Electronic dog tags bring health records to battlefield
How might a medic on the battlefield get access to an injured warfighter’s medical history? One way would be to preload information onto a handheld device. Another would be to download data from a more personal object: an electronic dog tag.
The Telemedicine and Advanced Technology Research Center (TATRC) has been developing electronic dog tags with plans to integrate them with devices that run AHLTA Mobile, an offshoot of the Defense Department’s electronic medical record system. Electronic dog tags could allow medics to instantly access health information and automate the loading of patient data to AHLTA Mobile.
TATRC’s first attempt at an electronic dog tag was a Personal Information Carrier, a small, secure digital card inside a ruggedized sleeve. The Army’s 325th Airborne Infantry Regiment tested 20,000 of them in 2003, but several problems emerged. For one thing, soldiers didn’t always wear the cards around their necks. As a result, medics would have to search for them. Furthermore, they needed a special adapter to plug the cards into a handheld device or laptop PC.
Therefore, TATRC sought to develop a wireless device that could transmit information without having to be found or manipulated. The result is the Electronic Information Carrier.
EIC’s value lies in its ability to enhance efficiency and thereby reduce costs, said Lt. Col. Tim Rapp, the EIC program manager at TATRC. “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 plan is to allow AHLTA Mobile devices to communicate with EICs as far as 10 meters away. Medics would load data from the dog tags to handheld devices, and information they enter on the devices would automatically be saved to the EICs.
A wounded warfighter’s EIC would update his or her electronic medical record upon arrival at a battalion aid station by automatically and wirelessly transmitting the data to AHLTA Theater. Without EICs, such automated updates are impossible if patients are evacuated before battlefield medics can reach a location where bandwidth is available to upload the information they recorded.
Rapp said combat units are already asking for the devices. His team is evaluating a number of prototypes and plans to field the first EICs as early as next year.
— Peter A. Buxbaum
The scandal involving the care of wounded service members at Walter Reed Army Medical Center was a reminder that the Defense Department’s military prowess is only as good as its power to shield warfighters from harm and restore them to health. That explains in part why the military — and not the nation’s commercial labs — is funding the most sophisticated research in health information technology in the world.
Today, DOD produces a torrent of research that has put it years ahead of most private organizations when it comes to understanding how IT can improve health care. Work is under way on applications ranging from a digital dog tag loaded with personal health information, an electronic medical record (EMR) tool that supports triage on a global basis and a Web-based system that lets military doctors compare clinical data on eye surgeries.
An Army organization called the Telemedicine and Advanced Technology Research Center at Fort Detrick, Md., is managing much of that research. TATRC oversees more than $250 million in health IT research spread across 500 ongoing projects.
Although TATRC is not technically a lab, it manages and applies technical rigor to projects funded by more than 150 congressional line items and groups them into portfolios of projects that share common attributes or goals. In addition to health IT, those projects involve robotics, advanced prosthetics, simulation and training technology, and management of chronic diseases.
TATRC also has its own core program funding, which it uses to manage research in the areas of infectious disease, combat casualty care, operational medicine and biodefense.
“Every project is unique and has its own set of challenges,” said Col. Ron Poropatich, TATRC’s deputy director and senior telemedicine consultant to the Army surgeon general. “Our metric for success is the extent to which we get a research project into a program of record and then commercialize it to get into the hands of the warfighter. That is a very difficult process.”
Although the endpoint of that process is often the battlefield, it has its origins in the congressional budget battles over funding earmarks, better known as pork barrel legislation. Indeed, earmarks are TATRC’s stock in trade.
“We manage hundreds of millions of dollars every year in congressional special-interest money,” Poropatich said. “We work closely with our congressional partners and with the researchers to make their projects more military-relevant. The next challenge after that is to cross the chasm between research and development and commercialization.”
