October – December 2006

Perspective 1

MG Russell J. Czerw

Certification in Military Medicine: The Time is Now 3

COL Michael J. Roy, MC, USA, et al

US Army Clinical Investigation 13

COL James M. Lamiell, MC, USA, et al

Expanding the Role of the Nurse Practitioner in the Deployed Setting 20

MAJ (P) Edward E. Yackel, AN, USA, et al

Forward Deployed Neurologists? But That’s Where the Troops Are! 26

LTC Roman Bilynsky, MC, USA

Theater Immersion: Training a Medical Task Force for Operations in Iraq 28

COL James B. Henderson, USA

Application of Geographic Information System Technology to 34

Preventive Medicine Interventions

Joel Reyes, BS, et al

Featured Topic:

Electronic Medical Records

The New Name of the Military Electronic Medical Record 40

LTC Ron Moody, MC, USA; David Freeman

A Global Electronic Medical Record, Today’s Reality 42

LTC Ron Moody, MC, USA; David Blair, MD

AHLTA Deployment Status and Development Strategy 46

LTC Ron Moody, MC, USA, et al

Electronic Medical Records, Medical Coding, and Outcome Improvement 51

LTC Ron Moody, MC, USA

The Tactical Electronic Medical Record: The Key to Medical Transformation 56

LTC Edward Michaud, MC, USA, et al

Implementation of the Theater Medical Information Program 65

During Operation Iraqi Freedom IV

MAJ Mark L. Higdon, MC, USA
LTG Kevin C. Kiley

The Army Surgeon General

Commander, US Army Medical Command

MG Russell J. Czerw

Commanding General

US Army Medical Department Center and School

October– December 2006 The Army Medical Department Center & School PB 8-06-10/11/12

0625501

PETER J. SCHOOMAKER

General, United States Army

Chief of Staff

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October – December 2006 1

I remain impressed with the distinct authorship and

relevance of the articles published in our AMEDD

Journal. You will find that this edition validates the

AMEDD Journal’s continued success as a dynamic

and relevant peer-reviewed publication.

We are fortunate to begin this edition with a reprint of

a very timely article which previously appeared in an

international military medical journal. COL Mike Roy,

et al make an excellent case for a process to confer

formal certification in military medicine, and how the

elements of that skill set have wide applications in the

civilian medical sector. Such certification would

recognize the unique and challenging demands of

medical care in combat environments, as well as result

in a much better prepared and capable military medical

professional charged with the care of our most

precious resource, the combat Soldier.

Research is fundamental to the science of medicine.

COL James Lamiell, a gifted medical researcher, and

his team present a detailed picture of the AMEDD

Clinical Investigation Program, the formal structure

defining how clinical research is conducted within

Army medicine. This interesting and informative

article describes both the history and current status of

the program, and discusses the rationale and strategic

vision that frames these extremely important research

efforts. The article not only reflects the AMEDD’s

considerable investment in and support of clinical

investigation, but also underscores our unwavering

commitment to maintaining the highest standards of

medical expertise and practice.

As the AMEDD adapts to the long-term challenges of

the new combat environment posed by the Global War

on Terror, real world experiences are paramount in the

generation of new ideas and the adaptation of existing

methods and protocols. Three articles in this issue

directly address efforts to ensure the delivery of

quality health care during operational deployments.

First, in their article, MAJ (P) Ed Yackel’s group of

highly experienced Nurse Practitioners (NP) present a

very strong, thoughtful case for formalizing expanded

roles of the NPs in deployed environments. For years

the NP has been a vital element in the delivery of

health care in the fixed facility environment, both

providing primary care directly and serving in

supervisory positions over clinics and departments.

The experiences related in the article show that the

exigencies of operations place NPs in the same roles

while deployed. Unfortunately such assignments are

not directly addressed in doctrine, leading to

inconsistencies, confusion, and suboptimal use of vital

resources. Next, in a similar look at resource

utilization from the perspective of real-world

experience, LTC Roman Bilynski’s concise, thoughtprovoking article proposes a practical change in the

doctrinal use of Neurologists in combat deployments.

The third article looks at predeployment training in

realistic combat environments. Such training is as

absolutely important for medical units as it is for

combat forces. COL James Henderson presents a

detailed description of the planning, coordination,

attention to detail, resources, and sheer hard work that

is required to deliver the practical, intensive training

necessary to thoroughly prepare a unit for imminent

Perspective

Major General Russell J. Czerw
2 Army Medical Department Journal

deployment. Units are completely immersed in

realistic environments and intense situations which

replicate as closely as possible the conditions they

should expect. COL Henderson shows how training

planners especially draw upon the experiences of those

who have gone before to design and refine their

training plans. This is an eye-opening portrayal of the

too often overlooked efforts of dedicated training

support professionals who work tirelessly to prepare

our medical personnel for their critical role—saving

the lives of our combat Soldiers.

The creative use of emerging technologies has long

been a hallmark of the US military. Joel Reyes, et al

give us a look at how a seemingly unrelated

technology is being used with our medical applications

and data to create another important tool for medical

planners, especially in preventive medicine.

Geographic information systems are rapidly becoming

an indispensable part of medical planning for

transportation, natural disasters, and epidemiological

responses, to name a few. Recent events have greatly

increased the importance of regional planning for mass

casualty events, introducing the real possibility of

unconventional threats—biological, chemical, and

radiological—which could appear anywhere at any

time. You will find that this article provides a good

overview of how applications of this technology are

being adapted by imaginative, energetic people, not

only to plan for future, large scale events, but also to

simplify existing, routine requirements.

The featured topic of this issue is focused on an

evolving technological application which is already

becoming indispensable in the delivery of health care

in the US military, the electronic medical record

(EMR). LTC Ron Moody and members of his

AMEDD AHLTA implementation team have provided

3 very informative articles which describe the

background of AHLTA, the development and

deployment strategy, and its current status. These

articles present excellent information as to the how,

when, and (especially) why AHLTA has evolved as it

has. All AMEDD professionals involved in healthcare

delivery will find these articles extremely valuable in

helping to further understand and appreciate the tool

you use multiple times every day. In addition, LTC

Moody has written an article emphasizing the

importance of accuracy of the codes used in AHLTA

records. His article explains the classification schemes,

discusses the metrics used to assess the effectiveness

of the coding, and explains the impact of accurate

coding on outcomes and cost. He makes it clear that

the full potential benefits of AHLTA will not be

recognized unless practitioners carefully and diligently

apply themselves to ensuring the accuracy of the

entered information.

The last 2 articles expand the discussion of electronic

medical information to the user level, including its

value to and impact on the Soldier, how operational

units have used it, and the benefits derived. LTC Ed

Michaud and his coauthors present an easily readable,

very informative discussion of their experiences using

the tactical applications of the EMR. Their approach

discusses both practical and theoretical considerations,

covering benefits and disadvantages. This article

provides an interesting perspective on our evolving

EMR technology from perhaps the most important

user, the battlefield medical staff. MAJ Mark Higdon

then discusses the flow of digital medical data across

the battlefield, out of theater, and ultimately into the

Soldier’s record. Writing from his experience while

deployed, he carefully and clearly explains the Army’s

Theater Medical Information Program, its history,

functionality, successes, and shortcomings in the

operational environment.

As usual, this is another excellent edition of the

AMEDD Journal that I hope all of you will take time

to read. There is a nice variety of content and I am sure

that you all remain as impressed as I am with what our

great AMEDD Soldiers do every single day!

Perspective
October – December 2006 3

INTRODUCTION

Over the past two decades, an increasing amount of

attention has been paid to the training of military

physicians in the operational realm—preparing them

for combat-related and humanitarian deployments.

Military unique curricula (MUC) have been published1

and updated,2and various efforts have been made to

try to implement instruction and skills training.3,4

Pierce followed up the initial MUC with a

recommendation that a department of military

medicine be established at each of the US military’s

medical teaching centers,5but this has not occurred.

We now examine subsequent efforts to enhance

militarily relevant education, consider the benefits and

costs of certification in military medicine, evaluate

potential models for certification, and discuss

measures that would be necessary to establish a

meaningful certification program.

BACKGROUND

A review of the literature yields a number of

thoughtful treatises touching upon the subject of

certification in military medicine. Eiseman emphasized

the need for physicians to engage in mass casualty

planning, especially as it may apply to civilian

settings.6 He noted that mobilization from peacetime to

a state of formal warfare or battle required weeks to

months, with physicians involved in preparing for the

type of casualties anticipated. However, he

prophetically pointed out that terrorist attacks require a

similar response from the medical community, with

little or no lead-time to prepare. Physicians must

therefore be trained to deal with a wide range of

potential scenarios. A corollary is that military medical

responses may well need to be different from

standardized civilian responses, so that training

normally unavailable in civilian training programs

must be implemented in order to facilitate an

appropriate medical response to these events.

Military physicians quickly recognize differences

between war and peacetime medicine, but the lessons

learned in battle have often been forgotten between

wars, only to be painfully relearned by others. Bellamy

comments that physicians have long ignored

knowledge of military weaponry, believing the

knowledge to have little therapeutic value. However,

he asserts, only knowledgeable medical officers will

understand the intricacies of war injuries resulting

from battle.7For example, wounds from missiles of

high velocity may require less exploration and

Certification in Military Medicine:

The Time is Now

COL Michael J. Roy, MC, USA

COL Joseph Palma, MC, USAF

COL (Ret) Norman Rich, MC, USA

ABSTRACT

In recent years, military medical personnel in several nations have been working toward providing certification

in military medicine. Reasons for certification include the identification and recognition of expertise, and the

ability to match expertise with challenging assignments and missions. We review the literature, examine several

options, and propose a new method for certification in military medicine. Our model features 2 levels of

certification in military medicine, operational and expert, with the latter a potential basis for a master’s degree in

military medicine. Requirements would be completed through experience or coursework in each of 7 areas:

leadership, preventive medicine, field experience, administrative healthcare, casualty and incident management,

scholarly activities, and service and specialty specific requirements. Educational objectives and material should

be developed, standardized, and incorporated into an educational program leading to certification. Existing

courses and distance learning methods should be incorporated whenever possible. A certification exam is

recommended.

This article is reprinted from International Review of the Armed Forces Medical Services (2006;79(1):46-53) with

permission of the authors.
4 Army Medical Department Journal

debridement than those from projectiles that are

designed to fragment upon impact and further disrupt

tissues. Military physicians should also understand the

different physical, physiological, and psychological

impacts of wounds resulting from ammunition fired

from firearms, the blast effect of explosives, and flame

or incendiary munitions with the additional medical

compromise of thermal injury. The significance of

such issues highlights the need for specific medical

and surgical training requirements and objectives

beyond those that have traditionally encompassed

training programs.

A series of articles in the journal Military Medicine in

the early 1990s addressed the issue of whether military

medicine, or some of its components, has unique

qualities that augur a need to standardize the

discipline, and, in turn, whether to certify those that

complete the requirements. The purpose of

certification would be to identify those with

competence in their respective fields, facilitating the

fielding of a capable medical force. Rignault in

particular argued that “war surgery” should be

considered a unique specialty.8,9 He noted that since

1950, the peacetime practice of civilian and military

surgery has been marked by increasing specialization,

and that although the surgical management of wounds

continues to require a solid foundation in general

surgery training, additional specific training in

wartime surgery, historically unavailable in either

civilian or military peacetime training programs, is

necessary to avoid the significant challenges surgeons

face in treating and sustaining the war wounded.

Rignault emphasizes several key differences between

peacetime and wartime surgery. War surgery deals

with emergencies, providing almost exclusively

lifesaving surgery, to be followed by evacuation and

further staged surgeries in different locations

possessing increasing sophistication. Wartime surgical

and medical care is primarily provided in an

unsophisticated medical environment, with minimal or

no advanced diagnostic equipment, such as CT scans,

requiring greater reliance upon clinical diagnostic

skills. War surgery, in large part, involves the need to

sort large numbers of casualties simultaneously,

requiring triage, stabilization (taken to a new level by

the highly successful French Foreign Legion

“reanimation” teams, whose purpose was to parachute

in, stabilize casualties in far forward areas, and

evacuate them to safer areas for definitive hospital

care, dramatically reducing mortality in the 1970s),

and evacuation to a higher level of care. The initial

stabilization of war-injured patients is therefore

incomplete. The military medical officer must exercise

judgment based upon his or her knowledge of the

mechanism of injury, the injury or injuries themselves,

surgical procedure(s), natural history of the military

injury or injuries, the logistics and sustainability of the

military operation, and the medical evacuation chain

and system capability and capacity. The outcome for a

given patient is significantly influenced not only by the

host (injured casualty) and the environment

simultaneously, but also the lag time between the

injury and arrival to initial medical or surgical care, the

quality of the care, and level of care during transport.

War surgery is performed in sequential echelons (or

levels of care). This implies that the medical officer on

the front lines is responsible for initiating the sequence

of care, but that definitive care will likely be

performed at a rearward location with greater

capabilities, after evacuation. Continuity of care is thus

provided by the system, which standardizes medical

and surgical care to the military environment, rather

than by a single physician or team. The pathology of

war is also different. Common surgical injuries include

blast and crush injuries, missile injuries, and complex

traumas of a magnitude and scope beyond that of the

worst vehicular accidents. In addition, the diseases of

war may differ from peacetime environments, with

malaria, epidemic diarrhea, epidemic exposure

injuries, and even biological or chemical warfare

injuries. This poses greater challenges in training

physicians for deployment. Unchecked in a fighting

force, such conditions may result in defeat. Also of

import to military physicians are the implementation

of public health or preventive medicine measures that

must be present to sustain the effectiveness of the

fighting force. For example, Napoleon discovered that

his mighty army could not capture Moscow because of

the weather’s impact on his force. Ultimately, surgical

procedures and indications differ in the war

environment, as do medical interventions, dictated by

the available resources. One can therefore conclude

that military medicine is indeed a unique discipline,

warranting standardization of education, training, and

certification.6-10

Pories asserts that military surgery is already a

specialty and outlines its components.11 In his opinion,

certification is long overdue. Fifty years ago, general

surgeons treated cancer and performed gastrectomies,

Certification in Military Medicine: The Time is Now
October – December 2006 5

Whipple procedures, pediatric and cardiac surgery, and

orthopedic procedures. Today, increased technology

and specialization has resulted in each of these

functions being performed by subspecialists, not

general surgeons. In the United States, The

Accreditation Council for Graduate Medical Education

(ACGME) recognizes and defines subspecialties as

areas of graduate medical education which have a

prerequisite for enrollment, and require the completion

of an accredited residency and/or certification in a

discipline in which there is a primary or conjoint

American Board of Medical Specialties (ABMS)

board. Military surgeons, and other medical officers,

complete their primary residencies and become board

eligible or certified and are then eligible for

subspecialty training and education. The ACGME also

requires that a subspecialty have a unique body of

scientific medical knowledge sufficient for education

in a clinical field, not simply limited to learning a

procedure or other more circumscribed objective. In

this respect, military medicine also qualifies since

competence in military medicine is not just a matter of

learning a single new procedure. For example, Pories

points out that during the Vietnam War, the surgical

work of field-experienced surgeons was readily

distinguishable from that of newly arrived surgeons

applying surgical skills and standards learned for an

exclusively civilian practice. The latter resulted in

significantly poorer outcomes due to the lack of

knowledge of the intricacies of war casualty treatment

and management.11

EFFORTS TO ESTABLISH A MILITARY UNIQUE

CURRICULUM

In response to the Department of Defense efforts to

establish a military unique curriculum, some US

military training programs have incorporated elements

of an MUC. The family medicine residency program at

Fort Benning, Georgia, designed an innovative

program of rotations through pertinent aspects of

military medicine for their residents. The program

features 12 garrison (ie, peacetime) medicine modules

of instruction ranging from management of a troop

clinic to nuclear and chemical surety programs. There

is extensive coverage of predeployment planning and

issues, deployment topics including activation,

logistics, unit movement, patient stabilization and

evacuation, and redeployment issues and concerns.12

The Department of Medicine at Walter Reed Army

Medical Center (Washington, DC) implemented a

military unique curriculum in which internal medicine

residents experience didactic education in

operationally relevant aspects of subspecialty areas

such as cardiology, infectious diseases, and emergency

medicine, as well as participating in an operational

rotation with a field unit.3,4 More recently, the 6 US

Army medical centers banded together to establish a

military unique curriculum of 18 online modules that

all Army interns, in every specialty, must complete.

The family medicine program at Madigan Army

Medical Center (Fort Lewis, Washington) is also

working to establish a military unique curriculum for

family medicine physicians.

THE DIPLOMA IN THE MEDICAL CARE OF

CATASTROPHES

The British have established what we believe to be a

particularly valuable model for certification in military

medicine. In 1993, the Society of Apothecaries of

London (incorporated by King James I in 1617)

initiated the Diploma in the Medical Care of

Catastrophes, which includes many of the elements of

competence required of military physicians. The

purpose is to identify expertise in unique aspects of

contingency response, for both civilian and military

physicians interested in providing medical and surgical

care in major manmade or natural disasters.

Requirements for certification are divided into 7

areas13:

1. Survival — Satisfied through completion of a 5-

day Disaster Relief Operations Course (DROC),

or another equivalent course.

2. Field Team Training — The DROC or an

equivalent course also provides credit for this

element.

3. Multiple Casualty Management — Can be

completed through a number of different

courses, averaging 3 days in length.

4. Trauma Life Support — Satisfied through

completion of any of a variety of courses such as

advanced cardiac life support or advanced

trauma life support.

5. Preventive Medicine — Also covered in

DROC, or with a separate 2-day course.

6. Written Dissertation — Focused on an aspect

of medical care in catastrophes, up to 100 pages

in length.
6 Army Medical Department Journal

7. Supplementary Module — This features a

pick-list of topics, with completion of any two

required (Note: Medical practice and/or training

in a field often confers credit.):

 War medicine or surgery

 Psychological workshop

 General practice workshop

 Tropical medicine

 Intensive care

 Accident and emergency medicine

 Forensic medicine

 Pediatric medicine

DEFINITION OF MILITARY MEDICINE

In 2002, we convened an expert panel to consider the

development of a program for certification in military

medicine. Prior to those deliberations, the panel agreed

upon the following working definition for military

medicine:

Military medicine represents the knowledge, skills, and

attitudes inherent in the practice of medicine in austere

and/or militarily unique environments, cognizant of the

roles and capabilities of the military, and the means for

coordinating with other organizations.

ACADEMIC FOUNDATION

While there are variations between branches of the

service, between specialties, and between nations, we

believe that there is a body of knowledge that is

pertinent to all military physicians. The Military

Unique Curricula documents have outlined this body

of knowledge, and the vast Textbook of Military

Medicine series* provides considerable detail. There is

also an ever-expanding body of military medical

literature, particularly embodied in, but not limited to,

the archives of the journals Military Medicine and

International Review of the Armed Forces Medical

Services. There is also a range of military medical

courses such as the Combined Humanitarian

Assistance Response Teams (CHART) course,†the

Medical Management of Chemical and Biological

Casualties (MMCBC) course,‡and the Medical Effects

of Ionizing Radiation (MEIR) course,§ which cover

specific aspects of military medicine. More than 20

nations have programs in tropical medicine and

health,** many of which have significant components

of military relevance.

ADVANTAGES OF CERTIFICATION

Potential advantages include the following:

 Recognition of achievement, experience, and/or

expertise

 Academic recognition, similar to board

certification

 Basis for financial rewards such as bonus

payment

 Advantage for promotion

 Identification of a cadre of experts that can be

called upon in a time of need, or to impart their

knowledge and skills to others

 To qualify individuals for particular assignments

or positions of leadership within military

medicine

The form that certification takes can have a significant

influence upon which of the above goals are achieved.

As such, it is important to consider prioritization of

these advantages in determining the mode of

certification settled upon. We believe that each

advantage has importance, but in our minds the most

significant goal of certification is to recognize the

expertise and experience of physicians who have taken

it upon themselves to establish unambiguous

proficiency in operational medicine. There are also

potential obstacles to the establishment of certification

in military medicine that must be taken into account.

First, certification must be inexpensive—ideally, costneutral—since military medical budgets are already

thinly stretched, and a program that is costly to either

individuals or the military healthcare system is

unlikely to achieve implementation. Second, there

must be a certifying authority, someone that will

examine credentials and determine or judge eligibility

for certification, as well as recertification.

Certification in Military Medicine: The Time is Now

*Available from the Borden Institute at: http://www.bordeninstitute.army.mil

†Available at: http://coe-dmha.org/course_chart.htm

‡Available at: https://ccc.apgea.army.mil/courses/in_house/brochureMCBC.htm

§Available at: http://www.afrri.usuhs.mil/www/outreach/meir/meir.htm

**List available at: http://www.astmh.org/oppor/training.html
October – December 2006 7

ANALYZING THE ALTERNATIVE MODELS FOR

CERTIFICATION

One prominent model for certification is the board

certification system for physicians. At the present

time, the American Board of Medical Specialties

(ABMS) has 24 member specialty boards, ranging

from Allergy and Immunology to Urology.

Certification is an arduous and expensive process for

physicians, but is widely recognized as a wellestablished, well-defined, and rigorous process that

often increases the comfort level that patients have

with physicians they select for care. A military

medicine certification process that would

commensurately increase the confidence of line

service members with the physicians that are deployed

with them is a desirable goal. However, it must also be

recognized that military physicians already typically

maintain board certification within their respective

specialties, requiring significant investments of time

and money. In addition, the body of knowledge of

military relevance that is important for a specialist to

master, but is unique from that covered in the

specialty-specific certification process, may not be

large enough to warrant following a board certification

model. There are also many more certification bodies

that are not recognized by the ABMS, frequently

providing an easier path to claim certification in the

eyes of a confused public, but failing to meet the rigor

of the ABMS. While it may be difficult to achieve

certification in military medicine through the ABMS,

the Department of Defense (DoD) could establish an

independent certifying body, but the creation of a

meaningful certification process would have difficulty

surviving the twin obstacles of cost and resources

required for its establishment and maintenance.

Another model is the previously described Diploma in

the Medical Care of Catastrophes (DMCC). Upon

completion of the 7 modules outlined above, a

prospective diplomate must then sit for a two-part

examination. The first part is an oral examination of

the material covered in the modules before a board of

examiners. The second features an oral presentation

and discussion of the dissertation. In addition to strong

support for the program within the British military, the

examination is also provided at the Uniformed

Services University of the Health Sciences (USUHS),

Bethesda, Maryland, where a large number of faculty

are diplomates and serve as examiners. Moreover, the

DMCC is now required of military physicians in both

the United Kingdom and the Netherlands. The broad

scope and modular nature of the DMCC are

particularly useful characteristics to incorporate into

plans for certification in military medicine. There is a

book that codifies a corresponding body of

knowledge.14 However, it can be argued that the

orientation of the DMCC is not as specific to military

medicine as desired, which is perhaps not surprising

since civilians are eligible for the diploma, and the

orientation is more geared towards disaster and

humanitarian care rather than the combat environment.

Another consideration as a model is more specifically

geared toward the goal of recognition—rather than

providing a certificate per se, providing a ribbon,

patch, or other emblem to be worn on the military

uniform. This is not necessarily mutually exclusive of

bona fide certification, and in fact could be provided in

conjunction with certification, but the level of

infrastructure and rigor required to institute a more

classical certification program would not necessarily

be required for award-type recognition. Simplification

of the process, at least initially, might facilitate more

prompt implementation, while still achieving to some

degree the goals of providing recognition and earning

greater respect in the eyes of the line. If, on the other

hand, a certain degree of rigor is not incorporated in

the process, placement of an emblem on the uniform

might generate more resentment than respect,

especially if recipients of recognition such as the

Expert Field Medical Badge view this as a cheaper

path than what they accomplished to earn a symbol on

their uniforms.

Alternatively, a more robust approach to certification

might go so far as to confer a master’s degree in

military medicine. This could entail as much as one or

two years of in residence, a course of shorter duration

in conjunction with a set of courses currently available

to military physicians (eg, Medical Management of

Chemical and Biological Casualties, Medical Effects

of Ionizing Radiation, etc.), or courses taken part-time

or via distance learning methods over a less restricted

timeframe. This approach would be the most ambitious

and potentially expensive, but would achieve a greater

degree of control over content and more effectively

ensure mastery of the targeted content than any other

method. There are several models, albeit of lesser

scope, that provide onsite and distance learning

alternatives to achieve the same goal. One is the Good

Clinical Practice training for scientific researchers,
8 Army Medical Department Journal

which may be completed at a multiday course, or

completed with self-paced, web-based courses that

provide instruction followed by examinations. The

Army provides 2 different alternatives. First, the

Officer Advanced Course requires completion of a

series of self-paced minicourses and examinations,

followed by several months in residence at the US

Army Medical Department Center and School at Fort

Sam Houston, Texas. In addition, the next level of

officer training is the Command and General Staff

Officer Course, which can be completed through a

year in residence at the Command and General Staff

College, Fort Leavenworth, Kansas, or in a self-paced

series of courses, examinations, and written essays,

over as much as 2 years. A broad range of alternatives,

from entirely onsite education to completely self-paced

distance learning, best meets the range of motivations,

learning preferences, and schedules of active military

clinicians. In addition, providing credit for completion

of other courses that fulfill some of the requirements

for a master’s degree helps to avoid needless repetition

and unnecessary expense.

While establishment of a master’s degree program in

military medicine is the ultimate goal, we recognize

that this may take time to establish, and that an interim

“bridge” to the degree is a sensible beginning. We

propose the provision of 2 levels of certification in

operational medicine, an operational level and an

expert level, with the latter, supplemented by a

research project, forming the basis for the master’s

program. Completion of requirements through

experience or coursework in 7 different areas

(presented in the Table on the following pages) would

be necessary. In addition, there would be a

requirement for 3 letters of recommendation from

supervisors or colleagues to describe experience and

qualifications for certification. A certifying board

would review credentials and award certification. A

university would be a logical certifying authority if a

master’s degree is planned or implemented, with

USUHS or another military institution most sensible.

