One patient, one record

PROJECT at a glance

Who: The Defense Department Military Health System, Clinical Information Technology Program Office.

Mission: To support a mobile population of more than 9 million beneficiaries worldwide with electronic health records.

What was: The original Composite Health Care System (CHCS) was a customized application built in the 1980s.

What is: CHCS II takes a 'one patient, one record' approach that creates an electronic health care record that authorized users can access from anywhere. Its data repository currently contains more than 4.7 million completed patient encounters and clinical data on 6.2 million patients.

Users: When fully deployed, CHCS II will be used by more than 30,000 providers at 139 major military treatment facilities. As of last month, CHCS was deployed to six military treatment facilities. In the past year, more than 18,000 health care professionals across the Defense Department took training on the system.

Impact: The program makes electronic health records accessible at any time and from anywhere. Records effectively travel with a patient from, for instance, Iraq to a facility in Europe to a military hospital back home.

Duration: After several years in the works, the program began rolling out in January 2004. Officials expect full deployment by the end of next year.

Cost: About $1.3 billion over eight years.

Katrina gives system a pop quiz

Keesler Air Force Base in Biloxi, Miss., like New Orleans, was hit hard by Hurrican Katrina.

Keesler's industrial and housing sections were damaged, as was its hospital, and more than 50 patients were evacuated to Lackland Air Force Base in San Antonio. Other personnel went to other bases in the southeast.
The evacuation created a medical crisis that proved to be an early test of CHCS II. Twenty-five inpatients and 31 pregnant women and their families were driven to C-17 transport planes, according to the Air Force, and flown to Lackland along with three critical-care teams and an obstetrics team.

CITPO worked with medical staff at Wilford Hall Medical Center, Lackland's hospital and the largest in the Air Force, to set up the emergency response team.

Air Force Col. June Carraher, an M.D., said that while Keesler patient data had already been 'pulled' into the new repository, the base's health care providers were not fully trained to use it.

'They had CHCS II, but they were only two-thirds of the way through training,' she said. One of the IT contractors called in to help, Science Applications International Corp. of San Diego, set up secure, read-only Web access to patient accounts.

'Within a matter of literally a couple of hours, the hospital staff at Lackland were able to get the critical patient data,' Carraher said.

Air Force Col. June Carraher, Army Col. Victor Eilenfield, Navy Capt. Heidi Moos

Zaid Hamid

Clinical information team pursues e-records system in a big way

When the Defense Department decided to upgrade its computerized Military Health System, it opted for more than just replacing an awkward legacy system that had fallen behind the times. In a massive, multiyear, multinational undertaking, it is building what proponents say could be the largest medical information system in the world.

The Composite Health Care System II debuted in January 2004 with a rollout to seven U.S. facilities. By mid-September of this year, it was running at 66 facilities, according to Army Col. Victor Eilenfield, program manager at the Clinical Information Technology Program Office in Falls Church, Va.

When fully deployed, CHCS II will cover more than 9.2 million military beneficiaries, including families and retirees, and be used by more than 60,000 providers at 139 major military treatment facilities, according to CITPO.

CHCS II could be a model for electronic patient systems in an industry that has been notoriously resistant to new technology. CITPO has given demonstrations to private-sector companies.

The new system replaces CHCS, a custom application installed in the late 1980s. 'We had a common system, but what we didn't have was a common vocabulary,' Eilenfield recalled. So CHCS II developers had to normalize data across host computers, which Eilenfield believes is unusual in electronic medical systems. For example, 11 definitions for cholesterol were pared down to one.

The new electronic health records in CHCS II give providers most of a patient's medical history at their fingertips. The improved timeliness and accuracy of information is already improving patient health, said Air Force Col. June Carraher, a doctor and CHCS II user.

Carraher saw a patient at Langley Air Force Base in Hampton, Va., who complained about facial numbness. Unable to identify an organic cause, she was ready to write the symptoms off to anxiety. Then, in CHCS II, she found a reference to a visit to a Portsmouth, Va., Navy hospital'since forgotten by the patient'in which she had complained of vision problems.

Carraher was able to trace the cause to a dangerous tumor.

'In a paper-based medical-chart world, that chart would have been at Portsmouth,' Eilenfield said. Carraher added that while she had the patient's chart, it did not have all the recent information in it.

'I would have missed this without CHCS II,' she said. 'Without my ability to get that information at that point in time, the patient would have missed a follow-up visit, and she might have had a poor outcome.'

CHCS II is the offspring of several high-profile parents. The Chantilly, Va.-based Integic division of defense contractor Northrop Grumman Corp. was the prime system integrator and developer. Oracle Corp. supplied the database, while Hewlett-Packard Co.'s Superdome Unix servers are key components in the high-speed distributed network.

Many challenges

CHCS II presented a daunting data-consolidation effort. 'We have 100 silos of information,' Eilenfield said. But it posed other challenges, as well. Recent privacy and security laws had to be accommodated, for instance. It helped that developers knew much about the requirements of the Health Insurance Portability and Privacy Act of 1996 at the start, and that DOD was already familiar with IT security, said Larry Albert, senior vice president and health care practice leader at Integic.

Things looked dicey for CHCS II in the spring of 2004, when complaints about slow performance jeopardized the project. New installations were suspended or delayed.

'We literally deployed a 'war room' and had all these technical experts sitting around a big table,' Eilenfield said. 'We literally had a [network] hub sitting in the middle of the table, and they had all their laptops connected to it. It was like Medusa's nest.'

Eilenfield said the eventual causes were 'too many to enumerate.' But Albert said the main culprit was a Brocade fiber-optic switch that sits between the mainframe computer and a storage-area network at the system's primary data center. (A duplicate data center provides redundancy and backup in case of a failure.)

'As the usage started ramping up, the system became I/O bound,' creating bottlenecks, Albert said. The crisis 'was beyond painful,' he said.

Like nearly every project team ever charged with automating medical systems, CITPO encountered resistance from doctors, nurses and other providers used to working a certain way.
Eilenfield said such users probably felt CHCS II put a 'framework' around them.

'It's a big business-process change for them,' he said.

Albert agreed. 'These are not a tolerant group of users,' he said. 'They've got a waiting room full of patients, so the system has to really respond.'

Carraher, who did not use a computer until after medical school, said providers with previous experience on Microsoft Windows had an easier time adjusting. Others have legitimate con- cerns that CHCS II essentially introduces a third party to the traditional provider-patient interaction.

'It can be very off-putting to a patient,' Carraher said. 'It can create the impression that the provider is interacting with the computer rather than the patient.' Carraher compensates creatively: 'I tend to introduce my computer as Sally,' she said.

Ultimately, the greatest benefit of CHCS II's centralized data and broadly distributed access could be in removing barriers of time and distance, making location nearly irrelevant. With a 20 percent to 30 percent average turnover rate of active military personnel at each location, it's essential for information to follow people as they move.

'It's patient-centric,' not facilities-centric like most systems, Albert said. 'DOD recognized that they had over 100 hospitals around the world, with an amazingly mobile workforce. I have probably in excess of 6 million lives represented in that repository, with probably over 25 months of clinical data for each.'

Carraher cited the example of a soldier, injured in Iraq, who is first treated at a casualty recovery center at Baghdad International Airport, then transported to Germany and on to the states. With CHCS II, the soldier's latest electronic health record will be available to providers at every stop. 'The power of that is just ab-solutely awesome,' she said.

David Essex is a freelance writer in Antrim, N.H.

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