DOD's medical transformation

The military has been focused on transformation. But one of the most radical changes in recent years has been the Defense Department's health care system. Navy Capt. Robert Wah, a reproductive endocrinologist who serves as the director of information management for the Military Health System (MHS), views the clinical information and Computerized Provider Order Entry (CPOE) systems DOD has used for more than a decade as "better stethoscopes" that allow military doctors to provide advanced patient care with fewer errors.

Speaking as a clinician, Wah said DOD's Composite Health Care System (CHCS), provides him with quick and easy electronic access to a range of lab results without having to flip through paper charts.

He said CHCS, which Science Applications International Corp. first started to develop in 1988, also allows DOD clinicians to use a computer to quickly scan, for example, a patient's history of glucose tests, which are crucial to determining whether that patient is diabetic. The computer graphically displays the results on a chart, which makes the diagnosis easier.

Lab data, Wah added, is sent automatically from a blood analyzer machine directly to the CHCS patient record, which is accessible at 100 military health facilities worldwide.

When military doctors write prescriptions, they use the Pharmacy Data Transaction Service (PDTS) developed by WebMD, which automatically checks for potential adverse drug interactions and duplicate prescriptions.

Air Force Col. James Young, director of DOD pharmacy programs, said PDTS then routes that prescription for filling and pick-up to the pharmacy most convenient for the patient. A nationwide network of almost 55,000 commercial and military pharmacies fill military prescriptions for more than 9 million active-duty or retired military personnel and their families.

Wah said CHCS' scope and scale are far beyond any other electronic health care system outside the federal government.

James Reardon, MHS' longtime chief information officer who retired last month, told Congress in 2004 that CHCS is deployed at 75 military hospitals and 461 military clinics worldwide. It is used to electronically book 50 million outpatient appointments a year and handles 70 million prescriptions and 42 million lab tests a year, he added.

"CHCS has for years offered a tremendous amount of functionality," said John Quinn, chief technology officer in the health care provider practice at consulting firm Capgemini. Private-

sector hospitals are adopting aspects of the system.

Quinn added that DOD's command culture — absent in the private sector — plays a role in the widespread deployment and use of CHCS. That structure allows for a more controlled and disciplined rollout of new systems.

Besides making doctors more efficient, MHS clinical systems improve the quality of patient care, Reardon said. Since PDTS went online in 2001, it has prevented more than 99,000 potentially life-threatening drug reactions, he said.

Many private hospitals are just now starting to install the CPOE system, which is at the core of CHCS and has been used in MHS for more than a decade — just as DOD starts to deploy CHCS II, Wah said.

When SAIC began developing the first version of CHCS, now referred to as CHCS I, in the late 1980s, officials used the best technology available at the time: terminals with a text and command line interface connected to host computers. CHCS II, which MHS officials expect to fully deploy by January 2007, will be much easier to use because of today's standard graphical interfaces, Wah said.

The development of CHCS II also marks a quantum leap for MHS, Wah said. The system marks the organization's development from an institution-based system to an enterprise-based and patient-focused system, he said.

Today, CHCS runs on servers located at individual DOD hospitals or MHS regions such as Washington, D.C., or Puget Sound, Wash. That data, however, is not accessible by other hospitals or regions. For medical staff working with active-duty personnel, who relocate frequently, this was not good.

Wah said CHCS II will eventually hold patient records for all MHS patients in a central data repository that DOD has created at a secure defense megacenter — a center so secure that Wah refused to say where it is located for security reasons.

Larry Albert, senior vice president of the health care practice at Integic, which holds the CHCS II contract, said all MHS facilities will be connected to the central database via high-speed OC-3 (155 megabits/

sec) circuits provided by the Defense Information Systems Agency. Those circuits will allow any clinician at any MHS faculty to access records on any MHS patient wherever they are treated. That accessibility is also the goal of the Department of Health and Human Services' national e-health record project.

MHS officials are in the process of pulling two years of patient data from the existing 102 servers and sites that host CHCS I to populate the new central data repository, and they have already captured about half that information, Wah said.

Unlike the flat file records kept in CHCS I, CHCS II will use structured data elements that will make it easier to mine the clinical database repository for information on the patient population, Wah said.

CHCS II also includes new modules unavailable in CHCS I, including the ability for clinicians to automatically record patient notes that previously had been stored in paper charts, he said, which will pave the way toward completely paperless health records.

CHCS II has had its share of growing pains. In April and May 2004, the Oracle database used for the clinical data repository froze, Wah said. Integic's Albert said this was due to significant problems with a Hewlett-Packard storage-area network. He said the problems were traced to software running a fiber switch in that network that had missed a firmware upgrade.

Besides the network, HP also provides the multiprocessor Superdome servers for CHCS II's data center.

With the hardware and software problems now resolved, Wah said, MHS plans to have CHCS II fully deployed by January 2007, the culmination of a $3.5 billion project that started when DOD awarded the first CHCS I project in 1988.

This will mark the end of "one of the most comprehensive technology deployments ever undertaken by a health care system," William Winkenwerder, assistant secretary of Defense for health affairs, told Congress last year.