Other alternatives would be a military society such as

the Association of Military Surgeons of the United

States (AMSUS) or the International Committee of

Military Medicine (ICMM), depending upon the

format that is chosen. The duration of certification, and

the process of recertification, will also need to be

determined in the future.

A NEW MODEL FOR CERTIFICATION IN

MILITARY MEDICINE

Based on the academic foundations of military

medicine and medical experiences and lessons learned

from wars over the past century, we identified key

curricular elements, relevant military courses, and field

experiences with particular utility to military

healthcare professionals. We incorporated the selected

elements into 7 modules, which are modified from the

DMCC program (see the Table). It should be noted

that many of the examples that are provided represent

options within the United States, and that there are

many other opportunities available in other nations

that would fulfill the requirements. Corresponding

detailed educational objectives and material must be

developed, standardized, and incorporated into any

educational program leading to certification. We

propose the recognition of 2 levels of expertise, which

we define as operational (basic) and expert. A

certification exam should follow the completion of all

modules. We favor the development of a standardized,

comprehensive bank of questions to be used for

certifying examinations.

EDUCATIONAL MODELS

The most rigorous of a range of potential educational

models is the establishment of an organized, dedicated

program similar to the service schools, which require

the military member to move to a specific location and

school for prolonged dedicated study and pertinent

experiences. At the other extreme, less disruptive to

one’s career and duty status, is a modular approach to

learning such as the DMCC, or the distance learning

courses services use in other professional military

education courses. Overall, we believe the latter is

more realistic, given the many conflicting demands

facing military health professionals. However, it is

important to note that Australia established a master’s

program in military medicine that began in June 2004,

and both the United Kingdom and the Netherlands

anticipate the commencement of degree-granting

programs in military medicine in the near future.

Distance Learning. The most likely to be costeffective and most expedient initial effort is the

distance learning model, which requires significant

costs for initial development, but after that, only lowcost maintenance is needed. We believe that military

societies such as AMSUS, with the assistance of the

Certification in Military Medicine: The Time is Now
October – December 2006 9

1. Leadership

Operational

Coursework – Army officer advanced course, Air Force squadron officer school, joint task

force (JTF) surgeon course, or equivalent

Experience – Small unit team leader (eg, service chief at nonteaching military hospital,

brigade surgeon)

Expert

Coursework – Army Command and General Staff College or equivalent service-specific

course

Experience – Large unit team leader (eg, department chief at nonteaching military hospital,

service chief at teaching military hospital, division surgeon, or unit commander)

2. Preventive Medicine

Operational

Coursework – Tropical medicine course, CHART or humanitarian assistance course,

USARIEM environmental medicine course, Navy Environmental Health Command

operational preventive medicine course, or Air Force aerospace medicine primary course or

equivalent

Experience – Small unit preventive medicine responsibility for field sanitation in field

exercise or deployment (eg, Army brigade surgeon, Air Force squadron medical officer,

Marine battalion surgeon), or deployment in combat stress control

Expert

Coursework – Master’s degree in public health or residency training in preventive medicine,

public health, or occupational health

Experience – Responsibility for care in large refugee camp, joint task force operations, or

combat

3. Field Experience

Operational

Coursework/Exercises – Completion of training at Joint Readiness Training Center (JRTC,

Fort Polk, Louisiana), National Training Center (NTC, Fort Irwin, California), or other field

training exercise (FTX); C4, military contingency medicine (MCM), air assault, or survival

training course

Experience – Deployment of less than 3 months

Expert

Coursework – Advanced field course

Experience – Position of responsibility on joint deployment for more than 3 months

Categories of requirements for certification in military medicine, with proposed examples that would fulfill

each requirement.
10 Army Medical Department Journal

Categories of requirements for certification in military medicine, with proposed examples that would fulfill

each requirement (continued)

4. Administrative Healthcare

Operational

Coursework – Flight surgeon course, commander’s courses, risk communication course

Experience – Department chief at nonteaching military hospital, service chief at teaching

military hospital, or Division Surgeon; knowledge and conduct of service-specific medical

regulations and standards

Expert

Experience – Oversight responsibility for service-specific and/or joint regulations and

standards, or responsible position at major command, CINC Surgeon, service headquarters

staff, deputy commander for clinical services, or hospital commander

5. Casualty & Incident Management

Operational

Coursework – C4, air-evacuation course, MCM, MEIR, ACLS, ATLS, or equivalent

Experience – Operational leader, planner, or key provider for mass casualty (MASCAL)

exercise, medical staff for JRTC, NTC, or FTX

Expert

Coursework – Joint task force surgeon’s course or emergency preparedness course,

emergency medicine residency or other pertinent specialty training such as surgery or critical

care/pulmonary medicine

Experience – Operational leader or key provider for real-life mass casualty incident;

operational leader or key provider on humanitarian mission or combat deployment

6. Scholarly Activities’ Certification Requirements

Operational

Short analytic paper on topic relevant to military and operational medicine, or contributing

author to a militarily relevant publication in the medical literature

Expert

Primary author of publication of substantive scholarly work in the peer-reviewed medical

literature, or completion of a dissertation relevant to military medicine

Develop and provide a course or lecture series relevant to military medicine, or author a

chapter in a militarily relevant textbook

7. Service And Specialty Specific Certification Requirements

Operational

Demonstrated ability to manage elements of field care outside of usual peacetime scope of

practice

Expert

Specialty board certification and demonstrated capability to manage the full spectrum of the

medical field system, such as successful experiences as JTF medical commander, CINC

surgeon, UN peacekeeping force surgeon, NATO or joint operation or national medical

liaisons during deployments and/or contingency operations

Certification in Military Medicine: The Time is Now
October – December 2006 11

military medicine community, most notably the

Uniformed Services University of the Health Sciences,

could provide this service. This option requires

development of the curriculum and the distance

learning tools (website, CDROMs, standards

development, quality review, online testing, etc),

compiling of course materials (Textbook of Military

Medicine, military medicine curricular elements from

USUHS, service-specific and DoD-level military

medicine curricular material) and development and

maintenance of a standard bank of questions.

Distance and In-Residence Learning. A more

desirable model includes the above distance learning

element followed by a 2-week in-residence

requirement, which we believe can be sufficient to

provide practice in the field.

In-Residence Learning. A small capability should be

developed for a full in-residence program of one year,

equivalent to the Intermediate Service School model

for a select group of outstanding individuals. Selection

should be by service at promotion, similar to selection

for other military schools, and should fulfill the

pertinent professional medical education requirement.

It should not be necessary for senior personnel and is

not intended to replace the unique opportunity to

attend the Senior Service Schools (Air Force, Navy,

Army War Colleges or National Defense University).

IMPLEMENTATION PROCESS

Implementation of certification could be done in 2

stages, the first to be implemented in the short term,

which we call Stage I. The second we call Stage II. A

more formalized process should, however, be sought

by the establishment of a formal education program in

this discipline.

Stage I

 Application accompanied by letters of

recommendation

 Successful completion of the requirements

outlined in the modules noted above

 Review of application/credentials by a formally

appointed “board” or certifying body

 Certifying body will issue a certificate. A

nonaffiliated body with substantial knowledge of

competence in these areas such as AMSUS or

ICMM is recommended as the most appropriate

certifying body.

Stage II. Establish a formal educational program such

as a master’s degree level curriculum.

FUTURE IMPLICATIONS

The development of a certification examination will be

required to accomplish the goal of certifying

competence in this discipline. The examination should

be based on the currently available body of knowledge

in military medicine. A recertification process will also

be necessary. We recommend the establishment of a

master’s degree level program as a vehicle to

standardize the knowledge, skills, and attitudes

required for competence and certification in military

medicine as a capstone opportunity for selected

military medical officers designated as experts in their

profession.

REFERENCES

1. Military Unique Curricula: Instructional Objectives

for Military Physicians and Graduate Medical

Education Programs. 1989, Uniformed Services

University of the Health Sciences, Bethesda, MD.

2. Military Unique Curricula. 1999, Uniformed Services

University of the Health Sciences, Bethesda, MD.

3. Roy MJ, Perkins JG, Bolan CD, Phillips YY.

Operational experiences during medical residency:

perspectives from the Walter Reed Army Medical

Center Department of Medicine. Mil Med.

2001;166:1038-1045.

4. Roy MJ, Brietzke S, Hemmer P, Pangaro L, Goldstein

R. Teaching military medicine: enhancing military

relevance within the fabric of current medical

training. Mil Med. 2002;167:277-280.

5. Pierce JR, Brennan M, Campbell J, McClurkan M,

Morgan JL, Stracner CE. The Department of Military

Medicine—a graduate medical education idea whose

time has come. Mil Med. 1989;154:536-537.

6. Eiseman B. Casualty care planning. J Trauma.

1979;19:848-851.

7. Bellamy RF, Zajtchuk R. The weapons of

conventional land warfare. In: Zajtchuk R, Jenkins

DP, Bellamy RF, Quick CM, eds. Textbook of

Military Medicine: Conventional Warfare; Ballistics,

Blast and Burn Injuries. Washington, DC: US Dept of

the Army, Office of the Surgeon General; 1991:1-52.
12 Army Medical Department Journal

8. Rignault DP. Is war surgery a specialty? Part I. Mil

Med. 1990;155:91-97.

9. Rignault DP. How to train war specialists. Part II. Mil

Med. 1990;155:143-147.

10. Smith AM, Hazen SJ. What makes war surgery

different? Mil Med. 1991;156:33-35.

11. Pories WJ. Military surgery: certification is long

overdue. Mil Med. 1995;160:100-103.

12. Goodell TP, Jones RJ. Curriculum design:

operational medicine. Mil Med. 1989;154:36-37.

13. The Society of Apothecaries of London. Examination

Regulations and Syllabus Relating to the Diploma in

the Medical Care of Catastrophes. March 2004/6.

Available at: http://www.apothecaries.co.uk/index.php?

page=26.

14. Lumley JSP, Ryan JM, Baxter PJ, Kirby N. Handbook

of the Medical Care of Catastrophes. London: Royal

Society of Medicine Press, 1996.

Certification in Military Medicine: The Time is Now

AUTHORS

COL Roy is the Director, Division of Military Internal Medicine, Department of Medicine, Uniformed Services University

of the Health Sciences, Bethesda, Maryland.

COL Palma is the Deputy Assistant to the Secretary of Defense for Chemical and Biological Defense Programs,

Washington, DC.

COL (Ret) Rich is the Chair Emeritus, Department of Surgery, Uniformed Services University of the Health Sciences,

Bethesda, Maryland.

UNIFORMED SERVICES UNIVERSITY

of the Health Sciences
October – December 2006 13

INTRODUCTION

Most definitions of research are general. For example,

DoD Directive 3216.2 defines human research as any

systematic investigation, including research,

development, testing, and evaluation, designed to

develop or contribute to generalizable knowledge.1

Research may be medical or nonmedical. Medical

research can be clinical or nonclinical. Nonclinical

medical research studies include bench, in vitro,

animal, and engineering studies. Clinical research (or

clinical investigation) studies include patient-oriented,

epidemiologic and behavioral outcomes, and health

services studies. Patient-oriented studies generally

include studies of human disease mechanisms,

therapeutic interventions, clinical trials, and

technology development. Clinical research can be

more difficult than preclinical or basic research for the

following reasons:

 Subjects are more variable.

 Measurements are less precise and accurate.

 There is less control over study conditions.

 Ethical issues are more common and complex.

 There is limited ability to discern disease

mechanisms.

 Study design errors tend to be more common.

 Study design and analysis require greater vigor.

 Study review and approval bureaucracy is more

burdensome.

Overcoming these challenges tends to make clinical

research more rewarding and relevant. The

fundamental Army Medical Department (AMEDD)

philosophy has always incorporated 3 interrelated

goals: provide quality healthcare, train to provide

healthcare, and conduct healthcare research. Herein,

we describe Army clinical investigation within the

AMEDD Clinical Investigation Program (CIP). We

describe the rationale, history, current status, impact,

and strategic vision of the CIP. We plan to publish

future articles describing US Army Medical Research

and Materiel Command (USAMRMC) clinical

investigations, Multinational Corps – Iraq clinical

investigations, the US Army human subjects'

protection program, and a practical guide to

conducting medical research in the US Army.

AMEDD CLINICAL INVESTIGATION PROGRAM

DoD Directive 6000.8 clearly describes the

fundamental CIP rationale, ie, the CIP is an essential

component of medical care and teaching intended to

 improve patient care quality,

 support graduate medical education (GME)

programs,

 generate an atmosphere of inquiry responsive to

the dynamic nature of medicine, and

 promote high professional standing and GME

program accreditation.2

Army Regulation (AR) 40-38 is the only US Army

CIP-specific regulation.3 AR 40-38 defines the CIP as

incorporating that medical research conducted at active

Army fixed medical treatment facilities (MTFs). AR

40-38 requires that a headquarters level office

coordinate and monitor CIP activity, and serve as a

point of contact for relevant policies and regulations.

This office is now known as the Clinical Investigation

Regulatory Office (CIRO), and it is part of the

AMEDD Center and School (AMEDDCS) special

staff. CIRO maintains the CIP records that are the

source of most of the CIP descriptive information

contained herein.

Early CIRO records are incomplete, but available

documentation indicates that a distinct Research and

Development Program commenced at Madigan

General Hospital in 1963, a Research and

Development Service was established at Tripler Army

Medical Center (TAMC) in 1967, and a Clinical

US Army Clinical Investigation

COL James M. Lamiell, MC, USA

COL Kent E. Kester, MC, USA

COL Charles E. McQueen, MC, USA

LTC Jennifer C. Thompson, MC, USA

COL Laura R. Brosch, AN, USA
14 Army Medical Department Journal

Research Service was established at Brooke General

Hospital in 1971. These entities were the forerunners

of the current Army Medical Center (AMC)

Departments of Clinical Investigation (DCIs), and

their creation roughly coincides with the initial 1971

publication of AR 40-38. However, numerous clinical

research studies (eg, MAJ Walter Reed conducted

yellow fever studies in 1900 and the Medical Research

Division was established within the Chemical Warfare

Service in 1922) were conducted at Army MTFs prior

to 1963. The US Army Medical Research and

Development Command (USAMRDC) was

established in 1958, and the initial version of AR 70-

25, the governing Army regulation entitled Use of

Volunteers as Subjects of Research was published in

1962.4 The Human Use Review Office (HURO) was

established within USAMRDC at Fort Detrick,

Maryland in 1973. In 1978, the Clinical Investigations

Program Division of HURO was transferred to the

Health Services Command in San Antonio, Texas.

When the Health Services Command transformed into

the US Army Medical Command, the Clinical

Investigations Program Division moved to the

AMEDDCS to become CIRO (Clinical Investigation

Regulatory Office).

A database (known as the Clinical Investigation

Research System or CIRS) of CIP research study

characteristics is derived from the written descriptions

of CIP studies (protocols) received at CIRO. Most of

these CIP protocols are from AMC DCIs, including

Walter Reed AMC (WRAMC), Eisenhower AMC

(EAMC), Brooke AMC (BAMC), William Beaumont

AMC (WBAMC), Fitzsimmons AMC, Letterman

AMC, Madigan AMC (MAMC), and TAMC.

Regular entry of CIP study protocol information into

CIRS commenced about 1980. There are currently

CIRS records for almost 18,700 CIP studies. Figure 1

shows the number of new and ongoing studies (for

each fiscal year) recorded in CIRS since its 1978

inception. CIRO stopped receiving new studies from

Letterman AMC in 1992 and from Fitzsimmons AMC

in 1997. CIRS record accrual is now relatively stable

with about 700 new studies per year and about 1,700

ongoing studies.

We were interested in current CIP study

characteristics. Therefore, we queried CIRS for studies

active on 1 December 2005, and identified 1,764

studies. Table 1 shows the general types of these active

CIP studies. About 95% of the studies involve humans

and 5% involve animals.

Table 2 shows the class of subjects enrolled in the

active CIP studies. About 9% of the studies involve

children. Pediatric studies are unique in that there

should be intent to benefit all subjects in accordance

with Section 980 of Title 10, United States Code.

US Army Clinical Investigation

Fiscal Year

Number of Studies

1980 1985 1990 1995 2000 2005

2500

2000

1500

1000

500

0

Variable

New

Ongoing

CIP Studies (CIRS Database)

Figure 1. New and ongoing CIP studies (for each fiscal

year) recorded in CIRS since its 1978 inception.

Table 1. Types of Active CIP Studies

Study Type Number Percent

More than minimal risk 1,060 60%

Minimal risk 597 34%

Animal 95 5%

Exempt 12 1%

Total 1,764 100%

Table 2. Classification of Subjects of Active CIP

Studies

Subject Classification Number Percent

Adult 1,477 84%

Other 129 7%

Adult/Child 87 5%

Child 71 4%

Total 1,764 100%
October – December 2006 15

Table 3 shows the gender of subjects enrolled in the

active CIP studies. About 17% of the studies involve

only female subjects while about 10% involve only

male subjects.

Table 4 shows the source of subjects enrolled in the

active CIP studies. About 70% of the studies involve

patients. We observed that 686 of the 1,764 active CIP

studies (39%) involve at least one drug, while 81 of

the 1,764 active CIP studies (5%) involve at least one

medical device.

Table 5 shows another active CIP study classification.

Importantly, about 32% of these studies involve

oncology research wherein there is significant overlap

between research and patient care. The only way to

obtain promising but as yet unproven treatments for

some malignancies is through participation in clinical

research. Of course, these emerging therapies may be

no better than conventional or no therapy at all (by the

null hypothesis), which is why they are the subject of

rigorous scientific examination.

Table 6 shows the funding for the active CIP studies.

At least 53% of CIP study funding comes from sources

outside the MTF conducting the study. CIRO was

granted cooperative research and development

agreement (CRADA) approval authority in 1994.

CRADAs provide a study-specific legal mechanism

enabling CIP staff to collaborate with nonfederal

partners (eg, pharmaceutical companies) to conduct

CIP studies. Since 1995, CIRO has negotiated and

approved 923 CRADAs potentially worth almost $88

million.

Table 7 shows the active CIP studies sites. The 3

busiest CIP sites account for about 75% of active CIP

studies while overall the AMCs account for 97% of

them.

Table 8 shows the principal (PI) and associate

investigator (AI) status for the active CIP studies.

About 80% of all CIP study investigators are active

duty military personnel, while the rest are civilian

government employees.

Table 3. Gender of Subjects of Active CIP Studies

Subject Gender Number Percent

Both 1,132 64%

Female 302 17%

Male 175 10%

Other 155 9%

Total 1,764 100%

Table 5. Classification of Active CIP Studies

Study Classification Number Percent

Other 1,165 66.0%

Oncology 560 31.8%

Behavioral/psychosocial 34 1.9%

Radioisotope 3 0.2%

Alcohol/drug 2 0.1%

Total 1,764 100%

Table 4. Source of Subjects of Active CIP Studies

Subject Source Number Percent

Patient 1,240 70%

Other 384 22%

Healthy/normal 140 8%

Total 1,764 100%

Table 6. Distribution of Funding Sources of Active

CIP Studies

Funding Source Number Percent

Other 646 36%

NIH 452 26%

CRADA 360 20%

Local 187 11%

USAMRMC 68 4%

Grant 51 3%

Total 1,764 100%
16 Army Medical Department Journal

Table 9 shows the respective professional corps

affiliations of the military investigators for the active

CIP studies. Note that 1,446 of 1,764 PIs (82%) are

Medical Corps (MC) officers. We found that 1,283

individual Army MC officers were investigators (PI or

AI) on 1,555 of the 1,764 active CIP studies, ie, Army

MC officers are directly involved with 88% of active

CIP studies. Table 10 shows the ranks of investigators

for 1,725 of the 1,764 active CIP studies.

The number of investigators per active CIP study are

depicted in Figure 2. Every study has at least one

investigator (PI), and the greatest number of

investigators per active CIP study is 19. The

distribution is skewed, but there is an average of 3.3

investigators per study with a standard deviation of 2.1

investigators.

Conversely, we examined the number of active CIP

studies per investigator. Figure 3 displays the number

of active CIP studies per PI. Twelve investigators are

US Army Clinical Investigation

Table 7. Active CIP Study Sites

Military Treatment

Facility Number Percent

WRAMC 665 37.70%

BAMC 356 20.18%

MAMC 287 16.27%

TAMC 208 11.79%

EAMC 116 6.58%

WBAMC 48 2.72%

WAMC 32 1.81%

West Point 26 1.47%

Ft Hood 11 0.62%

Ft Carson 4 0.23%

Ft Benning 2 0.11%

Ft Polk 2 0.11%

Ft Sill 2 0.11%

Ft Irwin 1 0.06%

Ft Stewart 1 0.06%

Heidelberg 1 0.06%

Landstuhl RMC 1 0.06%

Wurzburg 1 0.06%

Total 1,764 100%

Table 8. Professional Status of Active CIP Study

Investigators

Status PI* AI†Total Percent

of Total

USA 1,587 2,997 4,584 78.03%

Civilian 136 1,015 1,151 19.59%

USN 31 74 105 1.79%

USAF 10 24 34 0.58%

USPHS 0 1 1 0.02%

Total 1,764 4,111 5,875 100.00%

*Principal Investigator

†

Associate Investigator

Table 9. Professional Corps Affiliation of Military

Investigators in Active CIP Studies

Corps PIa AIbTotal Percent

of Total

MCc1,446 2,717 4,163 88.1%

MSd/MSCe/BSCf47 162 209 4.4%

ANg/NCh75 111 186 3.9%

SPi19 39 58 1.2%

DCj18 34 52 1.1%

VCk22 18 40 0.9%

ENl0 12 12 0.3%

Other 1 3 4 0.1%

Total 1,628 3,096 4,724 100.0%

a. Principal Investigator

b. Associate Investigator

c. Medical Corps (Army, Navy, Air Force)

d. Medical Service Corps (Army)

e. Medical Service Corps (Navy, Air Force)

f. Biomedical Sciences Corps (Air Force)

g. Nurse Corps (Army)

h. Nurse Corps (Navy, Air Force)

i. Medical Specialist Corps (Army)

j. Dental Corps (Army, Navy, Air Force)

k. Veterinary Corps (Army)

l. AMEDD Enlisted Corps (Army)
October – December 2006 17

the PI for more than 18 different CIP studies, and the

greatest number of studies per individual PI is 71.

Generally, oncology investigators are PIs for multiple

studies, many of which are open only for subject

followup and closed to new subject accrual, or are

quiescent since they concern very rare malignancies.

The distribution is skewed, but there is an average of

2.3 CIP studies per PI with a standard deviation of 5.4

studies.

The number of active CIP studies per AI is shown in

Figure 4. Twelve investigators are the AI for more than

20 CIP studies, and the greatest number of studies per

individual AI is 67. As is the case for PIs, oncology

investigators are usually AIs for multiple studies. The

distribution is skewed, but there is an average of 2.2

CIP studies per AI with a standard deviation of 3.4

studies.

Figure 5 depicts the duration of currently active CIP

studies. One study has been active for almost 27 years

(the age of CIRS). Generally, oncology treatment

studies are the most persistent, closing to accrual of

new subjects while remaining open and active for

enrolled subject followup. The distribution is skewed,

but there is an average of 3.7 years per CIP study with

a standard deviation of 3.9 years.

Table 11 shows the involvement of 4,221 currently

active Army MC officers with CIP studies. A roster of

active MC officers was obtained from the Medical

Operational Data Systems (MODS) on 1 December

2005. The Table 11 cross tabulation was generated by

comparing the MODS-derived active MC Officer roster

Table 10. Rank Distribution of Active CIP Study

Investigators

Investigator

Rank PI* AI†

Total Percent

of Total

MAJ/LCDR (O4) 473 1,122 1,595 30%

LTC/CDR/LtCol

(O5)

529 833 1,362 26%

COL/CAPT (O6) 363 589 952 18%

CPT/LT/Capt

(O3)

255 521 776 14%

PhD (civilian) 60 235 295 6%

MD (civilian) 45 249 294 6%

Total 1,725 3,549 5,274 100%

*Principal Investigator

†

Associate Investigator

Investigators/Study

Number

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

500

400

300

200

100

0

Investigators/Active CIP Study

Figure 2. Number of investigators per active CIP study.

Studies/AI

Number

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

1400

1200

1000

800

600

400

200

0

Active CIPStudies/AI

Figure 4. Number of active CIP studies per associate

investigator.

Studies/PI

Number

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

600

500

400

300

200

100

0

Active CIP Studies/PI

Figure 3. Number of active CIP studies per principal

investigator.
18 Army Medical Department Journal

with a CIRS-derived CIP study investigator roster.

Note that 1,824 of 4,221 (43%) currently serving

Army MC officers have been a CIP study PI or AI

some time during their active duty service. An analysis

by rank shows that 413 of 1,729 MC captains (24%),

642 of 1,299 MC majors (49%), 410 of 664 MC

lieutenant colonels (62%), and 359 of 529 MC

colonels (68%) have been a CIP study PI or AI some

time during their active duty service.

It is difficult to compare US Army military physicians

to non-Army physicians with respect to clinical

research participation. One group queried graduates of

the 1985 through 1995 classes of the Pennsylvania

State College of Medicine.5 Questionnaires we sent to

all graduates (n=1,013), and there were responses

from 42% (n=428). Among the Pennsylvania State

respondents (ie, physicians in practice for 10 to 20

years), 34% claimed to be currently participating in

clinical research. It is unclear how many of the Penn

State respondents were on active duty in the Army.

Nevertheless, this group is comparable to the Army

cohort of MAJ – COL, in which 1,411 of 2,492 (57%)

have participated in research (Table 11).

Clinical research is an essential part of graduate

medical education (GME).6 No Army GME program

has ever failed accreditation because of insufficient or

inadequate clinical research. The Clinical Investigation

Regulatory Office has tracked the annual number of

published manuscripts, abstracts and presentations

generated by the CIP since 1994. A graph of this

academic achievement is shown in Figure 6.

