving currently in contingency operations throughout the world.
The department’s medical surveillance program, led by Ellen Embrey, deputy assistant secretary of defense for force health protection and readiness, in the Office of the Assistant Secretary of Defense for Health Affairs, and the director of the Deployment Health Support Directorate, collects and analyzes information on the health of servicemembers pre- and post-deployment; identifies environmental health threats; conducts disease monitoring; and monitors medical encounters intheater. This information is shared with military commanders and medical personnel to ensure the deployment of healthy forces and the continued fitness of those forces.
“We learned in the first Gulf War that keeping good medical records of our deployed servicemembers and knowing where our medical assets are in the field is essential to better managing the care we provide to injured troops. Matching the patient’s needs with our capabilities allows us to customize the delivery of trauma care in-theater,” Embrey said. “This practice has been available at our military treatment facilities at home, and now we have the ability to do so in-theater, when time is a critical factor to successfully saving lives.”
TECHNOLOGY IMPROVING HEALTH CARE IN-THEATER
An intrinsic part of the military’s medical surveillance program is the health information technology systems developed to collect and analyze data in-theater. The Theater Medical Information Program (TMIP) develops and deploys information systems that support the Deployment Health Support Directorate’s mission. These systems—the Joint Medical Work Station (JMeWs) and the Joint Patient Tracking Application (JPTA)—provide interoperability between services’ information systems that enables the consistent collection and communication of medical information electronically to establish a lifelong electronic medical record for the servicemember. This information is also used by DoD to conduct epidemiological studies and research for future deployments.
THE JOINT MEDICAL WORK STATION
The JMeWs, implemented in 2003, is a Web-enabled tool that overlays the individual service systems and allows commanders and medical planners to monitor the physical well-being of deployed servicemembers and medical-treatmentfacility capabilities. The JMeWs archives deployment health surveillance data collected from each of the service-specific systems in-theater, and, through its ad-hoc queries and summary reports, it allows health care professionals to analyze and track trends such as biological outbreaks or chemical exposures. It also follows the patient’s care from frontline medical units to overseas medical treatment facilities to their home base.
According to deployment health-support officials, JMeWs technology has helped DoD quickly and efficiently identify health hazards and trends that have led to changes in deployment procedures. In the summer of 2005, heat injuries among deployed soldiers at a training site in Kuwait unexpectedly rose. By reviewing reportable medical events and available electronic health records in JMeWS, deployment health-support personnel determined that most of the events involved personnel who had recently arrived intheater with little time to acclimate to the new conditions. Close coordination with the local preventive medicine personnel and U.S. Central Command authorities redoubled emphasis on proven, effective, preventive measures to minimize these casualties. This ensured that there were no cases of heat stroke, the most severe form of heat injury. The lessons learned from this event were shared with all of the services’ commanders and medical personnel in-theater as the Deployment Health Support Directorate personnel continued to monitor heat injuries throughout the remainder of the season.
“With the implementation of JMeWs in 2003, we are able to capture the complete medical record for each servicemember. Having access to the pre-deployment health assessment gives us a baseline to evaluate, through the post-deployment assessment, how their experiences in-theater [have] impacted their health,” Embrey explained. If a problem is identified, the information collected by JMeWs can help health-support personnel determine whether the servicemembers were exposed to any environmental hazards while deployed and compare their records with other members of their unit. “This information is invaluable to improving our preventive health program. We can incorporate the lessons learned into the briefings provided to the newly deployed troops so that they can avoid similar exposures, such as advising them not to wear flea collars to prevent sand flea bites.”
But a system is only as good as the data it receives. In the 2005 DoD report to Congress, Department of Defense In-Theater Medical Tracking and Health Surveillance, it was noted that the records received by JMeWS are “often incomplete, data categorization can be imprecise and denominator estimates are poor.” DoD concedes that little progress has been made to resolve this complex issue, but there are efforts underway to gain improvement. Deployment health-support personnel monitor and evaluate the collected data and provide feedback to the field when errors in coding are identified. This has resulted in improvements at those specific sites.
