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Implementing the Theater Medical Information Program During Operation Iraqi Freedom

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 medical encounters.

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 models designed to create an EHR and transfer pertinent medical treatment information from the point of injury on the battlefield to 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 healthcare 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 Capabilities

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 2007.

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 system.

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 warfighters.

Lieutenant Colonel Mark L. Higdon is the Residency Director for the Martin Army Community Hospital’s Family Medicine Residency Program at Fort Benning, Georgia. After 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 Freedom.