In FY 2004 the entire CIP was funded with $11.8

million from Defense Health Program funds (as

allocated by MTF commanders, including DCI staff

wages) and $25.5 million from non-MTF funds

(including $13 million from cooperative research and

development agreements). The FY 2004 CIP DCI staff

included 29 officer, 28 enlisted, and 121 civilian

personnel. In total, the FY 2004 CIP was funded with

$37.8 million and a dedicated support staff of 178

people.

CONCLUSIONS

Clinical Investigation Program research studies are

usually greater than minimal risk (60%), and they

usually involve adult patients (70%). Drugs are

frequently involved in CIP studies (39%). The most

common class of CIP studies is oncology (32%). At

least 53% of CIP study funding comes from non-MTF

sources. Most CIP research is conducted at AMCs

(97%). Most CIP principal investigators are MC

US Army Clinical Investigation

Years

Number

0 4 8 12 16 20 24

500

400

300

200

100

0

CIP Study Duration

Figure 5. Duration of active CIP studies.

Table 11. Distribution of Active Army MC Officer

Involvement in CIP Studies

PI* AI† CPT MAJ LTC COL Total

No No 1,316 657 254 170 2,397

Yes Yes 93 266 204 209 772

No Yes 154 206 120 102 582

Yes No 166 170 86 48 470

Total 1,729 1,299 664 529 4,221

*Principal Investigator

†

Associate Investigator

Year

Number

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

1400

1200

1000

800

600

400

200

0

Variable

Presentations

Manuscripts

Abstracts

CIP Academic Performance

Figure 6. Annual number of published manuscripts,

abstracts and presentations generated by the CIP

since 1994.
October – December 2006 19

officers (82%), and MC officers are directly involved

in 88% of CIP studies. A typical CIP study has 3

investigators, and lasts about 2 years. The Army CIP

contributes significantly to the Army mission. The CIP

improves Soldier healthcare, provides DoD beneficiary

healthcare, and trains healthcare providers. The CIP

provides an important component of AMEDD officer

development. At least 42% of all current active MC

officers have been involved in a CIP study.

Furthermore, CIP involvement is continuous for MC

officers so that at least 24% of current captains have

been involved in CIP studies while at least 68% of MC

colonels have been involved in CIP studies. This

compares favorably to estimated non-Army physician

clinical investigation (CI) involvement. CI exposure is

important for AMEDD officer professional education

because it fosters and develops

 critical thinking,

 attention to detail,

 scholarship,

 inquisitiveness,

 skepticism,

 creativity, and

 tenacity.

AMEDD officer CI experience also helps develop

skills to better perform these critical functions:

1. Formulate questions

2. Use data to answer questions

3. Accurately collect and analyze data

4. Concisely describe a study with a protocol

5. Organize scarce resources to conduct studies

6. Present and defend studies to committees

7. Ethically deal with people (subjects) outside the

provider-patient relationship

8. Present and defend study results

9. Assess and assimilate others' research results into

medical practice

It is common for AMEDD officers to have long-term,

fulfilling, and meaningful clinical research

experiences.7

Our CIP strategy for the future is primarily directed

toward enhancing collaboration between the CIP and

USAMRMC. To this end, we intend to update AR 40-

38 and AR 70-25 as one regulation, and we will

exchange and cross-train CIP DCI and USAMRMC

staff as much as possible.

REFERENCES

1. DoD Directive 3216.2, Protection of Human Subjects

and Adherence to Ethical Standards in DoDSupported Research. Washington, DC: US Dept of

Defense; March 25, 2002.

2. DoD Directive 6000.8, Funding and Administration

of Clinical Investigation Programs. Washington, DC:

US Dept of Defense; November 3, 1999.

3. Army Regulation 40-38, Clinical Investigation

Program. Washington, DC: US Dept of the Army;

September 1, 1989.

4. Army Regulation 70-25, Use of Volunteers as

Subjects of Research. Washington, DC: US Dept of

the Army; January 25, 1990.

5. Lloyd T, Phillips BR, Aber RC. Factors that influence

doctors' participation in clinical research. Med Educ.

2004;38:848-851.

6. Lamiell JM. Research for graduate medical

education. Mil Med. 1994;159:698-704.

7. Lamiell JM. Army clinical investigation of von

Hippel-Lindau disease. 1977-2000. Mil Med.

2001;166:839-842.

AUTHORS

COL Lamiell is the Chief, Clinical Investigation

Regulatory Office at the AMEDD Center and School, Fort

Sam Houston, Texas. COL Lamiell is also the Chairman of

the AMEDD Journal Editorial Review Board.

COL Kester, COL McQueen, and LTC Thompson are

assigned to the Walter Reed Army Institute of Research,

US Army Medical Research and Materiel Command, Silver

Spring, Maryland.

COL Brosch is assigned to the Office of Research

Protections, US Army Medical Research and Materiel

Command, Fort Detrick, Maryland.
20 Army Medical Department Journal

INTRODUCTION

Operation Iraqi Freedom has resulted in a paradigm

shift away from the concept of traditional war and

peacekeeping operations to that of combating terrorism

directly and urban warfare. The US Army is

transforming itself into a Future Force capable of

rapidly projecting scalable and modular combined

arms formations, tailored in force capability packages

to meet the requirements of diverse contingencies.1

The Army Medical Department (AMEDD) is also

undergoing transformation by redesigning theater

hospital assets into modular medical elements capable

of 24-hour operations with reduced administrative

overhead, a smaller footprint in the area of operations,

and greater mobility to perform specific battlefield

functions as required by the mission.1In light of the

future AMEDD transformation, careful deliberation

must be given to expanding the primary care role of

the deployed advanced practice nurse (APN). The

advanced educational training, clinical expertise, and

ability to offer primary healthcare make the APN an

invaluable resource to deployed military healthcare

teams.2

The nurse practitioner (NP), an APN, is educated to

make independent decisions and synthesize theoretical,

scientific, and contemporary clinical knowledge for

health promotion and the assessment, management,

and diagnoses of illness and health states.2-4 A master’s

degree is required for entry level practice. The

professional role of an NP is primary care provider

who practices in ambulatory, acute and long-term care

settings.4,5 Nurse practitioners are able to order and

interpret diagnostic and laboratory tests, as well as

prescribe pharmaceuticals. The American Nurses

Association supports the role of NPs as advocates of

health promotion and disease prevention with an

established record of providing excellent primary care

in diverse settings.6It is the ability of NPs to provide

primary care to a diverse population that enables them

to work in a variety of practice settings. One such

practice setting is the military healthcare system. Army

Regulation (AR) 40-68 authorizes NPs to provide

medical healthcare for diverse populations in primary,

acute, and long-term healthcare settings.5 The role of

the NP as a primary care provider in peacetime

healthcare has been well established, however, the role

of the NP in wartime medical care has yet to be

defined. Notably absent from AR 40-68 is any mention

of NPs as primary care providers in deployed settings.

The roles and experiences of 5 NPs deployed to OIF

are presented below to provide a better understanding

of the contributions NPs can make in providing

primary care in an austere wartime environment.

Expanding the Role of the Nurse

Practitioner in the Deployed Setting

MAJ(P) Edward E. Yackel, AN, USA

MAJ Julie Dargis, AN, USA

LTC (Ret)Theresa Horne, AN, USA

LTC Sophia Tillman-Ortiz, AN, USA

LTC Diane Scherr, AN, USA

ABSTRACT

Today’s military is experiencing rapid advances in technology and manpower utilization. The Army Medical

Department is redesigning the structure and function of deployable hospital systems as part of this effort. A

critical analysis of manpower use necessitates that an examination of the role function of assigned personnel be

undertaken to optimize the employment of each Soldier-medic. This article discusses the use of Nurse

Practitioners as primary care providers during deployment. The real world experiences of 5 Nurse Practitioners

deployed to Operation Iraqi Freedom are presented. Data gathered during the deployment and an analysis of the

literature clearly support the rationale for expanded and legitimized roles for these healthcare professionals in

future conflicts and peacekeeping operations.

This article is reprinted from Military Medicine: International Journal of AMSUS (2006;171(8):770-773) with permission

of the publisher.
October – December 2006 21

NURSE PRACTITIONER ROLES & EXPERIENCES

All the authors of this article deployed to Operation

Iraqi Freedom (OIF) with the 28th Combat Support

Hospital (CSH), a 296-bed corps level facility staffed

by an interdisciplinary healthcare team of 500 military

healthcare professionals. The 28th CSH had the

capability to provide Level III combat care and offered

the following services:

 Emergency/trauma

 Operating and recovery room

 Intensive care nursing

 Medical/surgical nursing

 Physical therapy

 Outpatient/sick call

 Radiology

 Laboratory

 Pharmacy

 Medical maintenance

 Combat stress care

 Chaplain

 Patient administration

Nurse practitioners are traditionally assigned to work

as medical/surgical nurses in a CSH, however, the

changing operational requirements of OIF necessitated

the use of these primary care specialists in a variety of

positions. Changing operational requirements and

phase of deployment were primary determinates of

role assignment for NPs.

The warning order to deploy the 28th CSH was issued

in February 2003. The predeployment phase of

operations readied personnel physically and militarily

for the impending mission. A nurse practitioner,

assigned as the primary care provider for the 28th

CSH, served as the commander’s advisor on medical

issues and was responsible for the physical readiness

of all personnel assigned to the unit. The NP prepared

personnel for deployment by reviewing medical

records and facilitated medical care for individuals

with outstanding medical problems by coordinating

healthcare with the local military medical treatment

facility. The NP also served as the immunization

coordinator after completing an online didactic module

and a real-time, hands-on, certification program

supervised by an immunologist. As a direct result of

having an immunization coordinator available within

the organization, over 500 28th CSH Soldiers were

screened for the immunizations necessary to protect

them against biological warfare agents. Furthermore,

the ability to field an immunization coordinator

enhanced the flexibility of the 28th CSH in accepting

similar missions in the deployment phase of

operations. The 28th CSH arrived at Camp Doha,

Kuwait in increments in the period March 8–10, and

was billeted in warehouses while awaiting mission

orders. A tasking from higher medical headquarters

directed that the 28th CSH send mobile immunization

treatment teams (MITT) to staging areas on the Iraqi

border to inoculate troops against smallpox and

anthrax. The NP, as immunization coordinator,

assembled and educated 4 MITTs comprised of

physicians, nurses, and medics which inoculated over

2,000 troops. The immunization mission continued as

the 28th CSH moved to its staging area at Camp

Victory, Kuwait on March 24 and assumed an

outpatient troop medical clinic mission.

Camp Victory was a holding camp for troops awaiting

orders for movement into Iraq. At the time the 28th

CSH arrived, Camp Victory was in a state of brisk

construction. Medical support was exceedingly

limited, consisting of an ambulance squad with 4

medics and 2 field ambulances. The medics provided

triage and treatment for minor illnesses out of their

sleeping tent. Patients with acute/urgent medical needs

were transported to a nearby Air Force hospital for

advanced care. It soon became apparent that the rapid

influx of troops created the need for the definitive, onsite medical care that could be ably provided by the

healthcare professionals of the 28th CSH, along with

the newly arrived 21st CSH. The 21st CSH, with a full

medical complement, was also awaiting movement

orders into Iraq.

Two senior NPs assigned to the 28th CSH were

selected to organize, equip, and staff an outpatient

troop medical clinic (TMC) as Officer-in-Charge

(OIC) and Assistant OIC. The NPs obtained

permission to establish an interim TMC through close

coordination with the leadership of Camp Victory, the

28th CSH, and the 21st CSH. An 8-section tent with

lights and air conditioning was rapidly assembled. It

contained a waiting area, screening section (with a

pharmaceutical distribution point), and treatment area

with 6 cots/beds. The TMC was open 7 days a week,

24 hours a day, with sick call each morning and an

immunization period each afternoon. The OIC and
22 Army Medical Department Journal

Assistant OIC made staffing decisions for the TMC

with responsibility for coordinating the work schedules

of physicians (family practice, internal medicine, and

general surgery), NPs, registered nurses (RN), medics,

a physical therapist, psychiatric nurse, pharmacist, and

administrative personnel. Qualified staff members

were able to suture lacerations, drain simple infections,

dress wounds, tape ankle sprains, provide intravenous

rehydration, and diagnose simple acute problems such

as upper respiratory infections, gastroenteritis, and

conjunctivitis. The 8 NPs who deployed with the 28th

CSH were an integral part of the healthcare team that

provided excellent primary care services at the Camp

Victory TMC. Tables 1 and 2 illustrate the variety of

patient care and workload data documented during a 9-

day period at the TMC. Note that many of the

diagnoses/illnesses listed in Table 2 are common in

both peacetime and wartime primary healthcare

settings. The ability of NPs to treat these common

illnesses in peacetime reinforces the continued

employment of NPs as primary care providers during

deployment.

The two NPs who led the Camp Victory TMC were

experienced professionals who demonstrated their

expert abilities and experience as primary care

providers and leaders in that successful effort. The

NPs not only supervised clinic operations, but also

treated patients daily, coordinated with higher

command and the medical regulating officer on

evacuation issues, and procured medical and

administrative supplies for the TMC. Advanced

knowledge of pathophysiology and pharmacology

enabled the NPs to teach critical thinking skills and a

systems approach to assessment, management, and

diagnosis of common illnesses to medics and RNs

working in the primary care setting. The success of the

Camp Victory TMC is a telling example of the

benefits inherent in having experienced, senior NPs in

the deployed environment.

Flexibility in accepting role assignments enabled all

the NPs in the 28th CSH to make valuable

contributions in each phase of operations. For

example, the NP assigned as the immunization

Expanding the Role of the Nurse Practitioner in the Deployed Setting

Table 2. Patient Data at the Camp Victory Troop

Medical Clinic

3-12 April 2003 30-Day

Total

Total Number of Patients

Seen in Clinic 520 1,560

Anthrax immunizations 132 396

Smallpox immunizations 40 120

Prescriptions filled in clinic 206 618

Prescriptions sent out for

next day pick-up

142 426

Note: 30-day total is estimated.

Table 1. Distribution of Diagnoses of Patients at

the Camp Victory Troop Medical Clinic

Diagnosis 3-12 April 2003 30-Day

Total

Psychiatric (all reasons) 8 24

Dermatologic 54 162

GI, infectious 60 180

Gynecologic 24 72

Heat/cold 25 75

Injury, rec/sports 2 6

Injury, MVA 1 3

Injury, work/training 43 129

Injury, other 2 6

Ophthalmologic 44 132

Respiratory 111 333

STDs 2 6

Fever (unexplained) 0 0

All other medical/surgical 182 546

Dental* 17 51

Misc/admin/followup†59 177

Viral illnesses 10 30

Chem-bio casualties 0 0

Medical evacuations‡8 24

Total 652 1,956

*Dental patients were sent to the local Dental Clinic at

Au Al Salem

†

Primarily “other” orthopedic diagnoses and special

prescription refills

‡

Air and Ground Evacuation

Note: 30-day total is estimated.
October – December 2006 23

coordinator in the predeployment phase of operations

was reassigned as a primary care provider at Camp

Victory. Upon deployment into Iraq, this NP was then

employed as an evening/night supervisor and worked

in the emergency medical treatment section of the

hospital providing primary care.

The movement of the 28th CSH from Camp Victory

into Iraq required role reassignments of the NPs

because operational orders directed the 28th CSH to

reconfigure from a 296-bed CSH into 2 separate

autonomous and functional hospital units. The first

increment of the 28th CSH entered Iraq as a 42-bed

package designated as the Rapid Mobile Surgical

Hospital (RMS). The mission of the RMS was to

provide emergency, surgical, and intensive care

services wherever and whenever mission requirements

dictated. The 28th RMS deployed into Iraq on March

29, 2003, traveling through the war-torn country to

arrive at their final destination of Forward Logistics

Base Dogwood on April 6, 2003. Two NPs deployed

forward with the RMS. One of the NPs had extensive

experience as a critical care nurse and demonstrated

leadership ability. Therefore, she was selected as the

head nurse of a busy intensive care unit (ICU) that

cared for wounded US Soldiers, coalition personnel,

Iraqi civilians (including women and children), and

enemy prisoners of war. A second NP, who had

experience in emergency nursing, worked in the

emergency medical treatment area, providing acute

and primary care not only as a clinical staff nurse, but

also as an NP. The advantage of assigning an NP as an

ICU head nurse was the ability of this primary care

provider to collaborate between nursing and physician

staff with regard to patient admission, discharge,

clinical care, and evacuation issues. In this situation,

the NP assisted physicians in writing admission and

discharge orders during rapid influxes of casualties.

An additional benefit of employing an NP in the ICU

environment was the presence of a healthcare provider

who can communicate advanced clinical knowledge

and skills to others. The NP was the lead educator for

ICU nurses and medics and taught critical topics such

as Advanced Physical Assessment and Care of the

Pediatric Patient. The opportunity to learn advanced

assessment skills was exceptionally important for the

relatively inexperienced ICU staff that cared for a

large number of critically injured patients with a

variety of injuries, including blast injuries, gunshot

wounds, burns, fractures, blunt trauma, and psychiatric

illness. The versatile clinical skills and leadership

possessed by the NP were tremendous assets to a

medical team that was challenged to identify and

overcome barriers to patient care in the midst of war.

Advanced education and the critical thinking skills of a

primary care provider make NPs a valuable resource

that can be employed in a variety of practice settings.

For example, an NP from the 28th CSH was directed

to exchange positions with a pediatrician assigned to

the 549th Area Support Medical Company (ASMC).

The ASMC had a need for a primary care provider and

the 28 CSH needed a specialist to care for critically ill

and injured Iraqi children. Tacit recognition of the

NP’s ability to provide primary care resulted in an

equal exchange of qualified personnel to accomplish

both organizations’ missions.

The NP quickly became an integral member of the

549th ASMC primary care team. The ASMC was

responsible for providing basic field medical care

(outpatient services) and relied on the 28th CSH for

specialty care. Limited diagnostic equipment dictated

that ASMC clinicians use astute physical exam and

assessment skills to arrive at diagnoses and treatment

options to return Soldiers to duty as quickly as

possible. An outbreak of gastroenteritis in the early

summer months of 2003 resulted in over 100 patients

being treated at the 549th ASMC every day. It was

estimated that 85% of patients treated for

gastroenteritis were returned to duty within 48 hours of

presenting symptoms. Expert primary care knowledge

and assessment skills equipped the NP assigned to the

549 ASMC with the expertise necessary to diagnose

and treat patients with gastroenteritis and other

illnesses.

In June 2003, the 28th CSH was tasked to deploy a 32-

bed surgical hospital to Tikrit in support the 4th

Infantry Division. Nurse practitioners were once again

tasked to lead the primary care mission for the

organization. The newly established hospital in Tikrit

ventured into unfamiliar territory whenit created an

acute care clinic to meet an expanded mission of

providing primary care sick call for active duty troops.

The acute care clinic was situated adjacent to the

emergency medical treatment (EMT) section and

contained orthopedic, physical therapy, and

comprehensive medical/surgical sick call capabilities.
24 Army Medical Department Journal

Two senior NPs were assigned as the primary care

providers for the clinic. One NP served in the

additional capacity as OIC. The acute care clinic

served as the gateway into the hospital system for

patients with nonemergency illnesses and injuries.

Redirecting an estimated 800 patients a month through

the acute care clinic created the flexibility needed

within the hospital to concentrate on truly emergency

cases in the EMT. The employment of NPs as primary

care providers had a measurable effect on the

organization’s ability to provide expanded medical

services.

DISCUSSION

Military tactical and technical preparedness were

essential elements in assisting NPs to transition from

the predeployment phase of operations to the deployed

environment. Soldiers of the 28th CSH were required

to qualify with their assigned weapons, practice

wearing the protective (gas) mask and chemical

protective overgarments, and perform selfdecontamination procedures. Participation in hospital

equipment and tent assembly training and orientation

to standard operating procedures assisted Soldiers in

becoming technically proficient in their assigned roles.

Clinical preparedness was another important element

in the deployment process. NPs listed Advanced

Cardiac Life Support, Advanced Trauma Life Support,

and the Field Medical Chemical Biological Courses as

important adjuncts to building a knowledge base

essential to deployment. The simulated war

environment created at the Joint Readiness Training

Center (JRTC), Fort Polk, Louisiana, presented an

opportunity for two of the NPs to integrate their

clinical, tactical, and technical skills. The NPs

considered their JRTC experience as a pivotal training

event in preparation to go to war.

The role of the NP as a primary care provider has been

well established in the literature,4,6 however, Army

Regulation 40-68 does not address the role of the NP

in a deployed combat setting.5It should be noted that

combat medical units have positions designated for

advanced practice nurses (APN) working in the

operating room, but not for APNs working in primary

care. The failure of regulation and doctrine to define

the wartime role of the primary care NP directly

influences role assignments in the combat medical

unit. Nurse practitioners deploy as medical/surgical

RNs and are often assigned as a staff nurse, nurse

administrator, or head nurse, depending on the needs

within the organization. In comparing doctrine and the

freshly experienced realities of war, several questions

regarding the use of NPs in a traditional RN role are

relevant:

 Do the primary care skills of NPs degrade over

time during extended deployments?

 If data show that skills do degrade over time, what

impact does this have when NPs resume their

peacetime primary care mission?

 Are NPs able to transition from a primary care role

to the RN role in a seamless manner, or is

reeducation needed?

Seven of the NPs assigned to the 28th CSH were

tasked as primary care providers in at least one phase

of the deployment. Slotting NPs in a primary care

provider role required subtle shifts in staffing to

accommodate role reassignments. Perhaps fewer

staffing shifts would have been necessary had several

NP slots been designated on the unit’s staffing matrix

prior to deployment. A careful analysis must be

conducted to reevaluate the requirements of NPs on

the battlefield, the staffing plan for deployable

hospitals, and the requisite number of primary care

slots for NPs in deployed medical organizations.

When analyzing future staffing plans for deployable

medical organizations, it is important to consider the

interchangeable nature of the physician assistant (PA)

and NP roles in peace and war. Both PAs and NPs are

intermediate or midlevel care providers. The

differentiation between the two groups is that PAs are

typically assigned to units located near the front lines

of battle, whereas NPs are typically placed in rearechelon medical units such as a CSH.7 The

unprecedented transformation of the Army into a

Future Force necessitates a reexamination of

previously assigned roles for NPs in peacetime and

wartime for validity and applicability in today’s world.

Army Regulation 601-280 envisions the Future Force

as an organization that is flexible, proactive, and

responsive, with management and support processes to

take care of the Soldier.8 Recent academic initiatives at

the Uniformed Services University of the Health

Sciences are transforming the Future Force vision into

a reality. The graduate nursing faculty has developed a

comprehensive program of practicums and specialty

rotations in suturing, orthopedics, podiatry,

Expanding the Role of the Nurse Practitioner in the Deployed Setting
October – December 2006 25

dermatology, emergency and burn care which provides

NP students with the additional skill sets necessary for

employment as midlevel providers in deployable

medical organizations. The proactive and responsive

addition of skill sets to the NP program has given the

Army Medical Department the flexibility to consider

substituting NPs for PAs in future deployments.

Working together, NPs and PAs have a rare

opportunity to shape the future of medical care for

deployed Soldiers. Validation of the interchangeable

nature/roles of PAs and NPs must be analyzed in terms

of clinical outcome criteria and warrants further study.

The versatility of the NPs assigned to the 28th CSH

was clearly demonstrated by their ability to function in

such critical roles as head nurse, primary care

provider, OIC, and evening/night supervisor. Nurse

practitioners selected clinical acumen and experience

level as important predictors of their ability to perform

these critical roles. The real-world experience and

proven performance of deployed nurse practitioners

are true to the historic reputation of Army nurses:

ALWAYS ABLE TO GET THE MISSION DONE

ACKNOWLEDGMENT

The authors thank Linda Yoder RN, PhD, AOCN (AN,

USA (Ret)) for her valuable assistance in the

preparation of this article.

REFERENCES

1. Army Concept Branch, Concept Development

Division, Concepts & Experimentation Directorate,

TRADOC Futures Center. Army Concept Summaries;

2004.

2. Davis U, Scherr D, Parsons T. Meeting women’s

needs during deployments: A case for the increased

use of APN. US Army Med Dept J. July-August

1997; PB 8-97-7/8.

3. Mezey MD, MCGivern DO. Nurses, nurse

practitioners: Evolution to advanced practice. 3 ed.

Philadelphia, PA: W.B. Saunders; 1998.

4. American Academy of Nurse Practitioners. Nurse

practitioners as an advanced practice nurse role

position statement; 2002. Available at:

www.aanp.org.

5. Army Regulation 40-68. Medical Services: Clinical

Quality Management. Washington, DC: US Dept of

the Army; February 2004; 26-30.

6. American Nurses Association. Advanced Practice

Nursing: A new age in health care. Nursing Facts.

1 9 9 5 ; I t e m P R - l i . A v a i l a b l e a t :

www.nursingworld.org.

7. Knopper, M. For clinician’s who practice in uniform:

Are traditional roles changing?. Clinician News.

2004; 8: No. 2: 18-19.

8. Army Regulation 601-280. Personnel Procurement:

Army Retention Program. Washington, DC: US Dept

of the Army; 31 March 1999; 1-137.

AUTHORS

MAJ (P) Yackel is the Officer in Charge of the Troop

Medical Clinic and Aviation Medicine at the Tripler Army

Medical Center, Hawaii.

MAJ Dargis is a Family Nurse Practitioner in the

Department of Primary Care at Robinson Family Medicine

Clinic, Fort Carson, Colorado.

LTC (Ret) Horne is Director of Nursing, Maternal Child

Health, Lakeland Regional Medical Center, Lakeland,

Florida.

LTC Tillman-Ortiz is the Officer in Charge, Bennett Health

Clinic, Fort Hood, Texas.

LTC Scherr is Chief of Hospital Services/Assistant Chief

Nurse at Keller Army Community Hospital, West Point,

New York.
26 Army Medical Department Journal

Forward Deployed Neurologists?

But That's Where The Troops Are!