In addition, they are working with the Army to use personnel-location data from their Deployed Theater Accountability Software (DTAS) in JMeWS. This system is able to track the location of deployed Army and Marine personnel, along with a few Navy and Air Force people who may be assigned to other services, in much greater detail. With DTAS data, JMeWs will be better able to determine the common denominator for events of interest.
For example, if a sudden spike in influenza- like illnesses at several different military treatment facilities occurred, a query to DTAS can identify where the affected personnel had recently been and plot their locations on a map. If there are areas where several of the affected people were together at the same time, another query to DTAS can identify all the people who were in the same area at approximately the same time and take appropriate action for treatment.
JOINT PATIENT TRACKING APPLICATION
JPTA is another Web-based patient tracking application developed by the Landstuhl Regional Medical Center (LRMC) that collects, manages, analyzes and reports data on patient transfers. JPTA provides information about the transportation, treatment and location of injured servicemembers as they make their way through the medical system. It also provides an information interface between commanders, case managers, service liaisons and health care providers to assist in the decision-making process that ensures the best medical strategy is developed for each patient that meets their specific needs.
DoD adopted the system militarywide in November 2004. Prior to its inception, LRMC medical personnel were manually incorporating information from each of the services’ different systems into one report that would track the status of patients. This was inefficient and often incomplete. Unless they called Landstuhl, commanders and medical personnel in Iraq were prevented from tracking where and what was happening to their troops and when the troops were flown out of theater for medical care. JPTA merges the services’ information into one Webbased system that allows users from different locations to access real-time information about patients. Using JPTA, commanders and medical personnel now have easier access to all relevant information in order to determine the status of patients—no matter where they are throughout the military health system.
TRAINING IS KEY
Technology works when people know how to use it. Since up to 45 percent of the deployed forces come from the Reserve Component, it is essential that adequate training programs are in place that educate the users how to access accounts, what information is available in these systems and, depending on the role of the user, how to input information into the system or how to navigate the system to get the information they need. Each of the services has individual training programs that the TMIP has helped to design to prepare the servicemember in the field to use JMeWS and JPTA.
In addition to this training, the Deployment Health Support Directorate offers two-hour training sessions at the request of individual units in coordination with combatant command representatives, to familiarize the users with the systems and provide updates to new features that have been implemented.
“Both systems have Web-based interfaces and [are] intuitive for the user,” Embrey commented. “While training is the responsibility of the services, we collaborate with them to ensure comprehensive, up-to-date lesson plans are used in their training.”
The Deployment Health Support Directorate has also developed a specialized training module that focuses on teaching how these systems can be used in the early detection of a pandemic outbreak, such as avian influenza in a population. In the event of an influenza-like outbreak, the JMeWS will be used to consolidate data and provide real-time information to commanders and medical personnel theaterwide, and JPTA will track infected patients. Ultimately, this will help in limiting the spread of disease and hasten the care to those infected.
SURVEILLANCE INNOVATIONS TO THE HOMEFRONT
The Electronic Surveillance System for the Early Notification of Community-based Epidemics IV (ESSENCE IV), which is part of the JMeWs system, has helped to make DoD’s medical surveillance program a leader in syndromic surveillance. The ESSENCE IV module applies advanced statistical methods to health event diagnostic and pharmacy data to determine if there are unexpected trends that might be consistent with a disease outbreak, whether natural or deliberate.
In addition to developing its own pandemic influenza plan for the military, DoD has partnered with the departments of homeland security and health and human services to assist in the development of the nation’s plan. Through this collaboration, the DoD has shared the lessons learned from its in-theater use of ESSENCE IV to the civilian agencies. In addition, the agencies are comparing the different analytical approaches used by ESSENCE and the Centers for Disease Control and Prevention system, BioSense, to identify any significant performance differences in order to improve or enhance one or both systems. This joint endeavor has illustrated the need for interoperable and interdependent coordination between federal agencies in the same way that DoD realized using its joint military capabilities to support its fighting force would benefit the overall mission. ♦