Congressional earmarks go to researchers who might or might not have a particular interest in working with the military. “We manage these for fiduciary oversight,” he said. “We are looking for good science and help the researchers develop a good proposal. Then it goes through an internal and external review to try to make them militarily relevant. Once the project is under way, we oversee [it] for adherence to cost, schedule and performance goals.”
Impressive contributions The organization has made some impressive contributions to military health care. They include advances in health information sharing between the Defense and Veterans Affairs departments, providing workflow and analytical tools for medical and surgical procedures, and enhancing the capabilities of robots on the battlefield.
There are two major challenges to seamlessly moving medical information between DOD and VA: the divergent architectures of the departments’ systems and the different data ontologies, or classification systems, they use.
“The ultimate goal is complete interoperability,” said Lt. Col. Hon Pak, chief of TATRC’s Advanced IT Group. “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 exchanging information incrementally. “We have taken significant efforts in the last two years to share some information one way and some bidirectionally,” Pak said. Information on allergies and lab results, for example, are now accessible by both systems.
At the architecture level, VA is moving toward a more centralized system while DOD is allowing greater localization, Pak said. But the biggest challenge comes at the data level, where each system uses different standards and ontologies for lab tests, pharmaceuticals and other data elements.
“Sometimes those codes don’t match up and something gets lost in the translation,” Pak said.
To achieve complete interoperability, the two departments might have to tinker with their systems at the data level — a laborious process. However, they are developing an interim solution in the form of an application that will mediate between the two systems and translate terminology as necessary.
TATRC has other ongoing projects that aim to enhance the availability and value of information included in AHLTA, DOD’s EMR system, Poropatich said. Those projects include providing additional decision-support and data-mining functions.
Syncing medical records But the center doesn’t spend all of its time on high-level architectural problems. Much of its work is focused on the more microscopic needs of health care specialists.
For instance, surgeons at the Walter Reed Army Medical Center wanted to measure the efficacy of the refractive eye surgeries they were performing. So they asked TATRC to adapt an existing medical information system called the Field Deployable Record (FDR) into something that could meet their specific needs.
“Historically, medical records are messy,” said Mark Jeffrey, telemedicine technology manager at TATRC. “They don’t allow for the outcomes analyses that are required in today’s world.”
Refractive eye surgery encompasses a number of surgical procedures that are used to correct nearsightedness, farsightedness and astigmatism, and decrease dependency on eyeglasses or contact lenses.
FDR is a Java-based application that allows medical professionals to record injuries in the field. John Pajak, a TATRC software programmer, worked with surgeons at Walter Reed to understand their workflow and ended up creating the Refractive Surgery Information System (RSIS). “My main focus was to develop an understanding of their methods and procedures,” Pajak said.
The ultimate objective was to develop an outcomes-analysis application that draws information from the Military Health System’s electronic medical record database. Statistical analysis of that data would help physicians improve the safety and efficacy of refractive eye surgery.
RSIS, a Java-based client/server application, has since been enhanced with a Web interface to become Web-enabled RSIS (webRSIS), whose easy-to-use interface for recording information during surgery enables surgeons to manage and accurately report outcomes.
“The interface is modeled after the doctors’ workflow,” Jeffrey said. “It is designed for data capture with the doctors in mind. The software captures information in the same way they are used to so it doesn’t interfere with their current workflow.”
The system generates a report that doctors use to understand outcomes. “They are able to analyze when surgeries are overcorrecting or undercorrecting eyesight,” Jeffrey said. “This package enables them to provide a better product that helps maintain the agility and the mobility of the warfighter.”
Since first fielded in 2004, webRSIS has been enhanced with additional analytical and reporting functions and support for custom queries.
Government Health IT presents Rick Friedman, director of the division of state systems for the Center for Medicaid and State Operations with the U.S. Department of Health and Human Services, in this recent eSeminar regarding how the federal Centers of Medicare and Medicaid Services is partnering with state Medicaid and health and human services officials to bring Medicaid into the digital age. Paul McCloskey, Government Health IT editor, moderates.