LTC Roman Bilynsky, MC, USA

The role of the neurologist in the deployed military

force has typically been limited. A Combat Support

Hospital (CSH) deployed to a theater is often

augmented with a Neuro Detachment. This consists of

two neurosurgeons and a neurologist to provide

forward neurosurgical care. The neurologist functions

to support both pre- and postoperative neurosurgical

patients if needed and to provide primary neurological

consultation. I do not propose any changes to the

current configuration or utilization of this unit. It is

important to note that all combat support hospitals do

not have such augmentation. In Iraq, the detachment is

collocated with a CSH element in Baghdad. Due to

hostile conditions and distances involved, the actual

effective sphere of routine consultative referral is

restricted.

Neurologists can provide important consultative

services for the deployed force. Their expertise is

evaluation and/or treatment of Soldiers presenting with

headaches, migraines, concussions, seizures, syncope,

epilepsy, nonsurgical neck or back pain, chronic pain

syndromes, and vague neuropsychiatric complaints.

Such expertise closer to the line would minimize the

risks of transporting Soldiers to distant consultants

within or outside the theater. It would prioritize

Soldiers with medical conditions who need additional

neurophysiological and/or neuroimaging evaluations.

If local national facilities are available, the

neurologist's expertise in interpreting neuroimagery of

magnetic resonance imaging or CT computerized

tomography scans of the brain and spinal cord can be

effectively utilized. This would drastically reduce the

need for patient evacuation for routine or rule-out

studies. Most importantly, location of neurologists in

closer proximity to combat units obviously supports

the Army’s overall goal of maintaining critical combat

and manpower resources as far forward as possible.

Neurologists can also be invaluable for consultation

when rendering humanitarian aid. Based on my

deployment experience with the 4th Infantry Division

in Tikrit, I determined that there is a clear need for

specialty neurological consultation far below theater

level.

I submit the following implementation options for

consideration:

Division Level. There has been an emphasis on

forward mental health over the last 10 years that has

resulted in the formation of Combat Stress Control

teams and provision for a psychiatrist at division level

for consultative services. A similar emphasis on

providing forward neurological care could be initiated

relatively simply by assigning a neurologist to fill one

of the Professional Filler System (PROFIS) slots at the

level two main support battalion or divisional aid

station. This would enable the neurologist in the

division support area, visited by supported units for

logistical and other purposes, to provide neurological

consultation services in a convenient location.

Brigade Level. The neurologist can deploy as a

PROFIS physician provider at the level two forward

support battalion aid station. This is a convenient

location because logistical elements from supported

units in the brigade regularly travel to the brigade

support area for supplies enabling convenient access

for consultation purposes. The determining factor as to

whether all 3 or 4 brigades or just 1 or 2 brigades in a

division need an assigned neurologist would be the

overall disposition of the supported and adjoining

units. The brigade located near the division support

area would probably be the best location for a single

provider. My experience as a neurologist during

deployment is based on this model of staffing.

Battalion Level. Neurologists can deploy as the

primary PROFIS physician providing general medical

officer level one care at the battalion (infantry, armor,

etc) and concurrently be available for neurological

consultation. This type of provider positioning would

be optimal only if collocated with other units or if it is

along a main supply route. Consultation is only

feasible if patients have relatively easy access to the

consultant. If the provider is located at a nontransit

point, transportation of the patient to the point of care

will obviously be costly in terms of man-hours and

vehicles.
October – December 2006 27

CORRECTION

In the July – September 2006 issue of the AMEDD Journal, CPT David Admire, the author of the article

“Thumb Opposition Restoration: A Case Study,” was incorrectly identified as a Physical Therapist. He is an

Occupational Therapist. The Journal regrets the error.

The current trend in operational deployments and

future requirements of the large number troops in Iraq

(and Afghanistan) makes a compelling argument for

moving neurological specialty care forward.

Manpower shortages and requirements to provide

personnel for guard duty, details, convoy duty, and

provision for rest and relaxation and mid-tour leave

make this a necessity. Substitution of a neurologist for

another physician providing level one care does not

change overall deployed medical personnel strength

and does not necessitate changes in tables of

organization.

Iraq and Afghanistan are combat theaters of operation

within which deployment along traditional combat

front lines is not feasible. They represent the new,

modern battlefield. Travel between forward operating

bases is hazardous because of exposure to attacks from

small arms and/or improvised explosive devices.

Transportation of a patient to one location in a large

theater of operations involves one to several convoys,

helicopters, and/or aircraft. Consequently, routine

priority patients and accompanying personnel are

unnecessarily exposed to increased risk. Locating

neurologists at key transit points would be a major step

in the reduction of this safety risk and an additional

factor in the Army’s goal to maximize care for all of

our Soldiers. Forward deployment of neurologists is

forward thinking for the dynamic, fluid battlefield of

the future.

AUTHOR

LTC Bilynsky is currently assigned to the Patterson Army Medical Clinic, Fort Monmouth, New Jersey.
28 Army Medical Department Journal

Theater immersion is not a new concept for the Army.

For decades the Army’s Combat Training Centers

have employed the practice of “...placing leaders,

Soldiers, and units...into an environment analogous to

what they will encounter in combat.”* The critical

tenet of theater immersion is the deliberate, constant,

and practical study of the contemporary operating

environment. Successfully replicating the

contemporary operating environment requires a

training environment that is flexible and adaptable to

the current conditions into which our Army’s forces

will deploy. From 21 March to 30 May 2005 the

Soldiers and leaders of the 344th Combat Support

Hospital (Task Force 344 Med) trained in such an

environment at Fort McCoy, Wisconsin.

The ability of the training team at Fort McCoy to

replicate the operating environment into which Task

Force 344 would deploy was the critical element in the

successful preparation for its complex mission in Iraq.

Without question, the immersion of Task Force 344

Med in a tough, realistic, and demanding training

environment prepared its Soldiers to execute its

mission essential tasks to a rigorous standard. This

training environment also prepared them mentally for

the tough challenges that they would face during their

one-year mission. The combination of mental

toughness and superb task execution created in all task

force Soldiers a sense of confidence that they did not

have when they arrived at Fort McCoy in late March.

This self-confidence will greatly help the Soldiers of

Task Force 344 Med as they conduct a difficult and

demanding mission, namely, the provision of world

class healthcare to detainees at the Abu Ghraib and

Camp Bucca detention facilities.

STUDYING THE MISSION ENVIRONMENT

In late February 2005, the First US Army and the US

Army Reserve Command notified leaders of the 2nd

Brigade, 85th Division (Training Support) and the

Regional Training Site–Medical (RTS-Med), Fort

McCoy, that approximately 300 Soldiers of the 344th

Combat Support Hospital would mobilize and train at

Fort McCoy. The Soldiers of Task Force 344 Med

were due to arrive at Fort McCoy on 21 March and

were scheduled for an early June deployment to Iraq.

The 2nd Brigade and RTS-Med planning team

immediately initiated a study of the Task Force 344

mission and the environment within which it would

provide detainee healthcare. Members of 2nd Brigade

successfully established contact with key leaders and

staff of Task Force 115 Med, the hospital unit from

Fort Polk, Louisiana, that was presently providing

detainee healthcare at Abu Ghraib prison and the

Camp Bucca detention facility. 2nd Brigade planners

also established contact with members of Task Force

115 Med who had recently redeployed to Fort Polk.

Mission critical information soon began to flow into

the Fort McCoy training team (2nd Brigade and RTSMed) that would lay the groundwork for the

replication of the mission environment in Wisconsin.

The McCoy training team began to envision and

understand the Task Force 344 Med training

environment that the team must establish at Fort

Theater Immersion: Training a Medical

Task Force for Operations in Iraq

COL James B. Henderson, USA

*LTG Russell L Honore and COL Daniel L Zajac. Theater Immersion: Post-mobilization Training in the First Army.

First US Army Pamphlet; 2005.

The purpose of Theater Immersion is to rapidly build combat ready formations led

by competent and confident leaders who see first, understand first, and act first,

and are manned by battle proofed Soldiers inculcated with the Warrior Ethos.*
October – December 2006 29

McCoy. The 2nd Brigade S2 served as the conduit for

information between the McCoy training team, Task

Force 115 Med, and 44th Medical Command (the

forward deployed command for Task Force 115 Med).

Task Force 115 Med provided 2nd Brigade with

updated standard operating procedures for hospital and

detainee healthcare operations, its force protection

missions, and its report formats and submission

requirements. Members of the Task Force 115 staff

answered dozens of requests for information. The

Brigade S2 harvested information from classified web

sites of Forward Operating Base–Abu Ghraib and the

tactical units that operated in the vicinity of Abu

Ghraib. The training team studied satellite imagery of

the Abu Ghraib prison complex to better understand

the forward operating base layout. Trainers reviewed

and war-gamed recent insurgent attack patterns against

the prison and against coalition forces in the area and

main supply routes adjacent to Abu Ghraib. The S2

and the training team conducted the same kind of

environmental analysis for Camp Bucca and its

surrounding area. The training team now had enough

information to establish the physical and the missionspecific training environment at Fort McCoy. By the

second week of March, Fort McCoy installation

workers had broken ground on the Task Force 344

Med Forward Operating Base (FOB) training sites, and

the training team was fully engaged in developing

dozens of training scenarios tailored to the task force

mission.

BUILDING THE MISSION ENVIRONMENT

It was necessary for the training team to leverage

existing Fort McCoy training sites due to the limited

time available to prepare the sites for early-April

occupation by Task Force 344 Med. 2nd Brigade

planners worked with RTS-Med and the installation

staff on the construction of 2 base camps that would

simultaneously serve as training sites and life support

areas. The RTS-Med training site on Fort McCoy was

the obvious location for the main life support area and

training site. This site offered adequate space for

construction of a temporary life support area (LSA) for

300 Soldiers. The LSA consisted of 4 large contracted

general purpose (GP) tents, a dining facility trailer for

food service and a mess tent, a tent that served as a

training site for up to 100 Soldiers, field showers

linked to an installation water source and sewer line, a

trailer housing the S4 and unit supply room, and a

motor park. Installation workers moved observation

towers and bunkers from other training sites on Fort

McCoy to the FOB, and helped 2nd Brigade Soldiers

set up an entry control point into the operating base.

The Army-Air Force Exchange Service established an

exchange at the site that was open to Soldiers in the

evenings. The McCoy gym staff created a workout

area for the Soldiers. The entire site was enclosed in

privacy fencing to give the Soldiers the continuous

illusion of being in a walled compound.

The main training site also contained an RTS-Med

managed field hospital that would serve as the Task

Force 344 Med hospital at “FOB Abu Ghraib.” The

RTS-Med site administrators coordinated delivery of

medical equipment that was unique to the Task Force

344 Med healthcare mission, or in some cases was in

use by Task Force 115 Med in Iraq. The RTS-Med

staff provided a building adjacent to the hospital for

the Task Force Tactical Operations Center (TOC).

Personnel from the McCoy Directorate of Information

Management laid more phone lines and computer

network cable into the building. Through this effort the

TOC and the hospital staff were able to communicate,

quickly coordinate operations, and send or receive

mission specific reports.

The McCoy training team also developed a smaller,

more austere “Camp Bucca” training site on the south

side of Fort McCoy approximately 5 miles from the

Abu Ghraib site. This site consisted of 3 trailers that

served as work space for about 60 Soldiers and the

task force’s Camp Bucca staff, rudimentary field

hygiene facilities, and a temporary field hospital that

RTS-Med erected at the site. The Soldiers working in

shifts at Camp Bucca returned to the main LSA on the

north side of Fort McCoy in order to take showers and

sleep in the GP tents. This procedure saved the

installation money and did nothing to detract from the

Soldiers’ theater immersion.

The 2nd Brigade training team needed a training site at

which the task force medics could conduct detainee

sick call and wound care, and administer daily doses of

prescribed medication to the detainees. Fort McCoy’s

Enemy Prisoner of War training compound served as a

perfectly analogous site at which Abu Ghraib and

Camp Bucca medic teams could execute these tasks.

This site was within a mile of the Abu Ghraib FOB,

and was less than a 10-minute drive from the Camp

Bucca training site. Tents served as work areas for the

medical teams, and 2 tents provided holding areas for

detainee role players. While the site was not very

robust, the fenced compound did give the medical
30 Army Medical Department Journal

teams the illusion of being “inside the wire” at their

respective detention facility.

The 2nd Brigade established an exercise control center

(ECC) for the Task Force 344 Med collective training

phases. A small cell of Soldiers in the ECC replicated

the 44th MEDCOM staff and served as the Base

Operations Center (BOC) staff for both FOB Abu

Ghraib and Camp Bucca. Radio and phone

communication systems provided the primary means

of command and control between these notional

headquarters and Task Force 344 Med. Email also

served as a means by which the medical task force

provided routine reports to the exercise “44th

MEDCOM” and the BOC staffs. A parking lot

adjacent to the ECC served as the linkup point for

daily convoys that departed FOB Abu Ghraib or Camp

Bucca, the same linkup procedure used at both sites in

Iraq. While the ECC staff primarily administered

command and control over all of the training aids and

role players used to support Task Force 344 Med

collective training, the control center’s BOC/44th

MEDCOM staff did a superb job of exercising the

Task Force 344 Med reporting and staff planning

processes. The Task Force 344 Med staff used the

same report formats during collective training that it

would use for reporting to 44th MEDCOM and the

BOC once deployed. Replicating the command and

control procedures and using the actual task force

report formats contributed significantly to the theater

immersion of the task force and its staff.

Development of realistic and relevant training exercise

scenarios was also critical to Task Force 344 Med’s

successful theater immersion training. In early March,

the 2nd Brigade exercise planners assembled

healthcare subject matter experts from the First Army

Command Surgeon’s office, the McCoy RTS-Med

staff, and key staff members of the Fort McCoy Troop

Medical Clinic. Their purpose was to develop medical

training scenarios to replicate the kind of care that the

medical task force would perform in theater. The

planning team assembled each week to develop and

refine situations that applied to Task Force 344 Med’s

unique mission. The team scripted over 120 different

medical scenarios that addressed various aspects of

detainee healthcare, Level III/IV care for coalition

forces, and emergency care for local Iraqi civilians

wounded during US combat operations. These

scenarios ranged from routine care that clinical staff

provided each day in the hospital, such as physical

therapy sessions for injured detainees, to a mass

casualty type event of 8 to 12 wounded detainees or

coalition forces.

The complexity of this effort was compounded by the

need for detainees who received treatment to have a

medical history. This required the scenario

development team to craft over 150 unique medical

records that hospital personnel would use when

treating detainee patients. The planning team was able

to establish the frequency and type of medical

scenarios by studying Task Force 115 Med daily

medical situation reports submitted to the 44th

MEDCOM. The exercise planning team then used the

scenarios to develop a list of required training aids and

role players, the time required to execute the scenario,

and the need for any special preparation such as

application of moulage to a casualty or detainee. While

the McCoy RTS-Med planners provided some

scenarios that they use to train traditional combat

support hospitals, the unique mission of Task Force

344 required dozens of scripted events, presenting

training not routinely provided to a standard combat

support hospital at an Army Combat Training Center.*

The medical planning team was extremely successful

in developing rigorous, realistic, and very relevant

medical training scenarios that fully supported the

theater immersion of Task Force 344 Med.

A force protection training team consisting primarily

of 2nd Brigade planners and trainers worked in parallel

to the medical planning team. The team gathered and

assimilated information that was relevant to the

security and defense of in theater FOB Abu Ghraib

and Camp Bucca. Some sources of information

included FOB perimeter tower crew transcripts, the

Task Force Med life support area defense plans, and

Task Force 115 Med staff responses to various

requests for information. Armed with this information,

the brigade’s exercise planners and trainers developed

a Task Force Med Base Defense Plan that was similar

to the plan that the unit would have to execute once it

deployed. The plan replicated the same number of

*Based on discussions between the author and members of the Joint Readiness Training Center (JRTC) Echelon Above

Corps medical training team during a site visit at Fort Polk in early March 2005. The detainee care training provided at the

JRTC is not analogous to the care that Task Force 115 or 344 Med provided to detainees at Abu Ghraib and Camp Bucca.

Theater Immersion: Training a Medical Task Force for Operations in Iraq
October – December 2006 31

static battle positions that Task Force 344 Med would

occupy as part of its base defense responsibilities. It

also required the task force to form a Quick Reaction

Force capable of executing the same force protection

duties and responsibilities as the Task Force 115 Quick

Reaction Force. The exercise planners and trainers

then arrayed bunker positions and emplaced

observation towers in the FOB Abu Ghraib training

site that were similar to the actual in theater layout of

those positions relative to the hospital and the

Soldiers’ life support area.

The planning team’s interviews with recently

redeployed Task Force 115 Med Soldiers also

provided key information on how the task force plans

and executes its movement operations from FOB Abu

Ghraib to other locations, and the weekly rhythm of

these movements. The team then built scenarios and

resource lists from this information that trainers would

use to execute ground assault convoy training for Task

Force 344 Med. The training team had to designate

Soldiers and vehicles that would also participate in

Task Force 344 Med convoys during situational

training exercises and the task force Mission

Readiness Exercise, since the medical task force

always moves as part of a larger convoy in theater. By

providing these resources to Task Force 344 Med

during its training, the 2nd Brigade was able to ensure

that the task force would train like it would operate

once deployed. Having a unit “train like it will fight”

is the purpose of theater immersion.

TRAINING IN THE MISSION ENVIRONMENT

The theater immersion training scheme for Task Force

344 Med started almost immediately upon arrival at

Fort McCoy. Individual and leader training established

a basis for collective training conducted later in the

training scheme. Soldiers attended training on

Improvised Explosive Devices at the end of their first

week at McCoy. All Soldiers attended cultural

awareness training, and a team of instructors from the

Defense Language Institute provided the majority of

the Soldiers who work in the hospital with several

days of language immersion training. Former Iraqi

nationals now living in the United States and under

contract at the mobilization station as interpreters

during post-mobilization training continued to work

with members of the hospital on their language skills.

They would do so throughout the remainder of the task

force’s training. A Mobile Training Team of subject

matter experts from the Army Military Police School

and the Army’s Disciplinary Barracks at Fort

Leavenworth provided superb instruction on detainee

operations, handling, healthcare, and the impact of

these tasks on the Soldiers who would execute this

critical and stressful mission.

The task force moved into the FOB on 8 April and

would live, eat, and work there for the next 53 days.

Upon arrival at the FOB, they received instruction

from 1st Battalion, 338th Regiment trainers on several

battle drills that are fundamental to all operations in

Iraq: react to indirect fire, react to direct fire,

individual movement techniques, and establishing

personnel accountability after an attack on the unit.

Select Soldiers in the task force received training on

manning an observation post/tower, operating an entry

control point, and Quick Reaction Force operations.

The 2nd Brigade’s ground assault convoy (GAC)

training team and GAC live fire team provided superb

training on this critical mission to all members of the

task force. Training scenarios forced the Soldiers to

execute their GAC missions using the same tactics,

techniques, and procedures that they would use in Iraq.

Contracted and military role players portrayed

civilians on the battlefield and insurgent forces,

thereby making the unit’s GAC missions much more

complex and realistic. Opposing forces attacked the

convoys with direct fire and improvised explosive

devices. The unit had to treat and evacuate “casualties”

or Soldiers who were “killed in action.” Soldiers had

to conduct hasty recovery of disabled vehicles and tow

them to a rally point. Role players tried to interfere

with the unit’s convoys. Civilian vehicles attempted to

share the road with the convoy and infiltrate into the

convoy march unit. These scenarios forced the

Soldiers to employ a series of actions and graduated

responses that are part of the rules of engagement the

unit would employ in Iraq. This type of training is

theater immersion in full force.

By early May, Task Force 344 Med was ready for a

progressive series of collective situational training

exercises (STX) that would further train and

demonstrate the unit’s proficiency in its medical and

force protection missions. During the 2 series of

medical STX, the unit trained on all of the activities it

would perform inside the walls of the hospital at both

the Abu Ghraib and Camp Bucca sites. The task force
32 Army Medical Department Journal

operated a tactical operations center to command and

control its operation and to report to its higher

headquarters, 44th MEDCOM, on the daily status of

medical operations. Inside the hospital, the Soldiers

executed medical scenarios that closely replicated their

future mission tempo and tasks in Iraq. They provided

medical and dental sick call for US Soldiers around the

clock. They sent medical teams daily to the detention

center to conduct in-processing physicals, sick call,

medication pass, monthly health assessments, and

wound care for detainees. Additionally, they received

detainees in the hospitals daily for physical therapy

and occupational therapy, radiology, and dental exams,

and any other care that the medics at the detention

camp could not perform. Numerous scenarios also

required the unit to execute collective missions it

would likely perform in Iraq. Several times the task

force had to react to an increased casualty load caused

by detainee riots, Soldiers injured due to combat

actions, and civilian casualties resulting from combat

action in urban areas. The task force successfully

accomplished these tasks and then progressed into the

next phase of training, the Force Protection Field

Training Exercise (FTX).

During the Force Protection FTX, the unit trained and

executed all of the actions it would perform as a tenant

unit of FOB Abu Ghraib and Camp Bucca. This phase

of immersion training included the unit’s

responsibilities at the FOB’s different Readiness

Condition levels, reporting to the base operations

center, GAC operations to “Baghdad International

Airport” and “Camp Buehring,” sucker sanitation

truck (SST) movement security operations, and

reaction to direct and indirect fires. This phase of the

training also enabled the unit to practice its internal

standard operating procedures (SOPs), identify

strengths and weaknesses, and make adjustments in its

SOPs prior to the Mission Readiness Exercise.

The Mission Readiness Exercise (MRE) was the

culminating event of Task Force 344 Med’s 70 days of

training at Fort McCoy. During the MRE the task force

simultaneously performed its medical tasks and force

protection responsibilities in a split-base configuration;

one element at FOB Abu Ghraib and another, smaller

element at Camp Bucca. This phase was 5 days long

and the task force conducted continuous, 24-hour

operations throughout the entire exercise. During the

MRE, the unit was required to submit all required

daily reports to its higher headquarters and the Base

Operations Center at each FOB, and it conducted daily

medical and force protection operations similar to

those that it would execute during its upcoming

mission.

The unit conducted tactical operations center and daily

staff operations, public affairs operations with 3 live

interviews, force protection operations at both FOBs,

ground assault convoy and SST escort missions, and

detainee and coalition force medical support

operations. Over 100 role players supported this phase

of training. Role players served as detainee security

forces in the hospitals, other units in the daily GACs,

SST drivers, detainees, coalition casualties, contracted

workers on the FOB, and other FOB quick reaction

and security forces. Contracted former Iraqi nationals

served as interpreters on the hospital wards.

Throughout the MRE’s 5 days, Task Force 344 Med

in-processed 80 detainees, conducted sick call for 120

detainees, provided medications to 250 detainees,

treated wounds on 80 detainees, and conducted a

monthly physical assessment of 30 detainees. The

complexity, tempo, and continuous operations of the

exercise stressed all of the task force’s systems and

mission areas. The realism of the mission scenarios

provided the task force an indication of how well it

would operate under the most trying circumstances.

The total theater immersion of the task force into its

mission environment prepared the unit well for its

rigorous, demanding mission.

CONCLUSION

Theater immersion works extremely well in preparing

units to conduct operations in theaters around the

globe. Task Force 344 Med was immersed in a replica

of its operating environment at FOB Abu Ghraib for

53 days of tough training. The ability of the Fort

McCoy training team to develop a replica of Task

Force 344 Med’s mission environment required a

deliberate analysis and study of the contemporary

operating environment in Iraq at Abu Ghraib and

Camp Bucca. Establishing contact with Task Force

115 Med and bringing mission-related information

from Iraq to Fort McCoy was critical to the

development of training venues and training scenarios

for Task Force 344 Med. The successful training of the

task force was due largely to the skill of the Fort

McCoy training and garrison support team and what it

was able to do with the information provided by Task

Theater Immersion: Training a Medical Task Force for Operations in Iraq
October – December 2006 33

Force 115 Med. The Fort McCoy team quickly

developed a training environment that was a physical

and procedural imitation of what the unit would face

when deployed in Iraq. The demanding training

environment allowed Task Force 344 Med to conduct

operations across the full spectrum of its healthcare

and force protection mission set. The result of this kind

of demanding and rigorous training is a task force that

is well skilled in its missions, mentally tough, and

extremely confident. This result is the goal of any

training program, and theater immersion is the means

to that end.

AUTHOR

COL Henderson, an Armor officer, was Commander, 2nd Brigade, 85th Division (Training Support), Fort

McCoy, Wisconsin, at the time this article was written.

85th Division (Training Support)

“Custer Division”
34 Army Medical Department Journal

INTRODUCTION

Geographic information system (GIS) is a term used to

describe a software technology that relates various

databases to common feature geography. Specifically,

a GIS is composed of an integrated system of

computer software and hardware that allows users to

rapidly create customized maps and models that

capture only those features or objects that meet

particular selection criteria. GIS has already made a

positive impact on healthcare in the public, private,

and military sectors. Many public health departments,

both in the US and throughout the world, have applied

GIS in various ways, including the identification of

nearby medical facilities for ambulance services,

improved epidemiological response following

weather-related disasters, and hospital preparedness

for unconventional casualty events, to name a few.

1-3

Health service professionals in military installations

have used GIS to improve their understanding of

health issues. For example, an epidemiological study

of sexually transmitted diseases (STD) at Fort Bragg,

North Carolina, used GIS to track occurrences of

selected STDs in space and time, thus allowing

Preventive Medicine personnel to develop

interventions for the Fort Bragg population.4In 1993,

the US Army Center for Health Promotion and

Preventive Medicine (CHPPM) used GIS to integrate

the unit location registry database to track and map

troop locations relative to smoke from oil well fires

ignited during the first Gulf War. Since 1995, CHPPM

has expanded this system to track troop exposures to

other potential environmental hazards from specific

operational events. Future plans call for mapping

exposures to potential operational hazards such as

depleted uranium, ballistic missile impacts, and other

demolition activities.5

A current mission of the Department of Preventive

Medicine (DPM) at William Beaumont Army Medical

Center, Fort Bliss, Texas, is to integrate GIS capability

into the different health and environmental services it

performs. For example, the Environmental Health

Service (EHS) currently enters water laboratory data,

West Nile virus mosquito sampling results, monthly

dining facility inspection findings, hazardous materials

locations, and other information into a GIS (ArcView,

registered trademark of Environmental Systems

Research Institute, Inc. [ESRI], Redlands CA, 909-

793-2853), which can instantly generate maps

displaying trends of these features in space and time.

