Modern combat operations expose Soldiers to many
potential environmental health hazards, including the possibility
of chemical, biological, or nuclear attacks. The effects of
exposure to health hazards during combat operations may not
be apparent immediately. For example, the results of exposure
to Agent Orange during the Vietnam War were not known for many
years, and some veterans of Operations Desert Shield and Desert
Storm are being treated for a potential “Gulf War Syndrome.” History
has taught us that comprehensive health surveillance is necessary
to mitigate the loss of combat effectiveness caused by nonbattle
injuries or illness. Quality assurance studies demonstrate
that Soldiers treated at forward locations, where only handwritten
records are prepared, rarely have their permanent records updated
to reflect their treatment.
In 1999, Congress mandated that the Department of Defense (DOD)
develop a system for collecting, storing, and tabulating medical
data for all service personnel in an electronic health record
(EHR). In response, DOD created the Composite Health Care System
II (CHCS2) (recently renamed the Armed Forces Health Longitudinal
Technology Application [AHLTA]). In 2003, a version of that
system, the CHCS2–T (Theater), was introduced on the
battlefields of Operation Enduring Freedom and Operation Iraqi
Freedom. The goal of CHCS2–T is to provide commanders
the medical surveillance and monitoring capabilities they need
to evaluate force health protection needs. The use of CHCS2–T
on the battlefield provides a comprehensive, historical, durable
medical record for each warfighter encompassing all of his
shows four TMIP data systems and the echelons of
care for which each is used.
The EHR fielded by the Army is part of a system called the
Theater Medical Information Program (TMIP). TMIP is not a
single system; rather, it encompasses several computerized
designed to create an EHR and transfer pertinent medical
treatment information from the point of injury on the battlefield
the Soldier’s permanent health record. Starting in 2003
during Operations Enduring Freedom and Iraqi Freedom, TMIP
was fielded at various levels of the combat theater. This article
outlines the experiences of the newly deployed, transformation-based
4th Sustainment Brigade in using the TMIP system integration
during Operation Iraq Freedom 05–07.
At the core of TMIP development is the need for overall improvement
of both force health protection and real-time health surveillance.
Success of the TMIP is paramount to producing a seamless,
durable EHR that accurately captures, tabulates, and monitors
for warfighters throughout their military careers. TMIP is
the military’s answer to the need for a fully computerized
medical health record for all Soldiers that is comprehensive
and easily transferable from peacetime to combat operations.
TMIP’s primary purpose is to capture a Soldier’s
medical history in a usable database format. This information
then can be analyzed to determine trends and identify potential
hazards for all personnel, permitting preemptive actions such
as immunizations and prophylaxis treatments. TMIP, when fully
implemented, will integrate four core data systems in order
to capture and store medical information. The chart on page
39 shows the four data systems and the echelons of care for
which each is used. The chart above shows the basic flow of
information in the TMIP system.
The four TMIP computer systems are designed to communicate
seamlessly with one another. The basic system includes a rewriteable
electronic information carrier (EIC) in a card format designed
to be worn on the dog tag chain of each Soldier. Personal historical
and administrative medical data are preloaded onto the EIC
and carried by the Soldier at all times. When the Soldier is
treated in either garrison or the field, the EIC is scanned
to load his medical history and administrative data onto the
computer platform used.
The scanning device commonly used for the EIC is a handheld
computer called the Battlefield Medical Information System-Telemedicine
(BMIS–T), which is preloaded with pocket personal computer
software. Scanning the EIC with the BMIS–T eliminates
the need to spend time entering administrative data for each
Soldier. Medics use the handheld BMIS–T to enter data
during sick call visits and to document information that would
be entered routinely onto a field medical card (FMC). The BMIS–T
is most helpful in completing Post-Deployment Health Assessments.
Data from the BMIS–T are downloaded to the next TMIP
step, a laptop computer system often called the Medical Communications
for Combat Casualty Care (MC4) computer. This data transfer
most often occurs at the battalion aid station (BAS) using
the HotSync function common to most handheld computers. (HotSync
is the process of synchronizing information between a handheld
computer and a personal computer). The CHCS2–T computer
system transmits medical information to the Joint Patient Tracking
Application (JPTA) database through a standard NIPRNet (Unclassified
but Sensitive Internet Protocol Router Network) connection.
If possible, a local network of a unit’s CHCS2–T
computers is set up within a BAS to allow information sharing.
If networking is not possible because of tactical conditions,
information is stored on a handheld or laptop computer until
conditions allow the transfer of data to the JPTA database.
The JPTA is a Web-based tracking and information management
tool that reports data on Soldiers treated in forward operating
areas. Compiled JPTA data can be accessed by anyone with a
NIPRNet account and an assigned password. Passwords for the
JPTA database can be obtained on line (usually within 48 hours
of completing a registration form and password request). Commanders,
physicians, and other healthcare providers can use JPTA data
to ensure force health protection. Ultimately, the medical
data captured by both BMIS–T and CHCS2–T are uplinked
to the Soldier’s permanent medical record. This eliminates
the problem of lost records and saves time previously spent
recording purely administrative data on multiple handwritten
documents. The data compiled in JPTA enhance the ability of
field surgeons to track patients during the casualty evacuation
process and to review tabulations of disease and nonbattle
injury data to help identify possible trends of illness or
exposure. The powerful JPTA database also improves response
times when replying to command inquiries about the health status
of injured or evacuated warfighters.
