Electronic Health Records
The DoD has implemented an advanced system of electronic health records for its personnel. That system is able to capture medical encounters for warfighters whether they occur at a stateside clinic, a battalion aid station in theater, or on the battlefield itself.
By Peter A. Buxbaum
The United States Department of Defense, to a greater extent that probably any other organization in the world, has implemented an advanced system of electronic health records for its personnel. That system is able to capture medical encounters for warfighters whether they occur at a stateside clinic, a battalion aid station in theater, or on the battlefield itself.
But DoD is not resting on its laurels, nor can it afford to. The Military Health System, a unit within the Office of the Secretary of Defense, is constantly adding capabilities to the Armed Forces Health Longitudinal Technology Application, or AHLTA, DoD’s system of electronic medical records. These include enhancing AHLTA’s ability to capture X-ray images, adding functionality to its mobile application, and reaching for greater seamlessness and efficiency in the capture of patient information through wireless communications.
But the greatest challenge facing DoD is to fulfill the Congressionally mandated goal of interoperating with the electronic health system used to support the treatment of veterans. There are two major obstacles to seamlessly moving warfighter medical information from DoD health records to the Department of Veterans Affairs system: the divergent architectures of the systems and the different data ontologies that they employ. To date, the departments have undertaken this project by implementing incremental information-sharing capabilities. Full interoperability is still a long way off.
AHLTA is currently optimized for the capture and retrieval of computable data such as history narratives, doctor visit notes and laboratory results. The Military Health System is currently working on introducing two new imaging capabilities within AHLTA.
The first capability will allow easier retrieval of non-computable files, such as scanned documents and photographs, from the MHS Clinical Data Repository (CDR). The CDR is a central database which stores all Department of Defense health records. AHLTA is the application which interfaces between the CDR and the user.
“Clinicians can currently store images in the CDR,” said Dave Schroeder, MHS’s deputy director of health technology interagency sharing, “but they are difficult to retrieve. We would like to make it easier for clinicians to retrieve images at subsequent visits and in different locations.”
Later in the year, MHS will be introducing similar functionality for viewing radiographic images to a small number of locations. This second phase of the project will be rolled out worldwide over a period of several years.
The new imaging capabilities will be implemented by deploying a Web-based front end to a documentum enterprise content management platform, according to Barclay Butler, senior vice president at Apptis Inc., a technology integrator based in Chantilly, Va., and the prime contractor on the imaging project.
The imaging files will be placed in a separate registry within the CDR, Butler explained. The registry will enable clinicians to pull images up side-by-side with computable AHLTA data.
“The web applications provides a much faster cycle time,” Butler said. “AHLTA operates in a client-server environment where the cycle time is quite long.
“The key benefit of this effort is the reunification of the medical record,” Butler added. “These capabilities pull together records from all modalities to provide a complete medical record to the clinician.”
MHS has incorporated mobile capabilities within AHLTA since 2003. AHLTA–mobile, formerly known as the Battlefield Medical Information System-Tactical, or BMIS-T, has provided warfighter health history to medics on the battlefield and has enabled them to capture information on medical encounters when they are not connected to the network.
AHLTA–mobile is an application that runs on a palm-held device and includes decision support tools which enable medics to deal with everything from battle trauma to run-of-the-mill sick calls.
“The AHLTA–mobile tools allow medics to easily triage patients and to capture fully-tagged data for mapping into bigger systems,” said Renee Clerici, the AHLTA–mobile program manager at the Telemedicine and Advanced Technology Research Center (TATRC) in Fort Detrick, Md.
The device-agnostic, Windows-friendly application can use satellite, cellular or land-line communications to deliver battlefield information to AHLTA–theater, the EHR system used in areas of operation. Medics input data through screens taps and with little text input.
“We use a natural language processor in the background translate that into narrative text,” explained Clerici.
AHLTA–mobile was developed primarily to aid fresh medics on the battlefield. “We’re not catering to doctors but to younger line medics right out of boot camp,” Clerici said. “They’ve received their training, and now they’re being dumped into real war situations.”
Nor is AHLTA–mobile meant to provide a comprehensive medical record. Medics typically prepopulate the application with information on allergies and medications only for those in their group.
“Most of what medics deal with is sick call involving colds or blisters,” Clerici said. “These guys are doing a lot of routine medicine far forward and don’t have a doctor to tell them what to do. That is why we give them a lot of decision support within the application.”
Clerici plans to continue to enhance AHLTA–mobile’s capabilities with features such as voice input and with decision support capabilities such as evaluation tools for diagnosing and evaluating traumatic brain injury.
Other decision support tools for AHLTA are also in the works. ScenPro, Inc., a software developer based in Richardson, Texas, is working under a Navy contract on a system to track and analyze data associated with warfighters who received combat injury treatment, with an eye toward adopting future preventative measures. The tool is designed to be incorporated into AHLTA, according to Michael Gately, the company’s CEO.
“The tool allows analyzing data to see whether the warfighter was wearing body armor and what kind, whether or not the injury occurred in a vehicle, whether it took place during the day or at night, and during what time of year,” he said.