Similarly, the Industrial Hygiene Service uses GIS for

plotting biological, chemical, physical, and

radiological data that are collected as part of scheduled

sampling or for emergency response. In addition, DPM

has used GIS in simulations of hospital preparedness

for various scenarios involving chemical, biological,

radiological, nuclear, and explosive (CBRNE) events,

thus providing important information to hospital

decision makers.

DISCUSSION

West Nile Virus and GIS

West Nile virus (WNV) is a relatively new yet serious

health concern first documented in Texas in 2002.6

Statistics compiled by both the Texas Department of

Health and the Centers for Disease Control and

Prevention (CDC) show a total of 58 human deaths in

Texas alone since 2002.6,7 This virus causes mild to

severe infections in humans, typically through the bite

of a mosquito that has acquired the virus by feeding on

an infected bird. According to the El Paso City-County

Health and Environmental District, WNV cases

typically occur from August to October, which

Application of Geographic Information

System Technology to Preventive

Medicine Interventions

Joel Reyes, BS

Roene Neu, PhD

Josef A. Sobieraj, PhD

LTC Mark D. Harris, MC, USA
October – December 2006 35

correlates with migrating bird populations for the

region. The incubation period for WNV ranges from 3

to 14 days and symptoms generally last 3 to 6 days.8

The mild form of WNV infection is described as a

febrile illness of sudden onset often accompanied by

malaise, headache, anorexia, myalgia, nausea, rash,

vomiting, lymphadenopathy, and eye pain.

Approximately 1 in 150 WNV infections are severe,

including fever and even death. The CDC reports that

the most significant risk factor is advanced age, but the

sick and young are also vulnerable. El Paso CityCounty had numerous human cases of WNV

infections, including fatalities, in 2004. Fortunately, in

2005, although mosquitoes and humans tested positive

for the infection, no deaths were reported.

In April 2005, CHPPM published specific guidelines

with regard to how Army programs should

georeference West Nile virus surveillance data:

 Data must be in a format allowing it to be

integrated into a GIS.

 GIS data should be combined with local, state,

and national data for a more comprehensive

assessment of WNV.

 Accurately map local sites in GIS to develop

optimal sampling plans and best allocation of

resources.

The EHS at WBAMC is currently in full compliance

with this CHPPM guidance, effectively using the GIS

to plot mosquito trap locations and associated

laboratory results in space and time. As an example,

Figure 1 was generated in GIS using 2004 Fort Bliss

mosquito trap information to show trap locations

within the Fort Bliss golf course (an identified “hot

spot” for WNV mosquitoes9) which captured WNV

positive mosquitoes. Also highlighted on the map are

facilities with at-risk populations in the vicinity of

these traps, such as an elementary school and a youth

center in proximity to the golf course. Since 2004, the

EHS has been producing these maps to effectively

target positive WNV mosquito locations with fogging

intervention, education, and training of the at-risk

populations, along with other measures.

An agreement was recently established between the El

Paso City-County Environmental and Health District

and Preventive Medicine at WBAMC to provide

timely exchange of WNV information, including exact

locations of mosquito traps and laboratory results, and

the presentation of this data on a county map. Before

this agreement was formalized, these entities did not

share information regarding mosquito trap locations,

laboratory results, or sampling strategies. Figure 2 is a

GIS-generated map showing locations of mosquito

traps which captured positive WNV mosquitoes in

2004 using data derived from the combined El Paso

City-County and Fort Bliss databases.

Implementing a GIS-Based Emergency System

Numerous emergency services agencies (police, fire,

medical facilities, emergency shelters) in the US and

abroad have already established GIS-based emergency

systems as part of readiness programs for responding

to natural and non-natural disasters. GIS was an

important tool in the response, rescue, and recovery

efforts in the attacks of both September 11, 2001

(9/11) in New York City, and the London bombings in

July 2005.10-12 A GIS application can plot the location

of all mobile and landline callers on a digital map,

giving first responders the ability to find the site,

routes involving shortest distances, and shortest travel

times for ambulances, thus reducing emergency

response time by a critical 2 minutes.12

Hospitals and health systems have a tremendous stake

in a community's preparedness for any mass casualty

scenario related to a CBRNE attack. Since 9/11, many

hospitals have drafted plans for responses to such

events and other mass terror attacks.13 While hospitals

are fairly adept at scaling up for a predictable event,

most hospitals are not well prepared to respond to an

unexpected large-scale event such as an epidemic, the

release of a biological agent, or a terrorist attack.14 For

hospitals to respond promptly to these events, it is

crucial to have information of personnel and patients

in a medical facility readily available within minutes.

The Loma Linda University Medical Center in Loma

Linda, California, has integrated GIS in the

management of care networks and for hospital

strategic planning, to include mass casualty events.

They have merged GIS with digital floor plans of the

hospital, real-time patient data, physician in-care of a

specific patient relationships, and occupied and empty

bed information. Using this integrated GIS database,

new patients can be easily allocated to suitable beds

with matching roommates based on their condition and

the attending physician.15 The system can also be

queried for patients being treated by one particular

doctor, and provide a doctor with a floor plan map to

all his or her patients.
36 Army Medical Department Journal

The capability to predict damage and analyze

consequences from a CBRNE attack is an increasingly

important responsibility of the WBAMC Department

of Preventive Medicine (DPM), which is developing a

GIS-based model that predicts hospital capabilities and

readiness in the event of a CBRNE event in the

proximity of the Fort Bliss military base. For this

model, complete hospital floor plans have already been

incorporated into GIS. DPM has generated maps

showing exact bed locations for the hospital during

normal capacity, expansion of hospital capacity under

the emergency management and excess surge capacity

plans, and has even modeled bed locations with

hypothetical conditions of having increased isolation

wards for infectious patients or a contagious disease

outbreak facility (Figure 3). By taking into account

baseline patient bed occupancy and staffing levels,

DPM has modeled scenarios in which hospital

resources are either adequate and inadequate in space

and time for patient arrival surges from a CBRNE

event. Among other important information, these

models even reveal where process bottlenecks are

likely to occur during the triage process. This

information may assist hospital decision makers and

Figure 1. Map of Fort Bliss Golf Course and mosquito trap locations generated by GIS

(Note: Some GIS layers provided by the Fort Bliss Directorate of Environment through a

file-sharing agreement with the Department of Preventive Medicine)

Application of Geographic Information System Technology to Preventive Medicine Interventions
October – December 2006 37

reduce some of the disorder likely to occur during a

CBRNE event.

CONCLUSION

The Department of Preventive Medicine at WBAMC

has established a GIS platform with many beneficial

capabilities. Maps generated by GIS using integrated

databases showing mosquito sampling locations and

lab results for WNV, as well as the start of a GIS

collaboration between the El Paso City-County and

Fort Bliss communities, have already helped mitigate

the health risks from WNV by allowing more focused

interventions against the virus. Additional data-sharing

applications between El Paso City-County and Fort

Bliss are being evaluated. DPM is in the early stages

of using GIS to plan for a CBRNE attack as well as

prepare basic vulnerability assessments. By integrating

a GIS-based emergency system into a hospital

readiness program and the Emergency Operations

Center, WBAMC may have a more rapid response

allowing the immediate and effective use of personnel,

ambulance, and equipment resources to save lives

during a CBRNE attack. In such situations, even a few

minutes can make the difference between life and

death. GIS information may provide those minutes.

Figure 2. Positive WNV mosquito locations in 2004 generated by GIS from merged

databases between Fort Bliss and the El Paso City-County.
38 Army Medical Department Journal

Figure 3. GIS map of the WBAMC 4th floor Intensive Care Unit (ICU) and 7th floor surgical ward

showing patient bed locations under normal capacity (Capacity), emergency management plan

(EMP) capacity, as well as negative pressure isolation rooms and retrofitted isolation rooms.

Application of Geographic Information System Technology to Preventive Medicine Interventions
October – December 2006 39

REFERENCES

1. Peleg K, Pliskin JS. A geographic information system

simulation model of EMS: reducing ambulance

response time. Am J Emerg Med. 2004;22;No. 3:164-

170.

2. Waring SC, Zakos-Feliberti A, Padgett PM, Stone M.,

Wood R. The utility of geographic information systems

(GIS) in rapid epidemiological assessments following

weather-related disasters: methodological issues based

on the Tropical Storm Allison experience. Int J Hyg

Environ Health. 2005;208:109-116.

3. Schreiber S, Yoeli N, Paz G, Barbash GI, Varssano D,

Fertel N, Hassner A, Drory M, Halpern P. Hospital

preparedness for possible nonconventional casualties:

an Israeli experience. Gen Hosp Psychiatry.

2004;26;No. 5:359-366.

4. Zenilman JM, Glass G, Shields T, Jenkins PR, Baydos

JC, McKee KT. Geographic epidemiology of

gonorrheoea and chlamydia on a large military

installation: application of a GIS system. Sex Transm

Infect. 2002;78:40-44.

5. Brame L. Current status of Army’s position on evidence

of exposure to chemical agents in the Gulf War:

evidence of exposure to chemical agents in the Gulf

War. Desert Storm Veterans Association. 1997.

Available at: http://www.desertstormvets.org/health/

index.cfm.

6. State Health Experts Urge Personal Protection Against

West Nile Virus. [Video News Release]. Austin, TX:

Texas Department of Health; May, 2003. Available at:

http://www.tdh.state.tx.us/news/wnv_script.htm.

7. Centers for Disease Control and Prevention. West Nile

virus homepage. Available at: http://www.cdc.gov/

ncidod/dvbid/westnile/index.htm.

8. Centers for Disease Control and Prevention. West Nile

virus infection: information for clinicians. Available at:

http://www.cdc.gov/ncidod/dvbid/westnile/resources/

fact_sheet_clinician.htm.

9. Reyes J, Neu R, Bell L, Leyva E, Everett MA, Magaña

JC, Sobieraj JA, Harris MD. Preventing West Nile virus

in El Paso using geographic information systems

models for El Paso County and Fort Bliss communities.

El Paso Physician J. In press.

10. Kevany MJ. GIS in the World Trade Center attack- trial

by fire. Comput Environ Urban. 2003;27;No. 6:571-

583.

11. Lockey DJ, MacKenzie R, Redhead J, Wise D, Harris

T, Weaver A, Hines K, Davies GE. London bombings

July 2005: the immediate pre-hospital medical

response. Resuscitation. 2005;66:9-12.

12. London Ambulance Service-GIS experience:

geographical information systems - case studies. Bus

Comput World. February 1998:50-54

13. Morse A. Bioterrorism preparedness for local health

departments. J Commun Health Nurs. 2002;19:203-209.

14. Davenhall W. Preparing for large-scale events. ArcUser

[online]. October – December 2003. Available at: http://

www.esri.com/news/arcuser/1003/largescale1of2.html.

15. City University London, School for Informatics.

Overview of GIS for health organizations. Health

Geomatics [online]. December, 2000. Available at:

http://www.geog.ubc.ca/courses/geog471/notes/health/

Overview_GIS_Health.htm.

AUTHORS

Joel Reyes is a contracted GIS specialist in the Department

of Preventive Medicine at the William Beaumont Army

Medical Center, Fort Bliss, Texas.

Roene Neu is a contracted GIS specialist in the Department

of Preventive Medicine at the William Beaumont Army

Medical Center, Fort Bliss, Texas.

Josef Sobieraj is Chief, Industrial Hygiene Service, William

Beaumont Army Medical Center, Fort Bliss, Texas.

LTC Harris is Chief, Dept of Preventive Medicine, William

Beaumont Army Medical Center, Fort Bliss, Texas.

William Beaumont Army Medical Center
40 Army Medical Department Journal

The military health system recently changed the name

of its electronic medical record to AHLTA. The name

change is more than just a symbolic gesture. It reflects

an understanding and emphasis on the composition

and intended utility of the military health system’s

global electronic medical record (EMR). The name

change is also part of a greater effort to speed

integration of all the subcomponents of the system.

Many people think of AHLTA as the computer in their

office or exam room. While acknowledging the

“record” is kept in a large database in Montgomery,

Alabama, the global nature and the multiple systems

that compose AHLTA were not reflected in the name

Composite Healthcare System (CHCS) II. As

portrayed in the Figure, AHLTA includes CHCS,

CHCS II, CHCS II-T, and clinical data mining

capabilities. AHLTA also includes interfaces with and

information from the US Department of Veterans

Affairs EMR (Veterans Health Information Systems

and Technology Architecture) as well as other growing

network interfaces such as the Pharmacy Data

Transaction System (PDTS). The other reason for the

name change is an acknowledgement that management

of these subcomponents and interfaces must be

collaborative and in unison. Changes to or delays in

any part impact the utility of the other components.

The complexity of the largest EMR in the world and

the need to continually enhance it demands great

coordination at all levels, from the clinic to the

enterprise management office.

The name change did not signal a belief that AHLTA

was a completed product. Throughout its deployment,

it has been clear that use of AHLTA required changes

in the clinical work process. It is equally true that

necessary changes were identified by clinical teams

using the system. This has created a continual cycle of

evolution and improvement based upon real clinical

care. No EMR will ever be perfected in the lab; it

requires real-world use and feedback. During the first

2 years of full deployment, users recommended many

changes to AHLTA which have been funded.†

The list of impending improvements is impressive.

The changes will require the continued cultural and

clinical business changes in the Army Medical

Department (AMEDD). The provided capabilities

offer many improvements in clinical care, decision

support, and efficiency. The AMEDD realizes that

even these improvements will not complete the EMR.

Great innovations and recommendations for

improvement are occurring everywhere. To harness

this energy and entrepreneurial effort, the AMEDD has

developed a process to help capture, develop, and

share ideas and best practices.

SYSTEM CHANGE REQUEST AND BEST

PRACTICES

Individuals and groups can submit system change

requests to the AMEDD AHLTA Program Office or to

their regional representatives on the AMEDD EMR

Collaboration and Communication Board (CCB). The

AMEDD AHLTA system change request form is

available at the AHLTA website.† The person or group

The New Name of the Military Electronic

Medical Record

LTC Ron Moody, MC, USA

David Freeman

AHLTA Global View

*CBDM – Clinical Business Data Mart

CDW – Clinical Data Warehouse

*
October – December 2006 41

submitting the request is asked to clearly define the

outcome that the suggested change will allow. This

will help the AMEDD staff develop the idea with the

submitter. More often than not, the AMEDD staff is

able to let the requestor know the status on an earlier

similar request. The CCB, which meets twice monthly,

consists of representatives from each regional medical

command and other areas. It was chartered as a

committee of the AMEDD Information Management

Guidance Council to facilitate collection and review of

information from the field for improving AHLTA. The

group was also chartered to help improve the sharing

of best practices and use of AHLTA. In addition, the

CCB develops standardized reports so that every

military medical treatment facility does not “reinvent

the wheel.” Users are encouraged to contact their CCB

representatives. CCB representatives communicate

changes and solicit feedback on improving the

AMEDD’s electronic medical record, AHLTA.

MEDCIN® TERMS

The structured language that is the “note writer” in

AHLTA is MEDCIN, a commercial product developed

by Medicomp Systems, Inc. (14500 Avion Parkway,

Chantilly, VA, 703-803-8080) which is in use in many

civilian EMRs. Individuals and groups can request

additions and changes to the MEDCIN vocabulary

through the AMEDD AHLTA website.† A spreadsheet

to capture the requested changes to MEDCIN and

instructions on submitting changes are available on

that website. The requested changes are compiled and

submitted to Medicomp. Of course there is no

guarantee that the changes will be accepted. However,

it is guaranteed that changes will not occur if requests

are not made. In general, it takes about 6 months for an

accepted term to be released in AHLTA. The AMEDD

has had great success in getting clinical, readiness, and

administrative terms added. The consultants in the

Office of The Surgeon General (Army) are asked to

review and consolidate requested changes to MEDCIN

vocabulary for their areas. The consultants can also

assist in consolidating feedback to forward to the

AMEDD AHLTA program office as system change

requests.

SUSTAINMENT TRAINERS

The AMEDD AHLTA program office has a network

of sustainment trainers to help with ongoing training,

the collection and dissemination of best practices, and

troubleshooting AHLTA issues. This collaborative

network allows the quick identification and resolution

of training issues. It also has helped develop and

evolve system change requests into better ideas. The

sustainment trainers keep the medical treatment

facilities informed of changes through newsletters and

a growing list of training documents and frequently

asked questions. A list of these training documents can

be found on the AHLTA website.†

†The AMEDD AHLTA website is accessible through the

Army Knowledge Online (AKO) system (authorized users

only). Enter the AKO homepage, select Groups, enter

AHLTA, select Homepage. Or, from the AKO homepage,

enter https://www.us.army.mil/suite/page/406.

AUTHORS

LTC Moody is the Program Manager for AMEDD AHLTA

Implementation and Clinical Integration, Eisenhower Army

Medical Center, Fort Gordon, Georgia.

David Freeman is the Senior Analyst in the AMEDD

AHLTA Implementation and Clinical Integration Office and

Advisor to the Program Manager.
42 Army Medical Department Journal

Although full deployment of AHLTA was approved in

January 2004,* the military health system (MHS) has

been deploying an electronic medical record since

early 1980. The deployment and use of the Composite

Health Care System (CHCS) helped overcome many

issues. For example, computerized physician order

entry (CPOE) continues to be a stumbling block for

organizations trying to implement an electronic

medical record. The resistance to this change has

persisted for over 20 years despite the evidence that

CPOE improves patient safety by preventing medical

errors. Indeed, physician resistance to ordering

medication and labs through computers was present

within the Army Medical Department (AMEDD).

However, over time many users grew dependent on the

CPOE capabilities of CHCS.

What we call “progress” is the exchange of

one nuisance for another nuisance.

Havelock Ellis

The early years of CHCS deployment and use were not

without problems and controversy. The key complaints

about CHCS were that it was slow, not user-friendly,

resulted in lost productivity, and interfered with

physician-patient interaction. The complaints are

virtually identical to those heard about AHLTA. Some

of these issues surfaced because each of these systems

pushed the technology envelope of their time. The

issues also occurred because the systems were

designed for global use and were not customized to

any single location or practice pattern. However, most

of the issues are closely related to the impact that the

electronic medical record has on the “culture of

medicine.” Like CHCS before it, AHLTA has created

a fundamental need to change clinical-business

practices while not changing the high-quality of care

that is provided. The switch to the next generation of

TRICARE contracts has also created the need to

change practices. A great move has occurred from

counting visits to relative value units. The acceptance

of change in technology follows a predictable pattern.

Gartner1defined the new technology implementation

cycle:

 Technology Trigger. A breakthrough, public

demonstration, product launch, or other event

that generates significant press and industry

interest.

 Peak of Inflated Expectations. During this

phase of over-enthusiasm and unrealistic

projections, a flurry of well publicized activity

by technology leaders results in some successes,

but more failures, as the technology is pushed to

its limits. The only enterprises making money are

conference organizers and magazine publishers.

 Trough of Disillusionment. Because the

technology does not meet its over-inflated

expectations, it rapidly becomes unfashionable.

Media interest wanes, except for a few

cautionary tales.

 Slope of Enlightenment. Focused

experimentation and solid hard work by an

increasingly diverse range of organizations leads

to a true understanding of the technology’s

applicability, risks, and benefits. commercial offthe-shelf methodologies and tools ease the

development process.

 Plateau of Productivity. The real-world benefits

of the technology are demonstrated and accepted.

Tools and methodologies are increasingly stable

as they enter their second and third generations.

A good plan executed today is better than a

perfect plan executed at some indefinite

point in the future.

General George S. Patton, Jr

It has been shown that success in a time of cultural

change requires a clear vision and commitment to

achieve stated goals. The AMEDD deployment of

A Global Electronic Medical Record,

Today’s Reality

LTC Ron Moody, MC, USA

David Blair, MD

*See related article on page 40.
October – December 2006 43

AHLTA has been focused on the goals of improving

both the health of beneficiaries and the healthcare

systems. In 2001, an Institute of Medicine study2

detailed a significant issue with the US healthcare

system. The following statement from the study

summarizes the issue:

In its current form, habits, and environment, American

health care is incapable of providing the public with the

quality of health care it expects and deserves.

In a more recent study by the RAND Corporation, it

was estimated that implementation of health

information technology and electronic medical records

would improve clinical care and operational

efficiency. The study revealed that properly

implemented health information technology would

save money and significantly improve quality. The

total annual savings was estimated to be as high as

$162 billion. Savings would come from increased

efficiency ($77 billion), reduced occurrence of adverse

drug events ($4 billion), and improved condition

management and preventive care ($81 billion).

The AMEDD’s success with AHLTA implementation

has occurred because deployment continued despite

challenges. By focusing on the vision of improved

healthcare, AMEDD helped field and create solutions

to those challenges. The past and future successes of

AHLTA require a continued effort to learn how to use

and teach the uses of the application. Success also

requires both a plan and the evolution of that plan

through continued learning. Other efforts at large-scale

EMR implementation have met with similar

challenges. The United Kingdom’s effort to implement

a national EMR has been hindered by delayed delivery

of critical software. These delays have increased cost.

In preparing for battle I have always found

that plans are useless, but planning is

indispensable.

Dwight D. Eisenhower

The AMEDD strategy for implementing AHLTA can

best be represented in 5 phases:

Phase 1

Deploy AHLTA to all sites so there is a common

EMR available

Block 1 – Medical (February 2004 to July 2006)

Block 2 – Dental and Spectacle Request Transition

System II (August 2006 to finish)

Phase 2

Increase utilization by all sites and deploy AHLTA

to all medical area locations (theater, battalion aid

stations, Soldier readiness processing sites,

community based healthcare organizations) (January

2005 to December 2006)

 Better training and tools

 Preventive Health Reminders

 Clinical Data Mart – Initial deployment

 Shared Solutions from the field

Phase 3

Improve the Quality of Care by gathering and

utilizing Evidence-Based Care and Best Practices

(January 2006 to finish)

 Deploy Clinical Decision Support/Automation

of Clinical Practice Guideline/Registry/Outcome

tool

 Enhanced Clinical Data Manager and eventual

Clinical Data Warehouse

 Regulation and Policy Changes

Phase 4

Improve outcomes while decreasing costs as a

consequence of the above actions being successfully

accomplished (July 2006 to finish)

Phase 5

Prepare for inpatient success (July 2006 to finish)

Although depicted as phases, the activities are

occurring in parallel with great overlap. Completing

each phase will provide the base and infrastructure to

more rapidly achieve the next phase.

Presently the AMEDD AHLTA Program office is

managing new implementation and lifecycle

equipment management based on an established

program management plan. This plan continues to

evolve from lessons learned and feedback from users

as illustrated in the Figure.

Victory belongs to the most persevering.

Napoleon Bonaparte

Finally, success was not easy. As of July 2006, all

AMEDD medical treatment facilities have access to

the same patient record. This was accomplished with

hard work and effort from everyone involved. AHLTA

has created additional stress in everyone’s day as the

AMEDD goes through its present transformation and

the cultural change of moving from a paper-based
44 Army Medical Department Journal

system to a fully electronic medical record. The stress

on the system has been and will continue to be for the

singular goal of improving healthcare quality. The

cultural transformation is not over and AHLTA will

continue to evolve as the clinical care team finds better

ways to use this tool and demands more of it.

CORPORATE SUCCESS STRATEGY

Success in the continued pursuit of improving

healthcare requires a corporate vision, strategy, and

leadership. Organization as well as local success

demands commitment to and public support of the

strategy in all leadership actions. The success of the

AMEDD in this endeavor has been accelerated by the

action of senior AMEDD leadership and ongoing

review of strategy and goals. The AMEDD held 3

electronic medical record summits attended by all of

its senior leadership to ensure the successful

deployment of AHLTA. The focus of future summits

is no longer the electronic medical record, but the

improvement of healthcare now that a universal

system is in place. The following are key steps for

corporate success:

 Establish a clear vision and goals for use of the

electronic medical record.

 Develop strategy for information management and

technology to support the vision.

 Acknowledge the difficulty of medical change

without compromising the vision.

 Develop and communicate an implementation

strategy.

 Revise, do not abandon, the implementation

strategy. Acceptance of new technology normally

requires 12 to 18 months.

 Don’t let perfect be the enemy of good.

Remember: electronic medical records are not

perfected in the laboratory.

A Global Electronic Medical Record, Today’s Reality

Training completed

Sustainment trainer arrives

Training date

AMEDD physician onsite

Provider rollover

New build release

Pre-implementation Implementation Integration Sustainment

Hospital

Leadership

Technical support for

site preparation

MTF leaders named

Local guide developed

Continued command

support for CHCS II

IM/IT* Site surveys Hardware

delivery

Implementation

support New user support Deploy newequipment

User Training UNISYS trainers arrive Training new

users

Training new

capabilities

Clinical

Posting of AMEDD

specialty specific

templates

Provider

adjustment to

documentation

changes

Provider and nurse

adjustments to changes

in business process

Learning new

capabilities

Administrative Clinic schedule

adjustments Coding impacts

Command brief & development of medical

treatment facility implementation guide Equipment

life cycle

Site notified

* Information management/Information technology

Period requiring critical attention to CHCS II to ensure success

The Army Medical Department Strategic Plan Overview for AHLTA Implementation
October – December 2006 45

 Establish well-defined feedback loops with

developers and give users a reasonable expectation

of what modifications are possible.

 User must provide an objective evaluation of

clinical and business outcomes of any changes

desired.

 Do not design the system to perpetuate nonevidence-based actions.

 Avoid letting personal preferences dictate

corporate preferences.

 Finally, remember that Leaders must LEAD.