TMIP captures all information about the healthcare given to
Soldiers and eventually includes those data in their permanent
records. Redundancy is built into the system by having multiple
levels of information capture that could be used to update
any of the lower tiers of medical data collection. Research
possibilities and development of preventive medicine techniques
will be enhanced by greater use of the system by all units.
Army-wide implementation of the TMIP system is planned for
Implementing TMIP in the Sustainment Brigade
The 4th Sustainment Brigade deployed in support of Operation Iraqi Freedom 05–07
in September 2005. Before deployment, the brigade received all of the major components
of the TMIP system except the EICs. Unfortunately, without an EIC, the handheld
computer cannot be used as a replacement for the FMC. All initial echelon I (the
first medical care a Soldier receives) treatment notes completed in forward locations
were handwritten on the FMC.
A big obstacle to using the BMIS–T is its inability to transmit data wirelessly
to the CHCS2–T computers because the Bluetooth technology involved is not
secure. Currently, data transfer from a handheld computer to other TMIP systems
requires a hard-wire HotSync. In the brigade’s echelon 1 troop medical
clinic, most medics did not fully use the features available with BMIS–T;
most simply used their handheld computers to follow treatment algorithms during
sick call. Bluetooth expansion, including a secure wireless transmission, would
enhance system capabilities for medics who use BMIS–T as a replacement
for the standard FMC.
The CHCS2–T computers functioned as designed, but they were sometimes slow.
One of the most notable exclusions from the CHCS2–T software package was
an alternate input method (AIM) forms capability, which is available in AHLTA.
The AIM forms capability provides a format for inputting medical notes that is
similar to the format used on the traditional paper chart. The template-based
entry offered by CHCS2–T computers is time intensive and difficult to learn.
The AIM helps standardize treatment for common illnesses, allowing faster documentation
and quicker training. Given the inherent training difficulties that accompany
the fielding of a new product, the AIM would enhance the CHCS2–T software.
Although slow in the initial months of use, uploading the brigade’s medical
data from the CHCS2–T computers to the JPTA database did not present any
problems; the TMIP system functioned well. It took several hours for a completed
note to appear on the JPTA Web site, but the information was accurate and complete.
The delay in updating a note to the JPTA server (sometimes more than 3 hours)
prompted the field surgeons to make phone calls to various medical facilities
to obtain real-time casualty information.
One suggestion for enhancing the organization of the JPTA database is to organize
casualty data for each unit on the JPTA site and include a summary screen that
provides a unit snapshot of information so that field commanders can see where
their Soldiers are and what is currently happening. The summary screen could
include several data fields that could be customized for each unit. A virtual
private network (VPN) would increase the depth of review available with JPTA.
The JPTA data currently are limited to the theater of operations. By using a
VPN, home-station medical databases could be accessed by forward stations to
obtain needed medical information (such as medical profile information and historical
radiological studies). A medical readiness module to track medical profiles both
in garrison and in combat operations would eliminate the need for Soldiers to
have copies of their profiles. The data would be available instantly to anyone
having NIPR access to the JPTA, so field
surgeons and commanders could track and review medical profiles more accurately.
TMIP technical support was available at Forward Operating Base Taji, but it usually
took several days for the provider to arrive and troubleshoot networking problems.
Several of the delays the brigade experienced with TMIP could have been eliminated
with increased availability of technical support.
Another way to enhance JPTA organization would be to integrate the TMIP system
fully to all units. Expeditious fielding of complete TMIP systems and continued
software enhancements are necessary to meet the needs of the modern Soldier,
both during and after deployment. All commanders need the ability to compile
accurate medical data quickly and efficiently in order to maximize combat effectiveness.
The brigade’s medics and healthcare providers quickly came to rely on the
data management provided by the CHCS2–T.
Overall, TMIP is an outstanding concept that will eliminate the previous inconsistency
and fragmented data common with handwritten records. Continued efforts should
focus on seamless integration of both inpatient and outpatient data in the TMIP
Army-wide implementation of the EHR during both garrison and combat operations
offers the mobility of information needed to enhance force health protection.
The EHR is paramount to ensuring that commanders have full medical situational
awareness and offers myriad healthcare reporting and tracking capabilities. Continued
refinement of the durable EHR and TMIP are essential to meet the needs of today’s
Lieutenant Colonel Mark L. Higdon is the
Residency Director for the Martin Army Community Hospital’s
Family Medicine Residency Program at Fort Benning, Georgia.
obtaining his undergraduate and medical degrees, he completed
a family medicine residency at Fort Benning and fellowship
training at the University of North Carolina. When this article
was written, Lieutenant Colonel Higdon was assigned as the
Brigade Surgeon for the 4th Sustainment Brigade at Fort Hood,
Texas, which was deployed to Iraq in support of Operation Iraqi