DOD practices prevention through IT

The Defense Department's state-of-the-art medical information system not only will improve health care but will also help DOD spot outbreaks of illness caused by biological or chemical weapons.

Senior military health officials approved deployment of the Composite Health Care System (CHCS) II late in 2003 after a yearlong operational trial in nine military

hospitals.

The rollout, which includes training for doctors, nurses and other medical personnel who will use it in the 75 military hospitals and 461 clinics worldwide, will continue until mid-2006. A portable version is at work in Iraq and Kuwait.

With CHCS II, doctors and other medical workers can create and add to electronic medical records for each of the more than 8 million individuals they treat. These records include active and retired military personnel and their dependents. All the records are stored in a central Oracle Corp. database and are accessible to the health officials who may need them.

Recycling information

CHCS II has many advantages beyond merely making the practice of medicine easier for doctors and patients, said Lt. Col. Bart Harmon, a physician who is deputy director of information management, technology and re-engineering and chief of medical information in the Health Affairs Division of the Office of the Secretary of Defense.

The system also will help military leaders spot clusters of symptoms that point to a biological or chemical attack, Harmon said. Many biological and chemical agents trigger symptoms that resemble influenza and other common ailments. Odd symptoms sometimes are ignored on the theory that they are anomalies.

"There might not be enough information in any one patient seeing any one provider to raise an alarm, but if you saw a clustering of people with these funny new symptoms all in one geographical area, it might make you set off an alarm," he said.

The system also could help officials spot outbreaks of new diseases such as severe acute respiratory syndrome (SARS), whether the disease was introduced by hostile forces or was a natural phenomenon.

To make this aspect of CHCS II effective, professionals who record patients' symptoms must use a standard set of terms so that the system can determine if "sniffles" is the same as "runny nose," for example. Symptom incidence will be monitored automatically.

"I don't know of any other system that does this on the scale that we're doing it," Harmon said. He said officials at the Homeland Security Department have expressed interest in replicating CHCS II to identify biological or chemical attacks.

Workflow support

The system fits into health practitioners' normal workflow, Harmon said. When a doctor enters a prescription for a drug into CHCS II, the action triggers preparation of the prescription order. Before, doctors had to go to a computer other than the one they used to record patients' ailments or use a piece of paper to write the prescription. "It's a big step forward in terms of eliminating duplication and supporting the workflow of delivering health care," Harmon said.

Besides increased efficiency, he added, the one-step process will reduce discrepancies between doctors' notes and prescriptions. CHCS II will stem adverse reactions to medication because there will be a record in a database of allergic reactions that patients experience.

Soldiers' paper medical records are supposed to be kept at the bases where they are stationed, but they sometimes get lost during transfers. And even if the records are at the base, they don't always accompany a wounded soldier who is rushed from a battlefield to a hospital.

"In military medicine, constantly we're searching for the patient's chart," said Dr. Francis Holland, an Air Force family physician who has used CHCS II. Without a patient's records, Holland said, less than optimal care could result, especially if a patient is unconscious.

Up-to-date records can accelerate deployment. Soldiers need certain vaccinations before they go overseas, Harmon said, and online records will show which shots are current and which need to be updated.

The prime contractor for CHCS II development is Integic Corp. of Chantilly, Va. Larry Albert, a senior vice president at Integic, said the most challenging aspects of the program were creating the user interface, ensuring that medical professionals understand how to use the new system and establishing the worldwide data communications links. Delayed system responses are not acceptable to doctors on the job, he said, and local caching of data is one solution to that problem.

Common ground

The user interface was a challenge because the same system is used by many kinds of practitioners: X-ray technicians, cancer specialists, pediatric nurses, dietitians and pharmacists, in addition to doctors, Albert explained.

The large-scale monitoring of symptoms will take place through a data warehouse that mirrors the central database, he said. Besides identifying unusual clusters of symptoms, the warehouse will allow DOD analysts to review medical costs and study the efficacy of different approaches to treating ailments.

For this to work, the standardization of terms is critically important, said one observer who is knowledgeable about medical informatics. Nevertheless, getting medical practitioners from different specialties to use common coding for symptoms and diagnoses is incredibly difficult, according to Laura Marcial, director of technical operations at the Johns Hopkins University Points of Care Information Technology Center.

The importance of training users cannot be overemphasized during the rollout of such a system, Marcial said, because user resistance can defeat the intentions of the system's designers. If DOD officials encourage their medical professionals to embrace CHCS II, their acceptance will be "a good example for the rest of the medical world," she said.

Building blocks

The designers of CHCS II consciously made use of commercial off-the-shelf products that have been woven together to create the complete system, Integic's Albert said, adding that about two-thirds of the system relies on such products.

CHCS II has a modular architecture that can easily be modified and updated, he said. This is one reason DOD policy requires developers to use commercially available products. A second release, now under development, will add dental records and other enhancements.

When the portable version of CHCS II is used, the records are collected locally for review. They can be forwarded to the central database when it's convenient and safe to do so.

Ferris is a freelance writer in Chevy Chase, Md. She can be reached at ferrisn@att.net.

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Composite Health Care System II

Eventual patient records: 8.7 million

Users by 2006: 60,000

Cost over 18 years: $4 billion

Yearly visits to outpatient medical providers: 40 million

Defense Department legacy medical systems in 2000: 60

Source: Defense Department