FINAL THOUGHTS

Success remains an attitude. That attitude has the

AMEDD pushing for an accelerated implementation of

an inpatient electronic medical record. It also has

AMEDD policy increasing focusing on outcomes. This

includes changes in point of care information

feedback, performance-based reward for

improvements, and increasing efforts to centralize

medical monitoring to allow medical treatment

facilities to focus on outcomes.

REFERENCES

1. Gartner, Incorporated, 56 Top Gallant Road,

Stamford, Connecticut 06902-7700 203-964-0096.

2. Institute of Medicine of the National Academies.

Crossing the Quality Chasm: A New Health System

for the 21st Century. 2001. Available at: http://

www.iom.edu/CMS/8089/5432.aspx.

3. RAND Corporation. Health information technology:

can HIT lower costs and improve quality? 2005.

Available at: http://www.rand.org/pubs/

research_briefs/RB9136/index1.html.

AUTHORS

LTC Moody is the Program Manager for AMEDD

AHLTA Implementation and Clinical Integration,

Eisenhower Army Medical Center, Fort Gordon, Georgia.

Dr Blair is a family physician at the Bloomer Medical

Center in Bloomer, Wisconsin.

The Focus Must Be On Healthcare Improvement,

Not Electronic Medical Record Implementation.
46 Army Medical Department Journal

DEPLOYMENT REVIEW

AHLTA, the military health system’s (MHS)

enterprise electronic medical record (EMR), was

approved for worldwide deployment in January 2004.*

All US Army Medical Department (AMEDD) medical

treatment facilities (MTFs) completed Block 1

(outpatient EMR deployment) in August 2006. During

that short, 32-month time frame, the system was

deployed across the globe and is now used for over

80% of all AMEDD outpatient visits. It is the largest

employment of any EMR in the world. The AMEDD

role in the success of AHLTA is undisputed. The last

two Army Surgeons General set the AMEDD’s course

for successful AHLTA deployment and use. However,

the AMEDD held its first EMR summit to consolidate

its vision and strategy only relatively recently in

March 2005. It was at this initial summit where the

vision of AHLTA as the single enterprise EMR was

clearly established. At the AMEDD’s second EMR

summit in November 2005, the interrelated nature of

CHCS (Composite Health Care System), AHLTA,

CHCS II-T and the Clinical Data Mart/Warehouse was

discussed. The fact that the MHS EMR is dependent

on the aggregation of these systems is part of what

motivated the name change from CHCS II to AHLTA.

The third AMEDD EMR summit, held in April 2006,

was attended by the Army Surgeon General, the

Deputy Surgeon General, and all Regional Medical

Commanders, along with other AMEDD general

officers. The summit produced the plan to have all

future summits focus not just on the EMR, but on

Healthcare Improvement, which is the fundamental

basis for deployment of the EMR. A summary of this

event is available on the AMEDD AHLTA website.†

The AMEDD success at deploying AHLTA

notwithstanding, it is clear that AHLTA is not perfect.

No computer or information system is, particularly not

one as new and complex as AHLTA. The Surgeon

General’s directive was to field the system, use it, and

improve it. It had become clear that the system would

not be perfected in the laboratory. The strategy was

successful as the AMEDD and its end users have

guided much of the system’s evolution since

deployment. This has included improvements in speed,

stability, vocabulary, and functionality. Process

lessons have also been learned. For example, in the

early days, sometimes the preference of a single user

submitted as a System Change Request (SCR) and

incorporated into the system would subsequently

require removal, and the system returned to the

original state (or a third state) once further feedback

was received. SCRs are now processed using broader

user input and increased vetting, and additional routes

such as the AMEDD-unique SCR process have been

put into place. The AMEDD AHLTA Office and the

AMEDD Information Management Office will

continue to interact with the Tricare Management

Activity in tri-service prioritization and execution, and

continue to emphasize AMEDD-defined priorities. The

AMEDD has placed an emphasis on fielding critical

functionality at the earliest practical opportunity.

These processes maximize the AMEDD’s ability to

select, refine, support, and/or fund system

improvements that deliver maximum benefit to all,

especially the patient.

AHLTA, while necessitating some changes in how

care is delivered, does support outpatient specialty use

in its current form. However, there are specialties for

AHLTA Deployment Status and

Development Strategy

LTC Ron Moody, MC, USA

MAJ Jacob Aaronson, MC, USA

Carl Buising, MD

COL (Ret) Doug Barton, MS, USA

*See related article on page 40.

†Accessible through the Army Knowledge Online (AKO) system (authorized users only). Enter the AKO homepage,

select Groups, enter AHLTA, select Homepage. Or, from the AKO homepage, enter https://www.us.army.mil/suite/

page/406.
October – December 2006 47

which clear shortcomings exist. Planned improvements

to AHLTA will benefit most, if not all, specialties.

What is often debated is the fastest, most economical,

and best overall approach to delivering specialtyspecific functionality. A commonly suggested

approach is the purchase and integration of existing

commercial off-the-shelf (COTS) into AHLTA. The

following discussion explains the MHS and AMEDD

approach to AHLTA enhancements.

COTS SOFTWARE

There is considerable overlap in needed and requested

functionality for AHLTA among subspecialties, and in

the requests of subspecialties as compared wth those of

primary care specialties. The return on investment that

the AMEDD and MHS are seeking is not in any given

specialty, but across the clinical spectrum or the

patient, available to all system users in a standardized

format. The overarching goal is improvement in the

use and reuse of patient data across the continuum of

care. The main beneficiary is the patient, who will

have a unified, comprehensive medical record,

allowing improved outcomes and more effective

clinical management. For example, the Emergency

Department needs a flowsheet capability, as does

obstetrics/gynecology (OB/GYN). If a COTS

electronic medical record for the emergency

department is integrated with all its costs for interfaces

and data integrity, purchase of the flowsheet capability

for OB/GYN would still be necessary. Further,

pulmonary, urology, physical therapy, and others can

also benefit from a flowsheet. If a separate application

were bought for each area, it would be too expensive

to map data across the systems. Each area would be

left with its own silo of information to view. This

would be similar to one patient safety issue present

with CHCS—a patient’s allergies and medications

could not be viewed by other MTFs. The patient

record would be difficult to keep complete. The choice

facing the military health system: build a core

capability that is robust enough to meet enterprise

needs, or buy multiple EMRs specific for every

specialty area and then attempt to keep them

integrated. Unfortunately, the commercial EMR

industry limits standards in design and architecture.

Therefore, not only is the use of multiple COTS

products a more costly initial approach, but the longterm cost is higher as each new COTS change would

require changes to all integrated systems. While a

given COTS product may initially provide somewhat

smoother functionality for one clinical area than an

application developed with the overarching goals in

mind, the additional cost and effort to integrate such

products with the existing backbone is considerable. If

specialty products were purchased for every clinical

area, the redundancy in capability would be huge.

Further, at this point full data integration would

essentially be unaffordable. It is important to

appreciate that currently these applications are not

“plug and play.” Although sales professionals often

represent otherwise, true integration remains

challenging and very expensive. AHLTA commonly

faces integration challenges now, just with the various

COTS products already involved in AHLTA,

including those from Microsoft, Secured Services,

Oracle, 3M, SAIC, and others.

The short-term cost of COTS applications and

integration is initially higher because many of the

purchased capabilities are redundant. All EMR

products have basic functions, such as demographics,

check-in, test display, and encounter documentation,

as well as numerous overlapping specialty functions.

All of these areas must be mapped across all

applications so that data can be shared. The only

alternative is a system that does not cross-reference its

own data. Consider a system that does not use a

common demographic identifier for patients, allowing

overlapping and/or redundant records on the same

patient. In fact, as the legacy CHCS host data is rolled

into the AHLTA central data repository, we see

exactly this scenario as multiple local records on a

single individual from various hosts are aggregated

into the common database, necessitating complex

patient merge processes. Imagine that this necessity

was an ongoing, accepted process—a clinician would

not even know the location of the patient’s data. This

problem can be extrapolated to include any other data

element, and is of particular concern when the loss of

clinical meaning is considered. Systems that store

information of an encounter note in a “picture” format

are not truly integrated. A system based on this

approach would turn AHLTA into a very expensive

filing cabinet, a step backward in the evolution of our

EMR. Such sharing of note images only affords the

convenience of availability of the chart for human

review and interpretation of content. It fails to

capitalize on the inherent data processing power of

information technologies. This prevents the healthcare

system from taking advantage of the automated tools

that the Institute of Medicine has reported will

improve healthcare.
48 Army Medical Department Journal

POTENTIAL FOR ERRORS

As the complexity of system integration rises, the risk

of errors also increases. Interface and integration work

is required for each of the disparate subsystems, rather

than to the master application. Mapping and

integration of pulse oximeter data, for example, is

required for not only the COTS emergency department

product, but also to the pulmonary, pediatrics, family

practice, and other subapplications. Failure to

complete this work would likely result in the

presentation of erroneous data to the healthcare team.

The bottom line: COTS software may satisfy users in a

given specialty, but it is not the best choice for the

patient, nor is it the best choice for the military health

system and AMEDD’s users as a whole. The Tricare

Management Activity’s efforts have been directed

towards fielding an EMR that serves the entire

spectrum of patient healthcare, with the needed

functionality provided within—not external to, or

partially integrated into—AHLTA. Given time, the

needs of all specialties will be met through iterative

development.

STATUS OF CURRENT ENHANCEMENTS

As discussed above, the current strategy is to use

incremental, stepwise improvements in existing

functionality, based on current applications and

architecture. The following is a summary of major

current efforts, especially with regard to the

emergency department and ophthalmology. These

subspecialties have requested many capabilities that

are desired by others.

Emergency Department – Front End (Graphical User

Interface/GUI) vs. Application. Over the past 5 years

the Tricare Management Activity (TMA) has held at

least 3 requirements sessions with emergency

department (ED) consultants from all 3 military

services in efforts to define the functional capabilities

needed for the ED. These capabilities are sometimes

collectively called a module, but this is a misnomer.

The capabilities needed in the ED overlap with much

of what the current AHLTA system does, as well as

what is needed by other clinical areas. A separate ED

module might benefit the ED, but would likely be

duplicative in some areas of functionality, as well as

limiting availability of some of that functionality to

other clinical areas which share the needs. Even if the

MHS moves to the use of an ED electronic medical

record module that is part of an inpatient EMR, the

work done as part of the EMR will benefit other areas.

Additionally, in this case, like the inpatient module,

the ED module would essentially become part of

AHLTA.

The tri-service ED capabilities list was created to

allow vendors to bid on the inpatient capabilities

contract with ED functionality included. This

functionality goes well beyond a whiteboard and a

flowsheet, and TMA’s current acquisition timeline is

for 2010 or beyond. The Army Surgeon General has

asked TMA to evaluate ways to accelerate inpatient

EMR deployment. AHLTA development work is

currently underway to deliver essential ED capability,

including a patient tracking “whiteboard” function

which could be used by all clinics. It also includes

improvements for flowsheet use.

Ophthalmology – MEDCIN® Vocabulary. Due to

direct feedback from eye specialists, over 170 new eye

terms have been added to MEDCIN, and its developer,

Medicomp Systems, Inc. (14500 Avion Parkway,

Chantilly, VA, 703-803-8080), is prepared to add

more. This vendor has also considered user feedback

and AMEDD requests in the design of improvements

to their COTS product. A common complaint is that

MEDCIN does not adequately support the standard

ophthalmology clinical documentation process. That

concern and other feedback has been provided to

Medicomp which is evaluating how to refine the

product for this specialty requirement. A solid

functional relationship has been developed with this

company which is of great assistance in meeting

AMEDD’s needs. Getting complete subject matter

expert agreement on what vocabulary is truly “needed

and correct” is very difficult. The use of free text will

remain as an avenue by which to modify structured

terms to provide clarity and detail.

Drawing Tool. A capability requested by many areas,

the initial AHLTA drawing tool consists of basic

images, the ability to import images of choice from

your desktop, and the ability to import pictures from

elsewhere. The user will be able to write freehand on

these images in color. The basic images can be “copy

forwarded” into the patient’s next visit for update. The

tool will provide several features useful to all

AHLTA Deployment Status and Development Strategy
October – December 2006 49

specialties. The images will now be structured,

allowing a structured note to be composed while

drawing on the picture. The “drawing” can also be a

chart of results so that a paper-like input and output

chart of numbers can be entered and the notes will

print looking like the chart. The potential of this tool is

tremendous. The assistance of providers in all

specialties is needed to create an expanded library of

mapped images to meet clinical needs. The integration

of the advanced drawing tool into AHLTA will

probably begin in late 2006.

Note Writing Choices. Currently, a note can be

entered by use of templates and Alternate Input

Method (AIM) forms. This capability will soon be

augmented, first by the Advanced AIM (A3) form and

then with the drawing tool discussed above. Templates

have the advantage of local development to individual

preferences. AIM forms have the advantage that

developers can incorporate decision support

capabilities into them. This is a feature that is just

beginning to be used. The AIM forms are more like

paper and are designed by specialists in those areas.

Direct feedback can be given to the designer by

clicking on the “?” on the last tab of the AIM form for

your specialty area. The addition of the basic drawing

tool, the A3 form, and the advanced drawing tool will

provide more choices to meet the individual desires of

thousands of AMEDD healthcare professionals.

Tablet PCs and Equipment Changes. The AMEDD

has also changed the deployment concept of operations

for computers. Tablet personal computers are now part

of the hardware package deployed for providers. This

will permit easier drawing, the use of handwriting

recognition for free text comments, and facilitate the

move to wireless at some point in the future. Draw

pads and scanners are also being fielded to all sites as

a result of field input.

Equipment Integration/Interface. Interfacing simple

external devices such as vitals machines is not

difficult; the challenge is that there is little uniformity

of equipment across the AMEDD and our MTFs, and

interfacing each and every piece of equipment is not

feasible. That said, work is proceeding on the initial

device interfaces, and an overarching plan has become

one of the top 10 end-of-year items. Again, the goal is

to import mapped data, as opposed to relatively

meaningless, purely text documentation that must be

interpreted by human review. The generic interface

currently under design will allow the provider to see

the information at the time of the visit, and further

allow that information to be digested into structured

data for later use.

Document/Letter Writing Capability and Standard

Form Completion. AMEDD has funded projects to

enable both the production of standard forms (SF, DD,

DA) and the ability to create letters and documents.

Again, these forms will be mapped and intelligent, as

opposed to simple text fields. Fielding is expected in

2006. The SF tool will be capable of generating any

Standard Form (though mapping will be necessary for

creation), and the document capability will allow

creation of any form that the patient needs, for

signature, a note for work, or an overprint of

information for minor edits in the preparation of a

letter. As we have done with the obstetric summary

sheet, pertinent patient data can be pulled into a

defined note for a summary letter or specialty referral

letters.

Point of Care Decision Support. One of the key

advantages of a global EMR with a common data set is

that decision support is available at the point of care.

Without the standardized data set, such decision

support is not possible because the system does not

know how to interpret its data elements. Initially the

capability will become available in AHLTA as the

USPSTF*/individual reminders, and will be greatly

expanded in the patient registry and outcome tool,

often called the ACPG†project. This tool will allow

patient-centric data to be displayed at the point of care

as defined by the medical conditions, status,

medications, lab results, and the clinic providing the

care.

Refractive Surgery Information System (RSIS). The

AMEDD RSIS was recently reviewed by the Army

Surgeon General’s Chief Information Officer and the

AMEDD AHLTA Implementation and Clinical

Integration Office. It was determined that the RSIS

duplicates functionality provided in AHLTA, with the

exception of specialized decision support. A method to

achieve that function in AHLTA has been defined and

will be accomplished as an AMEDD initiative. The

*United States Preventive Services Task Force

†Automation of Clinical Practice Guideline
50 Army Medical Department Journal

development effort will provide decision support by

keeping all the patient information in a single

longitudinal and searchable database.

FUTURE PLANS

The Surgeon General’s directive from the AMEDD

EMR summits has been to use AHLTA for all

outpatient encounters once training is complete. Like

any system, AHLTA is not perfect, nor does it provide

exactly what every clinician or specialty wants today.

For example, AHLTA started worldwide deployment

without a pediatric growth chart, but the fact is that

currently the system is widely used in both the

pediatric and family medicine specialties despite this

glaring deficiency. Growth charts will be available in

the next few months, and, as time passes, all of our

clinical needs will be met. AHLTA use by the

AMEDD has helped improve the system, and created

better understanding of how the clinical business

processes must change. Despite its problems, the

existing system is usable in almost every outpatient

specialty. The current metric for AHLTA utilization is

95% of all encounters at a medical treatment facility.

EPILOGUE

Many clinical areas forward requests to the AMEDD

AHLTA program office for the review of specialtyspecific COTS products. Based on the preceding

discussion, several important questions are always

pertinent:

 Where would the integration of specialty EMR

products stop?

 Who decides that an area is so much more unique

than other areas that it deserves a custom EMR,

penalizing the safety and further development of

the total system for all users due to the long-term

requirements of integration of that custom

product?

 Most importantly, from the patient’s (not the

provider’s) perspective, what is the best course of

action to take?

Finally, it is a given that consensus on what constitutes

the “best” system is hard to achieve. This is

particularly true in view of the global and tri-service

nature of our EMR. Even with all the money, effort,

and subject matter expert time that were spent on other

interim applications fielded by the AMEDD, none

were completely accepted by all users. It is the hope of

AMEDD leadership that all users can work

synergistically for rapid improvement in AHLTA.

Such cooperative and collegial effort will speed

improvement so that we do not waste limited resources

in pursuits that are duplicative cause delay in effective

deployment and utilization of an EMR.

AUTHORS

LTC Moody is the Program Manager for AMEDD AHLTA

Implementation and Clinical Integration at the Eisenhower

Army Medical Center, Fort Gordon, Georgia.

MAJ Aaronson is the AHLTA Functional Requirements and

Integration officer. He is assigned to the Office of the Chief

Information Officer, Office of The Surgeon General,

AMEDD, Falls Church, Virginia.

Dr Buising is the Clinical Informatics Officer in the

Information Management Directorate, Office of The

Surgeon General, AMEDD, Falls Church, Virginia.

COL (Ret) Barton is the Senior Advisor to the AMEDD

AHLTA Implementation and Clinical Integration Office. He

is a Health Care Policy Analyst at the Walter Reed Army

Medical Center in Washington, DC.

AHLTA Deployment Status and Development Strategy
October – December 2006 51

ARE WE MEASURING THE CORRECT METRICS?

The Army Medical Department (AMEDD) and other

healthcare organizations expend much time and effort

on coding. This investment of personnel, time, and

money includes significant efforts to monitor coding.

Often, the stated goal of these efforts is to improve

coding “accuracy.” Unfortunately, as with many other

healthcare organizations, the AMEDD has not shown

continued improvement in coding accuracy, despite

substantial investment in personnel, time, education,

and monitoring of this metric. The healthcare team

may have little understanding of the relationship

between coding accuracy and outcome, or may

question if such a relationship even exists. Therefore,

the following questions must be asked:

 Are we monitoring the correct coding metrics?

 What is the desired outcome of monitoring these

metrics?

 Can monitoring these metrics improve the desired

outcomes?

 Are current metrics adequate for monitoring Lean

Six Sigma business improvement processes

currently emphasized by AMEDD leadership?

 In order to address these questions, it is important

to be aware of the history of medical coding.

CODING CLASSIFICATION HISTORY

The International Classification of Diseases (ICD) was

designed to promote international comparability in the

collection, processing, classification, and presentation

of morbidity and mortality statistics.1 The name and

history of the modern day coding system indicate that

the system was designed to do what computerized

medical record databases can now do to even greater

levels.

In 1893, a French physician, Jacques Bertillon,

introduced the Bertillon Classification of Causes of

Death at the International Statistical Institute in

Chicago. A number of countries adopted Dr Bertillon’s

system, and in 1898, the American Public Health

Association (APHA) recommended that the registrars

of Canada, Mexico, and the United States also adopt it.

The APHA also recommended revising the system

every 10 years to ensure the system remained current

with medical practice advances. As a result, the first

international conference to revise the International

Classification of Causes of Death convened in 1900,

with recurring sessions every 10 years thereafter. At

that time the classification system was contained in

one book which included an alphabetic index and a

tabular list. Indeed, the book was small compared with

current classification texts.

The revisions that followed contained minor changes,

until the sixth revision of the classification system.

With the sixth revision, the classification system

expanded to 2 volumes. The sixth revision included

morbidity and mortality conditions, and its title was

modified to reflect the changes: Manual of

International Statistical Classification of Diseases,

Injuries and Causes of Death (ICD). In 1948, the

World Health Organization (WHO) became the

organization responsible for developing and publishing

revisions to the ICD. In this capacity, the WHO

revised and published the seventh and eighth revisions

in 1957 and 1968, respectively. The ninth revision of

the ICD (ICD-9) was published in 1978. The US

Public Health Service made modifications to meet the

needs of American hospitals and called it International

Classification of Diseases, Ninth Revision, Clinical

Modification (ICD-9-CM). This remains the edition

used for outpatient care in the United States. Work

began on ICD-10 in 1983 and was completed in 1992.

ICD-10 expands the number of classifications to 10

times that found in ICD-9.

This expansion of classification has occurred far more

rapidly than the expansion of medical diagnosis. ICD10, although reported to “simplify” coding, not only

increases the number of classification codes, but also

the number of alphanumeric codes needed to report

Electronic Medical Records, Medical

Coding, and Outcome Improvement

LTC Ron Moody, MC, USA
52 Army Medical Department Journal

them. The Rand Corporation has estimated that the

cost in the US to switch to ICD-10 could be as high as

$1.2 billion.2 The constant changes necessary in the

healthcare system to meet the continuing changes to

the ICD classification system represents another

hidden healthcare cost. Adoption of ICD-10

classification was relatively swift in most of the world,

but not in the United States. Since 1988, US law

requires use of ICD-9-CM codes for Medicare and

Medicaid claims. With the passage of this legal

requirement, most of the rest of the American medical

industry followed suit.

Despite an extensive literature search, no detailed

information could be found on either the portion of

healthcare expenses related to medical coding or the

total cost of coding in the US from 1980-2000. The

review was undertaken to compare the impact of the

1988 mandate to use ICD-9 codes for medical billing

on healthcare cost.

ICD coding is a disease classification system that has

become tied to medical reimbursement as a result of

legislative actions. This disease classification system is

not always synonymous with clinical diagnosis. As

presently conducted, coding adds to the administrative

cost of providing medical care. Though initiated as a

classification system through which to record and

analyze disease prevalence and outcome, the system

has grown in complexity and cost. The utilization of

electronic medical records which use structured data

entry—and continually updated coding tables and

algorithms—may allow easier and less expensive data

sources to analyze disease prevalence and outcome.

The relational databases of the electronic medical

record will likely provide greater opportunities to

determine causation. Unfortunately, the continued

complexity and expansion of ICD-10 will probably

result in continued issues with compliance and

accuracy, without improving outcomes.

CODING METRICS

As previously discussed, one of the primary metrics

used to assess coding is often termed “accuracy.”

Accuracy is defined by Webster’s as “freedom from

mistake or error; conformity to truth or to a standard or

model; degree of conformity of a measure to a

standard or a true value.” The military healthcare

system also monitors compliance or completion by

timeliness and adherence to regulation and guidance.

Coding accuracy is often defined as a reproducible

conclusion based on the clinical information. An

evaluation and management (E&M) code is considered

to be accurate if the E&M level chosen by the person

(or computer) is the same as the one the auditor would

select. The auditor may have more coding knowledge

but is applying the same set of rules. Studies of

“coding accuracy” using this method have shown poor

coding by providers and poor agreement between

coding agencies.3,4 Reports of higher coding accuracy

likely indicate higher intercoder reliability or

consistency, which may or may not reflect greater

accuracy. Therefore, the reproducibility of coding is

really what is measured, rather than accuracy.

Studies comparing electronic medical record (EMR)

coding accuracy to human coding accuracy have

shown promise.5 An EMR that involves creation of an

encounter note by using structured data allows the

direct capture and reporting of the work performed.

The healthcare performed can be processed using

software algorithms to directly record procedures and

to deduce an evaluation and management code for the

visit. The computer-based algorithm provides a highly

reproducible code.

A potentially more useful metric for monitoring E&M

level usage is “appropriateness” and the use of

statistically relevant measurements of variation. The

metric of appropriateness evaluates whether a proper

E&M code level was selected. This depends on patient

status, type of service, and level of care provided.

Variation looks at the pattern of coding to indicate

possible trends indicating up- or down-coding.

Calculated results can be easily represented

graphically, with E&M code distributions displayed by

clinic and individual. This result can be compared to

national norms. If a standard distribution is present,

then E&M accuracy is likely present. Also, an audit

could simply analyze the variation of code between

originally documented codes and the audited codes to

determine the number of encounters coded one level

higher and lower. The standard deviation could be

reported using statistical methods, allowing the

determination of any variation that may be statistically

significant. The E&M code is influenced by multiple

factors, the most common being patient status, setting

of care, service type, and exam type. The selection of

the appropriate group can significantly alter

reimbursement as demonstrated in the Table. EMRs

Electronic Medical Records, Medical Coding, and Outcome Improvement
October – December 2006 53

can quickly reconfigure coding

information using these

parameters based upon user

action or automatically based

upon specific criteria. The

reporting of appropriateness

allows for process improvement

to occur on specific E&M coding

behaviors. For example, the

typical well-woman exam or

well-child visit should be coded

with preventive medicine E&M

codes. If this is not occurring, the

e v a l u a t i o n o f c o d i n g

appropriateness would suggest

that process improvement

measures are necessary to

evaluate and correct the clinic or

healthcare team process.