The data would be recorded right on the battlefield by a medic who would place a radio-frequency identification equipped wristband on the casualty and enter a small amount of data on the AHLTA–mobile device.
ScenPro is also working in a separate analytic tool which would help determine the level of resources needed in response to a chemical or biological incident.
AHLTA–mobile’s capabilities could be enhanced in the coming months with the ability to upload patient data wirelessly from a digital dog tag. Besides enabling battlefield medics to access individual warfighter information, such a device could also be used to automate the prepopulation of patient data to AHLTA–mobile.
The interest in this automatic transfer of data led to research and development of the electronic information carrier, or EIC. The EIC’s utility goes to efficiency and costs, said Lieutenant Colonel Tim Rapp, the EIC program manager, who works at the Uniformed Services University of Health Sciences in Bethesda, Md. “Insurance industry studies show that 80 percent of ancillary care is repeated and could be avoided if the patient had a copy of what was already done,” he said.
The concept is to allow an AHLTA–mobile device to communicate with the EIC within 10 meters. A medic could load data from the dog tag to the device. Medical encounter information loaded into AHLTA–mobile would also be automatically saved to the EIC.
Information from the EIC of an evacuated patient would be automatically synchronized with the patient’s electronic medical record in AHLTA–theater when the patient arrived at a battalion aid station by automatically and wirelessly transmitting that data to the system. Without the EIC, this synchronization is impossible if a patient is evacuated before the medic, in a forward position with no connectivity, and could a reach a place where bandwidth is available to upload the information.
Rapp said that combat units are already clamoring for the devices. His team is currently evaluating a number of EIC prototypes and expects to be able to field the first EICs as early as next year.
The military’s desire for automation and seamlessness now extends to providing the necessary data on personnel who have left the military and come under the treatment of the Department of Veterans Affairs.
“The ultimate goal is complete interoperability,” said Lieutenant Colonel Hon Pak, TATRC’s chief of informatics. “To say we are working on one interoperable system is a step too far. In 20 years we will probably get there.”
In the meantime, the two departments are endeavoring to exchange information incrementally, according to Pak. “We have taken significant efforts in the last two years to share some information one way and some bidirectionally,” he said.
DoD and VA announced three enhancements to their information-sharing abilities in 2007. In December, data on allergies and lab results became accessible across both systems. In October, VA was provided access to DoD in-theater clinical data. In July, pharmacy, allergy, microbiology, chemistry/hematology data and radiology reports were made available.
These improvements were being made to the Bidirectional Health Information Exchange (BHIE) and the Clinical Data Repository/Health Data Repository (CHDR). BHIE, first implemented in 2004, provides a real-time interface between AHLTA and the VA’s electronic health record system, known as VistA. The CHDR software synchronizes data between DoD and VA repositories to enable the exchange of information for shared patients.
The two major hurdles the departments must jump to achieve full interoperability are at the system architecture and data levels. At the system architecture level, the VA is moving from a decentralized toward a more centralized system while DoD is allowing greater localization, Pak explained.
Data standardization remains the biggest hurdle to the ultimate goal of VA/DoD electronic medical record interoperability. To achieve interoperability, both agencies must standardize how data is defined, structured and communicated and agree on interagency code sets for domains such as pharmacy, allergy, chemistry, radiology and others. Most of these elements have not yet been standardized.
“Sometime those codes don’t match up and something gets lost in the translation,” Pak said.
An interim solution is coming in the form of a terminology mediation server, a project that Pak is overseeing. That application will mediate between the two systems and disambiguate information that is not understandable by the other.
“VA and DOD have made progress in both their long-term and short-term initiatives to share health information, but much work remains to achieve the goal of a shared electronic medical record and seamless transition between the two departments,” said Valerie Melvin, a divisional director at the U.S. Government Accountability Office, in testimony she gave a Congressional committee last year.
“In the long-term project to develop modernized health information systems, the departments have begun to implement the first release of the interface between their data repositories,” she added. “Although the data being exchanged are limited, implementing this interface is a milestone toward the long-term goal of modernized systems with interoperable electronic medical records.”
The two departments have also made progress in their short-term projects to share information in existing systems, Melvin concluded. “However, these exchanges are as yet limited, and it is not clear how they are to be integrated into an overall strategy toward achieving the departments’ long-term goal of comprehensive, seamless exchange of health information,” she said. “To achieve this goal, significant work remains to be done.”
Melvin’s remarks refer to the exchange of information between the DoD and VA departmental health systems. But there remains yet another challenge to providing information in support of veteran health that she did not touch on: extending information exchange to the private sector, where the majority of veteran health care takes place.
“Sixty percent of patients in the veterans health care system are seen by outside providers,” said Pak, “but less than 15 percent of private doctors in the United States use electronic health records.” Most private health providers, at this point, are not interested in spending the money to acquire and implement the technology.
TATRC is currently sponsoring pilot projects in Pennsylvania, Florida and South Carolina that seek to extend information exchange to private clinicians by way of a Web portal. But that project is still in its infancy. The technological and cultural problems associated with that effort will no doubt be occupying the military and veterans health systems for some time to come. ♦