Tutorial: How the Military Health System is an IT leader

Despite recent EHR implementation setbacks, the U.S. Military Health System is a role model for using IT -- especially mobile health and data exchange -- to treat patients.

The U.S. Military Health System (MHS), administered by the Department of Defense (DoD), has been a pioneer in the use of mobile health and is currently testing a variety of mobile health applications that aim to improve medical care for soldiers in the battlefield. 

Among health care organizations, the MHS has also been an early and large-scale adopter of service oriented architecture (SOA) and electronic health record technology -- though recent efforts to upgrade its system, like many EHR implementations, ran into complications. 

The Military Health System also works closely with the Veterans Health Administration (VHA) to coordinate care for members of the military after they leave active duty. These efforts include the development standards-based health information exchange (HIE) and integrated clinical data repositories.


What is the structure of the Military Health System

The Assistant Secretary of Defense for Health Affairs leads the Military Health System. The MHS has a budget of more than $50 billion and a staff of more than 133,000 physicians, nurses, researchers and educators, both military and civilian.

Each branch of the military has its own surgeon general. (This is a product of history. The Army, Navy and Air Force were not brought together into the Department of Defense until 1949; prior to that, each branch had its own medical service.) Meanwhile, the Coast Guard, a branch of the Department of Homeland Security, has its own chief medical officer. 

In addition, the Military Health System offers numerous additional offices and programs, six Defense Centers of Excellence, the office of Force Health Protection & Readiness, a health benefits program known as TRICARE, a research facility known as Uniformed Services University, and a Chief Information Officer.

Given its size and influence, the Military Health Service is among the organizations playing a role in developing federal health IT strategy. A DoD representative sits on the federal Health IT Standards Committee as well as its workgroups discussing clinical operations and health IT implementation.

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What is the current DoD EHR system? 

In June 2011, the DoD finished the implementation of a new EHR system. The DoD EHR -- CliniComp Essentris, from CliniComp Intl. -- will be used at nearly 100 facilities in seven countries and, in all, will cover some 9.6 million patients within the Military Health System. The new DoD EHR also uses bidirectional HIE (explained below) to share data with nearly 150 medical centers operated by the VHA.

This EHR implementation follows the troubled Armed Forces Health Longitudinal Technology Application (AHLTA) system. AHLTA began in 1997 as a means of replacing the Composite Health Care System, the original DoD EHR. However, a 2010 Government Accountability Office (GAO) report found the AHLTA system, despite a $2 billion investment, to be poorly planned and managed. The AHLTA system was slated to be implemented in four phases by 2007, but at the time of the GAO report, the final two phases had been terminated, and the second phase had only been partially implemented.

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How is the military using SOA?

In a typical week, the Military Health System sees nearly 20,000 inpatient admissions, more than 100,000 dental visits, 1.8 million outpatient visits and more than 2.2 million prescriptions, said Chuck Campbell, MHS CIO, during the July 2010 SOA in Healthcare conference. Much of this activity occurs in remote areas nowhere near a traditional medical facility -- on a battlefield, for example, or a ship at sea. Add to that the visits that military personnel pay to private and public providers outside the Military Health System and you have an organization that needs to incorporate patient data from innumerable sources. 

To address this need, the MHS is rolling out a SOA model to integrate its separate systems. Using this model, data is entered locally, synced to the database server when a connection is available. In addition, the SOA model allows for the deployment of services, which can be developed more quickly than full-blown applications and, as a result, provides better flexibility to medical officers in the field. 

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How is the military using mHealth?

Delivering medical services at the point of care has led the Military Health System to develop several applications for mobile health -- or, in military terms, the Theater Medical Information Program - Joint, or TMIP-J. These applications include a mobile version of the AHLTA system that runs on handheld computers, a Web-based medical data store that can, if needed, be deployed during a non-military disaster, and a patient tracking application that tracks soldiers from Central Command to the Landstuhl Regional Medical Center in Germany to MHS and VHA facilities in the United States.

 The military is also testing a variety of other health applications for smartphones. These includemobile video conferencing for mental health treatment and the ability to report combat injuries, vital signs and the GPS coordinates of an injured soldier's location. The tests are part of a larger U.S. Army initiative to develop smartphone applications for a variety of purposes, including mobile health and digital instruction manuals. The Army said its aim in testing the applications is to determine if consumer devices running the iOs or Android operating system can provide the same functionality -- and durability -- as rugged devices developed by the military.

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How is the MHS working with the VHA?

The Virtual Lifetime Electronic Record (VLER) initiative, announced in 2009, is part of an effort to provide military personnel with continuous health care from active duty through veteran status. The VLER initiative is using Nationwide Health Information Network (NHIN) standards to ease the process of health information exchange between the Department of Veterans Affairs (VA) and DoD, as well as the Social Security Administration and private health providers such as Kaiser Permanente.

Along with the VLER initiative, several other VA/DoD health information sharing projects are underway.

  • Under the Federal Health Information Exchange (FHIE) program, which began in 2002, each month the DoD transfers service members' PHI to a joint repository accessible by the VHA. This data includes demographics, lab results, pharmacy data and so on.
  • The Bidirectional Health Information Exchange (BHIE) builds on the FHIE program and, as its name implies, allows for two-way sharing of PHI for patients eligible to receive care from both the DoD and the VA. BHIE data includes pre- and post-deployment health assessments, discharge summaries and progress notes.
  • Developed in 2006, the Clinical Data Repository/Health Data Repository, or CHDR, is an interface between the DoD's Clinical Data Repository and the VA's Health Data Repository. It, too, supports bidirectional data exchange -- in this case, pharmacy data such as drug-drug and drug-allergy interactions.
  • Finally, the Laboratory Data Sharing Interoperability (LDSI) initiative supports the exchange of chemistry and hematology lab orders and results among the VA, DoD and commercial laboratories. It supports the Logical Observation Identifier Name Codes (LOINC) and Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT) data standards.

This collaboration is not without challenges. In October 2010, it was revealed that, in one instance, sensitive patient data from a physician's progress note, entered as free-form text in a field in the VistA EHR system, had been transmitted to the DoD's EHR system without consent. As one expert analysis suggested, this over-disclosure of EHR data presents two issues -- the use (and control) of free-form text fields within all EHR systems and the difficulty of identifying a clear consent model for the health information exchange process. 

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