A second aspect of evaluating

coding is the use of Current

Procedural Terminology (CPT)

and Health Care Financing

A d mi n i st ra ti on C ommo n

Procedure Coding System

(HCPCS) codes. These codes impact relative value

units and reimbursement. Reports on the use of CPT

and HCPCS codes are also often reported based on

accuracy. Accuracy does not indicate the nature or

cause of any “inaccuracy.” Potential alternative

metrics to help improve coding would be reports on

the following data, which specifies behavior that can

be monitored and corrected:

 Percent of all charts with failure to document CPT

code

 Percent of all charts with the wrong CPT code

 Percent of all charts with failure to document

HCPCS code

 Percent of all charts with the wrong HCPCS code

A final aspect of coding that is often addressed under

the rubric of accuracy can simply be labeled as

“other.” This is the body of rules that make coding an

art. These rules are detailed in the 1995 and 1997 CPT

Manuals. The existence of 2 sets of rules that can

define accuracy further complicates medical coding.

Regulations cover many aspects of how codes are

assigned, such as the correct prioritization of listed

ICD-9 codes, the association of CPT/ICD-9, and other

rules that impact the selection of the classification term

which does not impact the medical diagnosis. The

latter group is pertinent to this discussion. Current

coding guidelines state that a “fifth-level code should

be utilized...” The guidelines further state that rarely

should a 3-digit code be utilized. The reason cited is to

give a more accurate diagnosis. This is a false

assertion because, as previously stated, ICD-9 is a

classification system and not a diagnostic system. The

coding of many encounters is listed as inaccurate, even

though the correct diagnosis is listed. The inaccuracy

is based on the need to meet ICD-9 classification

system guidelines, not diagnostic accuracy. It is

unclear if a more detailed reporting of classification

has resulted in better population healthcare outcomes

or lower total healthcare cost. This is another area

where EMRs provide a powerful advantage. The use

of classification systems arose prior to the creation of

structured databases. An EMR using a structured

database allows the patient’s condition to be

documented and stratified in greater detail based upon

symptoms, physical findings, diagnostic test results,

Relative value units for types of service, illustrating the impact of service

classification on reimbursement.

E&M*

Code Description

Relative

Value Unit

99201 New Patient Focused Problem 0.45

99202 New Patient Expanded Problem 0.88

99203 New Patient Detailed Problem 1.34

99204 New Patient Comprehensive Problem 2.00

99205 New Patient Comprehensive – High Problem 2.67

99211 Established Patient Focused Problem 0.17

99212 Established Patient Expanded Problem 0.45

99213 Established Patient Detailed Problem 0.67

99214 Established Patient Comprehensive Problem 1.11

99215 New Patient Comprehensive – High Problem 1.17

99241 Consultation Patient Focused Problem 0.64

99242 Consultation Patient Expanded Problem 1.29

99243 Consultation Patient Detailed Problem 1.72

99244 Consultation Patient Comprehensive Problem 2.58

99245 Consultation Patient Comprehensive – High Problem 3.42

*Evaluation and management
54 Army Medical Department Journal

and other coexistent disease processes. EMRs can

facilitate truly standardized reporting of clinical and

business data. The use of structured data and databases

allows the automatic creation of registries along with

direct monitoring of outcomes. Structured notes also

permit the billing of E&M levels based on recorded

interventions and actions in a way that is measurable

and reproducible.

EMRS, CODING, AND THE BUSINESS OF

MEDICINE

With such potential benefits to improve medical care

and business management along with potentially

reducing spiraling healthcare costs, it seems odd that

EMRs are not rapidly being adopted. This is

particularly true when the advocacy for EMR use is

reviewed. President Bush has called for universal

utilization of EMRs by 2014. A recent RAND

Corporation report estimates that $182 billion could be

saved annually from medical IT adoption.2 Although

financial savings are important, the improvement of

health outcomes is the true core business of medicine.

In 1999, the Institute of Medicine (IOM) released a

study titled To Err is Human.6 The report emphasizes

that the healthcare system should be safe, timely,

efficient, effective, patient-centered, and equitable.

Subsequently, in 2001 the IOM released Crossing the

Quality Chasm,

7 which concludes that:

In its current form, habits, and environment, American

health care is incapable of providing the public with the

quality of health care it expects and deserves.

Neither study states that the individuals on the

healthcare team are incapable of delivering better or

more cost-effective care. The reports also do not

indicate that a higher volume of care is what is needed.

The issue is clearly one of effectiveness of healthcare

and not productivity, as measured by number of

encounters. This is why it is critical to establish an

accurate and reproducible method for reporting the

value of healthcare delivered (measured by relative

value units) as the United States moves toward the

possibility of performance-based payment systems.

Despite the evidence supporting the role of the EMR

in helping to improve healthcare outcomes, the cost of

automation is often stated as a barrier to

implementation. Changes to business practice must

occur with use of an EMR for full financial benefit.8,9

To facilitate a rapid move to better healthcare

outcomes and decreased healthcare costs, clinicalbusiness reorganization should align changes in

billing/reimbursement with the use of EMRs.

RECOMMENDATIONS

1. Focus coding monitoring on metrics that provide

actionable data:

a. E&M coding variation from coder/auditor

review:

i. Percent of codes consistent with coder.

ii. Percent of codes one level higher.

iii. Percent of codes one level lower.

iv. Percent of codes 2 or more levels higher.

v. Percent of codes 2 or more levels lower.

b. Incorrect E&M class based upon

inappropriate use of service type, patient

status, location of care, or type of exam

listed. Metric: Number of records with

wrong E&M class/total records reviewed.

c. Modifier(s) required but not used. Metric:

Number of charts requiring modifier/total

charts reviewed.

d. Diagnosis codes:

i. ICD-9 use: Wrong ICD-9 code assigned

for the diagnosis entered on the chart

(code and description mismatch).

Metric: Percentage of ICD-9 codes that

match between the written record and

record of billing for all records

reviewed.

ii. V codes: Failure to use V codes when

appropriate. Metric: Number of records

with failure to use V codes/total

AHLTA*-coded records.

iii. Sequencing of ICD-9 codes. Metric:

Percent of incorrect sequencing/total

records reviewed.

e. Procedure Codes:

i. Failure to include CPT code when action

was documented. Metric: Percent of

records missing CPT code.

Electronic Medical Records, Medical Coding, and Outcome Improvement

*See related article on page 40.
October – December 2006 55

ii. Wrong CPT code chosen for procedure

documented. Metric: Percentage of

records with incorrect CPT code.

iii. Failure to use HCPCS Level II codes

when appropriate. Metric: Percentage of

encounters missing HCPCS code when

documentation supports their use.

2. Establish process improvement measures to use

the above metrics to improve the system.

3. Evaluate the role of coders with use of the EMR.

The wide adoption of the EMR will result in

changes in the role of coders. Human coding

skills may be needed more in the highly complex

and procedure-oriented clinical areas. There may

also be a transition to the roles of auditor,

process improvement, and consultants to the

clinical team.

4. Legislative Changes: Legislative changes should

be considered that allow direct electronic

Medicare billing when invoices are sent from

approved EMRs that use structured-text entry.

This will give direct financial incentive to adopt

use of EMRs by negating the healthcare

practitioner’s current financial burden of

continuing to fund coding infrastructure with

EMR implementation. The switch to structuredentry-based EMRs should provide a more

reliable and consistent report of actual healthcare

work. The transition will be facilitated in the

same manner that the 1987 legislative action

moved the United States healthcare system to

the use of ICD codes for reimbursement.

CONCLUSION

The transition to and use of EMRs that use structureddata entry will help to improve healthcare outcomes

and decrease cost. The transition must be coupled to

clinical and business process changes, such as coding/

billing to expedite national EMR integration and

usage. This transition, which could be aided by

legislative changes, could also help achieve the

original intent of ICD use—more reliable reporting of

disease classification and more standardized billing

practices.

REFERENCES

1. History of ICD. World Health Organization.

Avaliable at: http://www.who.int/classifications/icd/

en/HistoryOfICD.pdf.

2. Libicki M, Brahmakuiam I. The costs and benefits of

moving to the ICD-10 code sets. TR-132-DHHS.

RAND Corporation. March 2004. Available at: http://

www.rand.org/pubs/technical_reports/2004/

RAND_TR132.pdf.

3. King MS, Sharp L, Lipsky MS. Accuracy of CPT

evaluation and management coding by family

physicians. J Am Board Fam Pract. 2001;14:184-

192.

4. Bentley P, Wilson A, Derwin M, Scodellaro R,

Jackson R. Reliability of assigning current procedural

terminology-4 E/M codes. Ann Emerg Med. 2002;40

(3):269-274.

5. Morris W, et al. Assessing the Accuracy of

Automated Coding Systems in Emergency Medicine.

Proceedings of the AMIA 2000 Annual Symposium.

November 2000. American Medical Informatics

A s s o c i a t i o n . A v a i l a b l e a t : h t t p : / /

w w w . a l i f e m e d i c a l . c o m / d o c u m e n t s /

LifeCodeEMPerformanceAMIA2000.pdf.

6. Institute of Medicine of the National Academies. To

Err is Human. 1999. Available at: http://

www.iom.edu/CMS/8089/5575.aspx.

7. Institute of Medicine of the National Academies.

Crossing the Quality Chasm: A new health system for

the 21st century. 2001. Available at: http://

www.iom.edu/CMS/8089/5432.aspx.

8. Wong S, et al. A cost-benefit analysis of electronic

medical records in primary care. Am J Med. April

2003;14(5):397-403.

9. Ebell M. Integrating information technology into

clinical practice. Clinics in Fam Med. December

2003:5(4):1027.

AUTHOR

LTC Moody is the Program Manager for AMEDD

AHLTA Implementation and Clinical Integration at the

Eisenhower Army Medical Center, Fort Gordon, Georgia.
56 Army Medical Department Journal

INTRODUCTION

As a nation at war we must leverage information for

victory. Army transformation is bringing information

into action. Health transformation involves reducing

cost and improving care by optimizing the potential

uses of medical information systems. Army medicine

has made significant progress in transformation of

many areas of information management, from medical

readiness to continuity of care. Fort Lewis, with its

transforming units and highly digitized medical center,

is a convergence of the overall Army’s transformation

with Army medical transformation. An objective

integrated system, however, remains a distant goal.

This report describes the tactical requirements, the

progress of the Stryker Brigade Combat Teams

(SBCTs), and the process and systems involved in

achieving a functional tactical electronic medical

record.

MEDICAL READINESS

The Department of Defense (DoD) defines medical

readiness as the ability to mobilize, deploy, and sustain

field medical services and support for any operation

requiring military services; to maintain and project the

continuum of healthcare resources required to provide

for the health of the force; and to operate in

conjunction with beneficiary healthcare.1 Medical

readiness can be further broken down into Soldier

health readiness, individual medical training, unit level

medical training, medical equipment maintenance and

logistics, and the Soldier’s family health readiness.

Soldier health readiness tracks measures of the

individual Soldier’s health. Some measures, such as

dental readiness, are required for deployment. Other

measures must be met prior to attending schools, such

as the periodic physical. In recent years,

cardiovascular health, combat stress injury prevention,

and physical injury prevention have been recognized

as important measures for screening a Soldier’s health

readiness. An ideal health readiness system would be

integrated with the tactical electronic medical record

so that medical screenings, diagnostics, and

interventions would be entered as they are performed.

Such a system would allow the medical histories to be

easily accessible by a medical advisor who could

analyze and present data to ensure that the command

knows the current health status of their Soldiers.

A well-trained force has been recognized as critical to

the success of an army since the wars of the Prussian

king, Fredrick the Great (1740–1778). The US Army

recognizes the importance of a well-trained medical

force and continues to improve its training. Command

surgeons must track and supervise all medical training

in their unit. For an operational unit this includes the

91W (medic) transition and sustainment training,

Combat Life Saver Program, Field Sanitation Team

training, training for low density military occupational

specialties like lab and radiology technicians,

physician assistants, and Professional Filler System

physician training. An integrated information system

allows tracking of that and any additional training a

unit may mandate, such as tactical trauma training.

Medical unit training is also important, ensuring that

medical platoons, medical companies, and echelon

above brigade units are trained to standards outlined in

their Army Training Plans. That training must also be

tracked and monitored.

The real time sustainment of medical forces is very

important for medical readiness. An integrated

information management system should provide

visualization of current data and enhance coordination

for tactical medical care. Planners at all levels must

know not only the status of individual patients, but the

status of evacuation assets, cot/bed status, medical

equipment operability, class VIII, and blood. An

integrated system should allow supply requests to be

generated automatically as supplies are used or parts

are needed.

The Tactical Electronic Medical Record:

The Key to Medical Transformation

LTC Edward Michaud, MC, USA

CPT Michael McClendon, MS, USA

LTC Keith Salzman, MC, USA
October – December 2006 57

The health of a Soldier’s family is also a critical piece

of our Army’s overall medical readiness. World class

healthcare provided to our Soldier’s spouse, children,

and other dependents allows our Soldiers to execute

their mission, assured that their families are well cared

for in the Military Health System. Family advocacy

efforts are important, not just because caring for our

Soldiers’ families is the right thing to do, it also makes

the Army family stronger. An objective system would

allow a unit’s command surgeon to track family health

issues and advise his commander of identified needs,

thereby improving the units’ medical readiness.

CONTINUITY OF CARE

Electronic access to patient medical information

clearly improves the overall quality of care. Military

health providers appreciate the importance of medical

record documentation. However, the current method of

recording and storing on paper the medical record

information of our Soldiers, civilians, contractors, and

detainees is inadequate in that documentation is rarely

available for review at the point of care. The

Government Accounting Office reports that the state

of current medical documentation within the DoD,

although variable, is generally very poor.2Providers

need documentation of prior encounters to properly

care for a patient. Information such as the differential

diagnosis, treatment plan, procedures performed, and

patient exposures are examples of critical information

that, when absent, can adversely affect quality care.

Often Soldiers neglect to tell the caregiver significant

aspects of their past medical history. The treating

provider must have the ability to obtain information

from past encounters, such as laboratory results, xrays, and other relevant clinical information. To be

effective, the electronic medical record must provide

that historical clinical documentation for review by the

caregiver wherever and whenever required.

The availability of information within the direct

sequence of a Soldier’s military caregivers is not the

only capability of the electronic medical record. As

part of the concept of “health information exchange”

advocated by the Institute of Medicine, clinical care

information must also move across traditional business

boundaries.3 To that end, our objective system must

not only accept information from a variety of different

sources, but also be accessible to a variety of different

organizations, eg, civilian facilities to which a Soldier

may be referred or present for emergency care. A

system that does not allow such capability is not

acceptable.

CONFIDENTIAL VS SECRET

When considering the most effective use of electronic

information in combat situations, it is important to

consider the confidentiality of patient information and

the operational security of tactical information. Patient

confidentiality was formalized in the Health Insurance

Portability and Accountability Act of 1996 (HIPAA)4

which codified confidentiality requirements for

medical practice. HIPAA created the impetus for many

physicians to adopt the electronic medical record to

simplify compliance with the confidentiality

requirements for billing and other medically related

records.

In today’s combat units, most information is

transmitted on secret networks. Attempts have been

made to use such networks for the exchange of

digitized medical information. The major impediment

to this is that medical information is classified as

confidential, not secret. Most providers cannot access

secret networks, so medical personnel can neither enter

the data, nor retrieve it from the network. Further, if

deployed providers were granted access to secret

networks for exchanging medical data, providers in US

fixed facilities would still not have access to that data.

Continuity of care would therefore be compromised as

a Soldier’s physician in the US would have limited or

no access to information entered into the system

during deployment.

Tactical electronic medical information obviously has

the greatest utility and value when all providers have

access to it. Therefore, medical information must be

entered into a system which is accessible by healthcare

providers who need it quickly at different locations. A

web-based system seems to be the most logical vehicle

as providers potentially could access it from both aid

stations and hospitals in the US. However, operational

security requirements dictate that information which

may be of value to the enemy must be safeguarded

with restricted access. Certainly there are instances in

which certain aggregate medical summaries should be

classified as secret, eg, casualties from a given unit or

location on a given date, or the amount of class VIII

requirements from a unit. Access to this type of data

must be limited and made available only on the secret

internet.
58 Army Medical Department Journal

MEDICAL SURVEILLANCE AND HEALTH

OUTCOMES

Medical surveillance is important for maintenance of

the health of any population. In the military, a unit

commander has special responsibility for the health of

his Soldiers. The military also has several unique

advantages in maintaining and improving population

health. Those advantages include a population which is

normally localized and motivated for improved health,

and prescribed periodic opportunities to effect change

in individual and group health, such as regular

physical examinations, mandatory briefs, and Soldier

Readiness Processing events. As the commander’s

advisor and his instrument for population health

management, the unit surgeon must have the ability to

track injuries and diseases to identify and analyze

trends, and advise the commander on the optimum

approach to keep his force healthy. The unit surgeon

will then take the lead in implementing those efforts.

Health outcomes (benefits performance metrics) is a

much sought after feature of the electronic medical

record.5Practice improvements in the operational

environment (training and deployed) would greatly

expand with a comprehensive tactical electronic

medical record. Such improvements would extend as

far forward as healthcare is delivered and documented.

As scientists, we have the responsibility to

demonstrate that our efforts to effect change in

population health are, in fact, effective. The ideal

electronic record would be able to track ICD-9

diagnoses, lab results including abnormal cultures, xrays, and medications. Easily accessible common

information would allow the surgeon’s section to track

injuries, infections, combat stress, and many other

metrics. Early detection of trends could allow early

intervention and avoidance of similar problems for

other Soldiers. Outcomes of those interventions could

themselves be tracked to measure their effectiveness.

MEDICAL REGULATION

Medics, commanders, and Soldier’s families are all

concerned about tracking Soldiers on the battlefield.

An ideal system would allow the tracking of Soldiers

throughout the medical system as outpatients,

inpatients, and during evacuation anywhere in the

world. For example, Federal Express and United

Parcel Service can track packages in their custody

anywhere in the world. In contrast, more often than not

we have difficulty responding to a First Sergeant’s

inquiry about whether or not a Soldier was seen at sick

call on a given morning. An ideal system would allow

any medical provider or support staff to quickly

determine where, when, and by whom a Soldier was

seen. It should also be able to track the disposition at

each level of care, ie, returned to duty, kept for

observation, or evacuated, and note the time of

disposition. It should also track patients as they pass

through various military hospitals around the world,

and give accurate medical status and prognostic

information. Doctrinally, evacuated Soldiers are no

longer the responsibility of their unit. This, of course,

makes no sense to the family member at Fort Lewis

who attempts to obtain information about their

Soldier’s condition from a rear detachment

commander, who is dependent on information from the

main body of his unit, primarily the surgeon’s section.

The US Transportation Command implemented the

Regulation and Command & Control Evacuation

System, a separate web-based system used to track

patients on medical transportation flights from

departure to destination. Although this system is a

good tool, but it does not track intratheater movement

of patients nor onward movement from the patient’s

destination facility. It also does not provide specific

information to a Soldier’s unit as to his treatment and

prognosis.

VERTICAL AND HORIZONTAL MOVEMENT OF

INFORMATION

The information available in the tactical electronic

medical record system should include a unit’s medical

readiness statistics, medical surveillance, medical

regulation, and healthcare logistics information and

needs to be shared both vertically and horizontally.

Individuals and units down to the lowest level in the

chain of command should receive certain information

but also have access to additional sources as needed.

Higher echelons should have access to detailed

information from subordinate units in remote

locations. Higher commands may have a requirement

to collect data from large segments of a population to

conduct theater-wide population health research or

syndromic surveillance. Horizontal sharing of

information between battlefield operating systems is

important. Medical and personnel staff must have the

ability to compare notes with regard to casualties, and

must share information on physical exams, dental

The Tactical Electronic Medical Record: The Key to Medical Transformation
October – December 2006 59

exams, and permanent profile restrictions. Far too little

information is currently shared between medical and

personnel sections. Flow of pertinent nonconfidential

information to the Electronic Military Personnel Office

is important. Military medical organizations must

design a system to share information effectively and

efficiently. Medical information must also be shared

among the services, with DoD, the Veterans

Administration, and some other government and

civilian systems to adequately care for Soldiers and to

support commanders.

TRAIN AS YOU FIGHT

There are many challenges involved in the adoption of

systems which are used only during deployment. The

biggest challenge is ensuring that Soldiers maintain a

level of proficiency on such a system while in

garrison. System maintenance is another major

concern. The system must work when needed.

Therefore, an ideal system for the military

environment would be used both in garrison and in the

field for the care of our patients. Such a system will

support the same daily business at aid stations, Troop

Medical Clinics (TMCs), and hospital clinics, and

require the same training for all environments. Both

garrison and field care would be documented into and

retrievable from the same system.

CONNECTIVITY IS KEY

There are many available off-the-shelf medical

programs that could be adapted to meet the tactical

needs of our medics and providers. The key is not the

program, but connectivity. If internet connectivity is

available, a tactical electronic medical record should

be available for use. Although the system should be

flexible enough for use on a standalone basis for those

times when connectivity is not available, planning for

regular and reliable connectivity is critical. Early

planning, supporting doctrine, and inclusion of

personnel and equipment assets in the Modified Table

of Equipment to support medical information systems

will ensure availability of connectivity and

functionality wherever a unit may be deployed.

ADDITIONAL BENEFITS OF MEDICAL

CONNECTIVITY

There is currently a high level of communications

capabilities existing within the medical chain of

concern. Contact with CONUS for medical

consultation is available at the Battalion Aid Station

Level. This may be as simple as an e-mail or a picture

to a specialist at the provider’s medical center of

choice, or as sophisticated as a video-teleconference.

Those medical reports which are not classified secret,

eg, Medical Surveillance Reports (the weekly Disease

Non-Battle Injury status of a unit), Medical Regulation

(the status of individual patients wherever they are in

the world), most Class VIII requisition and

maintenance requests, etc., can now be moved up and

down the medical chain of concern via the Army

Knowledge Online system. Access to continuity

records and web-based medical resources are just two

of many possibilities available through connectivity

within the tactical healthcare system down to the aid

station level. As a side benefit, internet access is an

undeniable, no cost morale boost for our patients and

medics during periods of low volume use.

HISTORICAL SYSTEMS

Historically, Army medical documentation systems

have been comparable to civilian counterparts,

specifically black ink on Standard Form (SF) 600s. In

the field we also use the SF 600 for most

documentation. These records are usually kept in the

file drawer of a field desk. In an ideal world these

records are sent to CONUS or redeployed with a unit

and filed in the Soldier’s permanent medical record on

redeployment. In practice, these records are rarely

joined with a patient’s permanent record. There are

many explanations for this discrepancy. Soldiers

receiving care come from many different units and are

examined in different clinics around the battlefield.

Soldiers often redeploy at different times or to posts

different from their supporting medical units. For these

and a variety of other combinations of circumstances

and occurrences, there are simply too many

opportunities to lose field records, despite the very

best intentions and efforts.

The electronic transfer of medical data made its debut

in Bosnia. Telemedicine was used there on a limited

basis. Teleradiology was more successfully employed

in Bosnia where x-rays imaged in Tusla were routinely

read by radiologists at Landstuhl Regional Medical

Center in Germany. Although this was effective and

very exciting, it was also a very limited capability.

Very few sites could send or receive electronic x-rays.
60 Army Medical Department Journal

Computer scarcity and bandwidth constraints imposed

limitations on both availability and speed. Fortunately

this has changed. Currently, plain films, CT scans, and

ultrasounds are stored and read within 24 hours by the

radiologist covering Bosnia and Kosovo from one of

the three Army Hospitals in Europe, Landstuhl,

Heidelberg, or Wurzburg.

MEDICAL COMMUNICATIONS FOR COMBAT

CASUALTY CARE

In the Stryker Brigades we pioneered the early

Medical Communications for Combat Casualty Care

(MC4) systems in 2001-2002. The MC4 hardware

included handheld computers (PDAs) used by medics

to enter patient care information, and laptops used by

physician assistants (PAs) and physicians to expand

the medics’ notes and complete patient documentation.

The software for the MC4 system included early

versions provided by the Theater Medical Information

Program. These programs included Mobile Medical

Data that was used by the medics on their PDAs, and

CHCS2-T (Composite Health Computer System II

Tactical) used by the PAs and physicians on laptop

computers. The patient record entered into the PDAs

using Mobile Medical Data could be synchronized

using a physical interface with the provider’s laptop

for continued use. Notes and other patient information

could either be printed or written to removable storage

for transportation with the patient to the brigade

surgeon, or the next level of care. This first attempt to

electronically facilitate patient documentation was

very awkward and had many limitations. After

upgrades and extensive training, the system was finally

used successfully during the medical platoon exercise

and evaluation in the fall of 2002. Notes for simulated

patients were generated, documenting patient care

from point of injury through the Battalion Aid Station.

However, the limitations to the system were obvious.

As mentioned earlier, the electronic record had to be

either printed or written to a disk and then transported

across the battlefield with the patient to his next

echelon of care. In addition, a separate copy of the

record had to be transported to the brigade surgeon for

medical surveillance and consolidation of records. The

information used by all of the other battlefield

functional areas was moved around the battlefield and

exchanged with CONUS electronically.

BATTLEFIELD MEDICAL INFORMATION

SYSTEM – TACTICAL

In the spring of 2003 we attempted several innovations

for the movement of medical information around the

battlefield in a training environment at Fort Lewis. We

used new equipment from the Army Medical

Department, which included the Personal Information

Carrier (PIC) and a new program for handheld

computers called the Battlefield Medical Information

System–Tactical (BMIS-T). Both were provided to the

Stryker Brigades by the Telemedicine and Advanced

Technology Research Center at Fort Detrick,

Maryland.6 The software on the handheld computers

presented a more user-friendly interface for our

medics, and the PIC is a device to keep the Soldier’s

electronic medical information with his dog tags to

move with him across the battlefield. Our medics

entered patient data using the BMIS-T programs and

The Tactical Electronic Medical Record: The Key to Medical Transformation

A CASE IN POINT

While training at JRTC a command sergeant major suffered acute abdominal pain which induced

diaphoresis and took him to his knees. He was taken to the emergency room of the Baynes-Jones Army

Community Hospital where his daunting history of a chain of abdominal surgeries and complications

made his diagnosis and management extremely challenging. Initial evaluation, including a CT scan of

the abdomen, revealed a mild transaminitis but was otherwise unremarkable. The emergency room

physicians and consulted internist were having difficulty developing a diagnosis and disposition for this

complex patient. Fortunately, we were able to access past surgical notes, CT scans, laboratory results,

etc, in the Integrated Clinical Data Base at the Madigan Army Medical Center from the Baynes-Jones

Hospital emergency room. This made initial and subsequent management much easier and eliminated

the requirement to evacuate this Soldier. The diagnosis of acute pancreatitis became clear on the

following day. He was managed conservatively and improved quickly. He was able to complete his

training and lead his unit’s deployment to Iraq. It should be noted that the physical therapy note for his

low back pain which bad been entered 2 weeks prior at JRTC was retrievable during his admission. It

was included in the information stored in the Madigan database at Fort Lewis, Washington.
October – December 2006 61

transferred the data to the PICs. The PICs were then

used to transfer data to a laptop and from which it was

downloaded into CHCS2-T.

We attempted to use the upper tactical internet as a

backbone for moving medical information around the

battlefield. The upper tactical internet consisted of a

near term digital radio (NTDR) that moved planning

and tracking information between tactical operation

centers (TOCs) on the battlefield. Our attempt to move

information from one TOC to another met with some

success, but only basic information was transferred,

not the entire medical note. Not only was this

extremely awkward but there were other limitations.

Access to an NTDR, typically at a battalion TOC, is

required. The sender must have the specific technical

expertise to use the NTDR and negotiate the interface.

Further, data transmitted through the NTDR enters the

networks at the secret level of classification. Medical

information is not secret, so NTDR transmission

needlessly places the data in a higher security

environment, adding a significant level of complexity

to the process.

With considerable assistance of the signal corps and

the mission support training facility, we explored use

of a Tactical Local Area Network (TACLAN) to

scramble the information transmitted by the NTDR

and descramble it using another TACLAN upon

reception. The TACLAN is used by logisticians who

also work with sensitive (not secret) information sent

over the upper tactical network. Unfortunately,

personnel were unable to obtain adequate training on

the equipment, interfaces, and protocols, so the

brigade’s unfamiliarity proved a significant limitation

to conducting a valid test of concept.

Use of BMIS-T to move confidential patient

information into and out of the PIC and into CHCS2-T

is a proven capability which is the keystone into

expanding the capabilities of electronic medical

records in the tactical environment.6 At the present

time, even the limited capability offered by that

approach is the best way to move medical information

around the battlefield, given the complexity of

transmission systems, limitations of accessibility to

those systems by providers, and the technical expertise

required to use them.

HEALTH-E-FORCES/INTEGRATED CLINICAL

DATABASE

While the innovative work described above was

ongoing, the Madigan Army Medical Center (MAMC)

at Fort Lewis made the successful transition to the

electronic medical record. Since CHCS II was not

deployable, in 2002 MAMC implemented the

Integrated Clinical Data Base (ICDB). ICDB was

initially developed by the Air Force as a framework

built on CHCS which integrated information from

CHCS and other programs to enable rapid access to

clinical information. ICDB was adapted for the Army

at the Walter Reed Army Medical Center (WRAMC)

and implemented in 2002 at MAMC and WRAMC.

The Stryker Brigades were brought online by MAMC,

receiving new computers and information management

support to ensure adequate bandwidth in all of our

troop medical clinics and aid stations. MAMC further

provided informatics support, rapidly making changes

to the system in response to our feedback. The

electronic medical record was fully implemented at

Fort Lewis by 2003. The system has significantly

augmented medical care for our Soldiers since all

patient notes entered at the aid stations and troop

medical clinics are accessible by specialists at MAMC,

and notes from specialists are accessible by providers

within the brigades.

During this time, MEDBASE II was being developed

by the Great Plains Regional Medical Command at

Fort Sam Houston, Texas. Its predecessor, MEDBASE

I, was a very successful medical readiness program

which provided units at Fort Lewis a highly functional,

web-based, operationally oriented database for medical

readiness needs. MEDBASE II presented the potential

to not only track all medical readiness, but also

Soldiers’ profiles (the actual electronic profiles

themselves) and electronic medical records with

automatic International Classification of Diseases,

Ninth Revision, diagnosis coding. With our feedback,

they included the capability to track field sanitation

and combat lifesaver training as well. In the interest of

moving toward a single system, the Central, Western,

Southeast, and North Atlantic Regional Medical

Commands agreed to unify the systems. The new

Health-E-Forces system is still recognizable to the

users of the ICDB but includes links and features from

other systems.
62 Army Medical Department Journal

The first full scale implementation of this system was

accomplished in the spring of 2004 at the Joint

Regional Training Center (JRTC) at Fort Polk,

Louisiana. During the reception, staging, onward

movement, and integration phase of the 1st Brigade,

25th Infantry Division Stryker Brigade Combat

Team’s (1/25th SBCT) deployment to JRTC,

healthcare was provided as usual from Troop Medical

Clinic 4 on North Fort Polk. Fortunately, the 62nd

Medical Brigade from Fort Lewis was deployed in

support along with their providers from MAMC. We

used our limited internet access to initiate

communication of patient care notes via MAMC’s

website directly from the troop medical clinic. This

included not only sick call visits but also physical

therapy and mental healthcare. We established internet

connectivity for our battalion aid stations scattered

throughout JRTC, first at our brigade TOC, and then at

the battalion TOCs. This was accomplished as each

battalion TOC set up their communications links. We

then worked with each battalion S6 to establish a link,

either in the form of running a landline or establishing

a tactical wireless internet, to connect the Brigade

Support Battalion TOC to the Treatment and Holding

tents which were located more than a kilometer away.

Once the links were established, we were able to

access Soldiers’ electronic medical records from

MAMC, and enter our notes from sick call, our

physical therapy treatments, and the brigade

psychologist.

CURRENT VERSIONS OF THE TACTICAL

ELECTRONIC MEDICAL RECORD

The current tactical electronic medical record in use by

the 1/25th SBCT in Iraq is the Health-e-Forces/ICDB

system. Its use in Iraq was pioneered by 3rd Brigade,

2nd Infantry Division SBCT (3/2nd SBCT) which

used ICDB to document patient care in Iraq.

Unfortunately, its use was not widespread because of

the limited availability of internet connectivity for the

providers. Access to the internet has continued to be a

difficult problem. This difficulty is not because of any

structural fault in programming or design, but

primarily due to unreliable connectivity and

NIPRNET* access. The lack of a system solely

dedicated to the medical community renders access to

internet communications tenuous at best. Currently,

medical connectivity competes with unit operations

and morale, welfare, and recreation needs. As a result,

NIPRNET access is extremely slow, and file transfer is

extremely difficult. The lack of a constant internet

protocol address hinders access to MAMC and

consumes a significant amount of time in setup. Also,

use of handheld computers by line medics has proven

to be very difficult, primarily due to the austere

environment and pace of operations.

In spite of these complications, it is obvious that the

Army is on the right track in developing digital

systems for the medical community. For example, the

1st Battalion, 5th Infantry has been extremely

successful in documenting patient care on the

handheld device, starting with care during ground

evacuation and completion of the digital record by a

provider at the battalion aid station. While deployed,

the 3/2nd SBCT stored over 800 notes which have

since been merged with permanent medical records at

MAMC. The 1/25th SBCT had advantages in many

aspects of medical operations by using the excellent

lessons learned from 3/2nd SBCT. The 1/25th SBCT

also had the advantage of the previously discussed

training in the use of the tactical electronic medical

record in garrison and for field training exercises.

When 1/25th SBCT deployed, their medics, PAs, and

physicians were accustomed to using these systems in

garrison, and had trained on these systems at Fort

Lewis and later at JRTC. As of March 2005, they had

filed over 3,200 clinical notes from Iraq.

Unquestionably, access to medical information and

contact with specialty providers at MAMC has been

invaluable. A good example is that of a Soldier who

was somehow deployed shortly after being diagnosed

with a new onset of epileptic seizures. He was

deployed shortly after being prescribed new epileptic

medications. Access to his medical historical records

and communications with the physician that treated

him allowed adequate care of this Soldier in an

environment that, until recently, would have

necessitated his immediate return. This is just one of

many examples of the extremely high contribution to

readiness represented by continued, real time access to

medical information of all Soldiers.

The Fort Lewis medical community could not have

realized theses successes on its own. The signal

section trained and prepared with us. They and the

command of 1/25th SBCT understood the importance

The Tactical Electronic Medical Record: The Key to Medical Transformation

*Nonclassified Internet Protocol Router Network
October – December 2006 63

of the electronic medical record and supported its use.

Dedicated medical connectivity for each aid station

would be a major step toward ensuring our patients

receive the best in medical care. Such a capability

would make the difference between a system which

can work, and a system that does work.

FUTURE SYSTEMS

The Department of Defense has chosen CHCS II as the

objective system to which all DoD medical systems

will migrate. The system has been under development

for a long time and promises much of what is required

in an objective tactical electronic medical record.

Unfortunately, the current, cumbersome acquisition

process is not responsive enough to keep pace with the

rapidly growing field of medical informatics and is in

large measure responsible for the delayed deployment

of CHCS II.7 Agility and responsiveness must be

incorporated into software development and

acquisition in order to leverage technical solutions for

end user requirements in a timely manner. Enterprise

solutions will be most effective when core applications

are shaped by local development that is iterative in

nature, and delivers timely results to end users. Those

solutions must be scalable for local, regional, and

service specific use, as well as applicability across the

entire military health system. CHCS II holds promise

to be a worldwide, web-based electronic medical

record data management system which meets the

requirements of providers, hospital administrators, and

tactical medical providers.

The Veterans Administration (VA) Computerized

Patient Record System is another enviable approach to

medical information management. The VA chose a

different path from DoD for their congressionally

mandated electronic medical record. They built on

their Veterans Health Information Systems and

Technology Architecture and created an integrated

web-based system for their medical providers which

has been used very effectively for several years now.8

Since the VA centrally manages and supports this

system throughout their structure of locations and

providers, they have made tremendous strides in

reacting to direct feedback from providers and

molding a system which literally makes patient

information available with the touch of a finger by the

provider who needs it. The option still exists for the

Army to adapt this superior system to our needs,

rapidly, and at a very modest price. This would of

course have the added advantage of improved

continuity of care for many patients who move among

the military, VA, and civilian healthcare systems.

Another option is the incorporation of free information

flow between systems, which is actively under

development in an ongoing DoD/VA project involving

the MAMC and the Puget Sound VA system.9

CONCLUSION

An ideal system is responsive to the needs of its

internal and external customers, with a focus on

patients and providers. A system may be able to

generate beautiful spreadsheets, but if it is not user

friendly, no amount of command influence will make

it successful. The system must share information

between planners, providers, logisticians, and

administrators. The system must provide health

providers access to the full spectrum of medical

information from any healthcare system. The key

requirement for a tactical electronic medical record is

the ability, at the point of care, to access a

comprehensive medical record and to document

observations, treatment, and care. Implementation of a

tactical electronic medical record will facilitate

improved care throughout a Soldier’s career and into

retirement care in any medical system. Use of the same

system in garrison and the field ensures ease of use,

continuity of care, and a force trained and equipped to

document care and retrieve documentation in all

situations and environments. One complex

omnifunctional system would, of course, be a major

improvement, but it may not be the ideal solution. A

modular concept of seamlessly integrated multiple

systems to meet the requirements could be preferable,

because of the innate flexibility and maintainability

such an approach offers. We are truly an Army in

transformation to meet the requirements of a nation at

war. As an integral part of that effort, Army Medicine

must make a transformation as well, and, as part of

that effort, take the lead in transforming military

medical information management.

REFERENCES

1. DoD Medical Readiness Strategic Plan, 1995–2001.

Washington, DC: US Dept of Defense, Office of the

Assistant Secretary of Defense for Health Affairs; 20

March 1995.

2. Curtin NP. Defense Health Care, DoD Needs to

Improve Force Health Protection and Surveillance

Processes. Washington, DC: US General Accounting

Office; October 16, 2003. Publication GAO-04-158-T.
64 Army Medical Department Journal

3. Hersh W. Health care information technology. JAMA.

2004;292(18):2273-2274.

4. Public Law 104-191 Health Insurance Portability and

Accountability Act of 1996. Aug 21, 1996: Available at:

http://aspe.hhs.gov/admnsimp/pl104191.htm.

5. Randell CL, Bero CN, Weidman L. Benefits of

worldwide government computer-based patient record

framework. J Health Care Infor Manage. 1998;12

(4):39-51.

6. Onley DS. Electronic medical records go into combat.

Govt Comput News [online]. Nov 22, 2004. Available

at: http://www.gcn.com/print/23_33/27923-1.html.

7. Riley DL. Business models for cost effective use of

health information technologies: lessons learned in

the CHCS II project. Stud Health Technol Inform.

2003;92:157-165.

8. Fletcher RD, Dayhoff RE, Wu CM, Graves A, Jones

RE. Computerized medical records in the Department

of Veterans Affairs. Cancer. 2001;91:1603-1606.

9. McKaughan J. Computer-based patient records. Mil

Med Tech [online] August 1, 2004;8(5): Available at:

http://www.military-medical-technology.com/

article.cfm?DocID=562.

AUTHORS

LTC Michaud is assigned to the AMEDD Center &

School, Fort Sam Houston, Texas. Previously, he was the

Civil Medical Affairs Director for Combined Joint Task

Force 76 in Afghanistan, and earlier was the Brigade

Surgeon for the 1st Battalion, 25th Infantry Division

Striker Brigade Combat Team.

CPT McClendon is assigned to the Madigan Army

Medical Center, Fort Lewis, Washington. Previously, he

was the Battalion Physician Assistant for the 1st Battalion,

5th Infantry in Iraq.

LTC Salzman is Chief of Informatics, Madigan Army

Medical Center, Fort Lewis, Washington. Previously he

was the Brigade Surgeon for the 3rd Battalion, 2nd

Infantry Division Striker Brigade Combat Team.

The Tactical Electronic Medical Record: The Key to Medical Transformation
October – December 2006 65

In 1999, congress mandated that the Department of

Defense (DoD) develop a computerized means to

collect, store, and tabulate medical data for all service

personnel into an electronic medical record (EMR).

Recent advances in computer technology have enabled

the DoD to create the EMR currently used in most

fixed facilities within the United States, commonly

called the Composite Health Care System II

(CHCS2).* Beginning in 2003, a similar version of

that military EMR, commonly referred to as CHCS2-T

(Theater), was introduced into the battlefields of

Operations Enduring Freedom and Iraqi Freedom.

Modern combat operations expose Soldiers to many

potential environmental health hazards, as well as the

possibility of weaponized chemical, biological, or

nuclear hazards. The effects of exposure during

combat operations may not be immediately apparent,

as evidenced by Agent Orange exposure during the

Vietnam War or the many complaints attributed to

Gulf War Syndrome. History has taught us that

comprehensive health surveillance is necessary to

mitigate the loss of combat effectiveness due to

nonbattle injuries or illness. Quality assurance studies

demonstrate that Soldiers who are treated in forward

locations utilizing handwritten records rarely have

their permanent records updated to reflect the care

rendered. The goal of CHCS2-T is to provide the

medical surveillance and monitoring needed by

commanders to evaluate their Force Health Protection

needs. The arrival of CHCS2-T on the battlefield

provides a comprehensive, historical, durable medical

record encompassing all medical encounters for each

warfighter.

The EMR fielded by the US Army was included in a

system called the Theater Medical Information

Program (TMIP). The TMIP is not a single system,

rather, it encompasses several computerized models

designed to create an EMR and transfer pertinent

medical treatment information from the point of injury

on the battlefield to the service member’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

paper outlines my unit’s experience (as a newly

deployed transformation-based sustainment brigade)

with the TMIP system integration during Operation

Iraq Freedom IV, 2005–2006. The 4 key components

of the TMIP system are discussed and feedback

regarding each component is presented.

Overall improvement of both Force Health Protection

and real-time health surveillance lies at the core of

TMIP development. Success of the Army’s EMR is

paramount to reaching the end state of a seamless,

durable electronic health record for each warfighter

that accurately captures, tabulates, and monitors

healthcare throughout a military career. TMIP is the

military’s answer to provide a fully computerized

medical health record for all service members that is

comprehensive and easily transferable from peacetime

to combat operations.

COMPONENTS OF THE THEATER MEDICAL

INFORMATION PROGRAM

The primary goal of TMIP is the capture of a service

member’s medical history in a useable database

format. When captured in a database, the medical

information can be analyzed to determine trends and

identify potential hazards for all personnel allowing

preemptive actions such as immunizations and

prophylaxis treatments. TMIP, when fully

implemented, integrates 4 core data systems from a

rewriteable data card worn on Soldier’s dog tags to a

mainframe computer server in order to capture and

store medical information. It is helpful when

discussing the various systems to link them to the

echelon of care for which each is used as shown in the

Table.

Implementation of the Theater Medical

Information Program During Operation

Iraqi Freedom IV

MAJ Mark L. Higdon, MC, USA

*Now known as AHLTA. See related article on page 40.
66 Army Medical Department Journal

As shown in the illustration, the various

computer systems of TMIP are designed to

seamlessly communicate with one another.

The basic system includes a rewriteable

electronic information carrier (EIC)—also

known as the personal information carrier—in

a durable card designed to be worn on the dog

tag chain of each Soldier. Personal historical

and administrative medical data is preloaded

onto the EIC and carried at all times. When a

Soldier is treated in either garrison or combat

operations, the EIC is scanned to load a

patient’s medical history and administrative

data into the processing system. The scanning

device commonly used to extract data from the

EIC is the medic’s handheld, wireless

computer known as the Battlefield Medical

Information System-Telemedicine (BMIS-T).

Scanning the EIC with the BMIS-T eliminates

the time spent entering administrative data for

each Soldier. The medic uses the BMIS-T

device to enter data during sick call visits and

to document information that would routinely

be entered onto a field medical card.

Data from the handhelds downloads to the next

TMIP step, a laptop computer system often

referred to as the Medical Care for Combat

Casualty Care (MC4) computer. This data transfer

most often occurs at the battalion aid station using the

HotSync©(Palm Inc, 950 West Maude Avenue,

Sunnyvale, CA) function common to most handhelds.

The MC4 computer then transmits medical

information to the Joint Patient Tracking Application

(JPTA) database across a standard NIPRNET

(nonsecure internet protocol router network)

connection. If possible, a local network of a unit’s

CHCS2-T MC4 computers is established within a

battalion aid station to allow information sharing. If

networking is not possible, information is simply

stored on the laptop or handheld until conditions allow

transfer of data to the JPTA database.

The JPTA is a web-based tracking and information

management tool that reports data on compiled JPTA

data can be accessed by anyone with a NIPRNET

Implementation of the Theater Medical Information Program During Operation Iraqi Freedom IV

Electronic

Information

Card (EIC)

BMIS-T

Handheld

Computer

MC4

CHCS2-T

Laptop

JPTA

Database

Permanent

Military

Record

Basic flow of a Soldier’s medical information through the various systems comprising the

Theater Medical Information Program.

The four core data handling systems of the Theater

Medical Information Program, the device involved for

each, and the echelon of medical care at which each

system is used.

TMIP System Data Processing

Device

Medical

Echelon

Electronic/Personal

Information Carrier

Dog tag card with

data chip Echelons 1, 2

Battlefield Medical

Information SystemTelemedicine

iPAQ Pocket PC* Echelons 1, 2

Medical Communications

for Combat Casualty

Care System

Laptop computer Echelons 1, 3

Joint Patient Tracking

Application

Centralized

servers

Echelon 4

*Product of the Hewlett-Packard Company

3000 Hanover Street, Palo Alto, CA
October – December 2006 67

account and an assigned password, allowing access for

treatment of Soldiers in forward operating areas.

Passwords for the JPTA database can be obtained via

an online registration form (normal 48-hour response

time following password request). Commanders,

physicians, and other healthcare providers can use the

JPTA data in the design and application of force health

protection measures. Ultimately, the medical data

captured by both BMIS-T and CHCS2-T is applied to

update the Soldier’s permanent medical record. This

capability eliminates the problem of lost records and

saves that time spent entering purely administrative

data onto multiple handwritten documents, with a

corresponding improvement in accuracy and reliability

of the data. The compiled data in JPTA enhances the

ability of field surgeons to track patients during the

casualty evacuation process and to review tabulations

of DNBI (disease, nonbattle injury) data to help

identify possible trends of illness or exposure. The

powerful JPTA database also improves response times

for command inquiries’ regarding the health status of

injured or evacuated warfighters.

TMIP captures all information related to a service

member’s healthcare and eventually inserts that data

into their permanent record. 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. Increasing use of the

system by all units will greatly enhance research

activities and development of preventive medicine

techniques. Army-wide implementation of the TMIP is

now planned for completion prior to 2007.

4TH SUSTAINMENT BRIGADE IMPLEMENTATION

OF TMIP DURING OPERATION IRAQI

FREEDOM IV

The 4th Sustainment Brigade deployed in support of

Operation Iraqi Freedom IV in September 2005. With

the exception of EICs, all major components of the

TMIP system were received prior to deployment.

Unfortunately, the lack of EICs prevented optimal use

of the handheld as a replacement for the field medical

card. All initial echelon 1 treatment notes (if

completed in forward locations) were handwritten

using the field medical card. A big challenge for the

BMIS-T is its inability to wirelessly transmit data to

the laptop (MC4) computers due to the nonsecure

nature of the Bluetooth®(Bluetooth SIG, Inc, 500

108th Avenue NE, Suite 250, Bellevue, WA)

technology. Currently, data transfer from the handheld

to other TMIP systems requires a cable connection

using HotSync. At echelon 1, most medics did not

fully use the features available with BMIS-T; most

simply used their handhelds to follow treatment

algorithms during sick call. A secure, wireless

Bluetooth capability is required before medics can use

BMIS-T as a universal replacement for the standard

field medical card.

Basically the MC4 computers functioned as designed,

albeit painfully slow due to limited memory. The

Alternate Input Method (AIM) forms capability, fully

available in the CHCS2 software used in the United

States, is not included in the CHCS2-T software. AIM

forms provide a familiar format for entering medical

notes that is similar to the traditional paper chart. The

template-based entry method used by the CHCS2-T

software is difficult to learn and time consuming to

use. AIM forms help standardize treatment for

common illnesses, allowing more rapid

documentation. Given the inherent training difficulties

that accompany fielding a new product, we

recommend that future upgrades of the CHCS2-T

software include the AIM form capability, as soon a

possible. Also, increased internal memory for each

laptop (MC4) computer will improve processing

speeds. Open expansion slots are available on each

laptop currently in use.

Although also an extremely slow process, transfer of

medical data from the MC4 laptops to the JPTA

database presented no other problems. It took several

hours for a completed note to appear on the JPTA

website, but the information was accurate and

complete. Most often, the delay in updating a note to

the JPTA server (>3 hours) resulted in the field

surgeons calling various medical facilities to obtain

real-time casualty information.

RECOMMENDATIONS

1. The capability to organize casualty data for each

unit on the JPTA site, including a summary

screen presenting a snapshot of information

concerning the status of Soldiers for

commanders, would greatly enhance the system.

The summary screen should be customizable for

each unit.
68 Army Medical Department Journal

2. A virtual private network* (VPN) could increase

the depth of review available with JPTA.

Currently JPTA data is limited to the theater of

operations. By using a VPN, home station

medical databases could be accessed, providing

important medical information, such as medical

profile information and historical radiologic

studies, to forward stations.

3. A medical readiness module to track medical

profiles in both garrison and combat

environments would eliminate the need for

Soldiers to possess a copy of their profile.

Additionally, field surgeons and commanders

could more accurately track and review medical

profiles as the data would instantly be available

to anyone having NIPRNET access to the JPTA.

4. TMIP technical support was available to the 4th

Sustainment Brigade’s location on Forward

Operating Base Taji, but it usually took several

days for the technician to arrive and troubleshoot

networking problems. Success of any new

system is directly related to full functionality.

Several of the delays experienced with TMIP

could have been eliminated with increased

availability of technical support.

CONCLUSION

Full integration of the TMIP system is critical for the

continued successes Army medicine has experienced

in the decrease of combat mortality. Expeditious

fielding of complete TMIP systems and continued

software enhancements are necessary to meet the

requirements in support of the modern Soldier, before,

during, and after deployment. The ability to compile

accurate medical data quickly and efficiently is

necessary for all commanders to maximize combat

effectiveness. The 4th Sustainment Brigade’s medics

and healthcare providers quickly became reliant upon

the data management provided by the electronic health

record (CHCS2-T). Overall, TMIP is an outstanding

concept that will eliminate the previous inconsistency

and fragmented data common with handwritten

records. Continued efforts should be focused on

seamless integration of both inpatient and outpatient

data into and within the TMIP system. Army-wide

implementation of the electronic health record both in

the garrison environment and during combat

operations offers the mobility necessary to

substantially enhance force health protection. The

electronic health record is vital to the commanders’

full medical situational awareness and offers a myriad

of reporting and tracking capabilities concerning

health surveillance. The 1999 congressional mandate

was only the impetus and the beginning. Continued

refinement of the durable electronic health record and

TMIP is essential to the support of today’s warfighters.

AUTHOR

MAJ Higdon is currently assigned to the Department of

Family and Community Medicine at Martin Army

Community Hospital, Fort Benning, GA. At the time this

article was written, he was the Brigade Surgeon for the

4th Sustainment Brigade, deployed to IRAQ in support of

OIF 05-07.

*A virtual private network (VPN) is a private network that uses a public network (usually the internet) to connect remote

sites (local networks) or users together. Instead of using a dedicated, real world connection such as a direct cable or leased

line, a VPN uses virtual connections routed through the internet among the various isolated local networks and further

into central servers. A VPN involves parts: the protected or "inside" network that provides physical security and

administrative security sufficient to protect transmission, and a less trustworthy or "outside" network or segment (eg,

internet). Secure VPNs use cryptographic tunneling protocols to provide the necessary confidentiality, sender

authentication, and message integrity to achieve the security required. When properly chosen, implemented, and used,

such techniques can provide secure communications over unsecured networks.

Implementation of the Theater Medical Information Program During Operation Iraqi Freedom IV
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