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The ability of military health systems applications to coordinate combat casualty care.

On February 23, 2007, Former Secretary of Defense Robert Gates said, "Our nation is truly blessed that so many talented and patriotic young people have stepped forward to serve. They deserve the very best facilities and care to recuperate from their injuries and ample assistance to navigate the next step in their lives, and that is what we intend to give them. Apart from the war itself, this department and I have no higher priority" (p. e 1). Veterans and active duty Armed Forces personnel operate in a complex continuum that often requires being in harm's way to perform their duties. In doing so, their injuries encountered can be complex. Caring for those with mere common injuries, such as injuries to the extremities (30% to 39.6%), is difficult; caring for those with less common injuries, such as genitourinary (0.5% to 8%), takes on an added level of complexity (Fisher, 2009). A complete picture of the injury can only be gained by visualizing their entire record of care. Traditionally, members of the health care team have not been able to link the episodes of care together seamlessly, preventing the ability to see the entire picture. The electronic health record enables better continuity of care and enhances quality (Menachemi 2008). The availability of a system to document health care provided in austere environments and connect these data with care provided in tertiary military medical care centers using records available throughout the Veterans Health Administration (VHA) will enhance the care provided. Members of the Department of Defense, the VHA, and private sector organizations are collaborating to provide world-class seamless health care. Although the end goal of a completely integrated record has not been reached, the advent of several recent initiatives has placed military health care firmly on the track to reach those goals.

Key Words: Military health system, information systems, electronic health record, veterans health, clinical data repository, nursing informatics.


Members of the U.S. military are a nomadic population that travels the globe in the performance of duty. These individuals are routinely transferred every few years, which challenges the health care recordkeeping system. Military members may be deployed to combat zones or to far away areas to support humanitarian missions, creating unique challenges for recordkeeping. Once the veteran transitions out of active duty, the ability to transfer and combine all these records into the Veterans Health Administration (VHA) system is complicated. Knowledge and documentation of service-connected injuries and illness are necessary to promote overall health.

Assembling a complete picture of the health care provided becomes even more critical when the injury is unique (Waxman, Beekley, Morey, & Soderdahlk, 2009). Knowing what treatment(s) is/are provided to an injury or illness to the genitourinary system received in a combat zone can indicate prevalence of injury patterns and injury severity, and predict morbidity and mortality (Paquette, 2007).

With the introduction of a worldwide health record relying on a single central data repository, the Military Health System has enabled the ability to digitize health records and tie disparate episodes of care together (Bouhaddou et al., 2008). The VHA now has the ability to document health care available throughout this system at the time of completion (Brown, Lincoln, Green, & Kolodner, 2003). Those two garrison systems are still not seamlessly connected. To overcome this, the VHA and the Department of Defense (DoD) have created a sharing system that provides the ability to cross boundaries and view the medical record for the purposes of comparison, thus creating a complete picture of the health care status of any individual member of the Armed Services (Bouhaddou et al., 2008).

Traditionally, capturing the record of health care in the deployed military medical environment was a manual process that required the health care team to document and pass information on an injured service member from one level of care to the next (see Figure 1). Although work was ongoing to build an electronic health record (EHR) for service members and veterans, it was not until 1997 that there was a specific mandate to build a complementary system to deployed military members. In 1997, Title 10 United States Code established an objective for DoD personnel that required all members to have records created by a medical tracking system. The Title 10 mandate catalyzed the move to introduce a system for service members while at their home station. An extension of that proclamation provides for the deployment of tools in operational areas for the purposes of capturing health care data.

Over the past 20 years, several technological advances have enabled the introduction of innovative tools that facilitate capturing the nuances of care at the initial point of care and in transit (Baer et al., 2009). In addition to capturing the health care record and promoting its completion, introduction of resourceful tools has further allowed the capture of data for analysis and to evaluate the effectiveness of care and promulgate best practices (Eastridge et al., 2009). What originally began as registries and rudimentary data collection has become a sophisticated system of interconnected solutions that permit capturing data from injury or illness onset to the transition to tertiary care (Glenn et al., 2008). In an ideal world, process of documentation should be easy, well understood, and provide the ability to follow the patient through the stages of care.

Episodes of Care

For the purposes of this article and in keeping with a focus on the innovation occurring in battlefield health care, there is a strong emphasis on the translation and documentation of health care and how it complements the health care record for the veteran. Further, there is an acute focus on wounded or ill service members deployed in the combat zone. The components of battlefield health care are predicted by location of the injury of the illness on the battlefield. Generally, five episodes are universally understood by all service components, and they lead to an eventual transition to care by the VHA. The capability of military health system personnel to record care increases as the service member progresses through the system.

The first formal episode of care revolves around casualty evacuation. This occurs after the service member is wounded or becomes ill. All service components and members of the international military community use a standardized process to call for evacuation. In the U.S. military, the call for support has been traditionally referred to as a Nineline medical evacuation request. This request includes location of pick-up site, the number of patients by precedence, and some military-specific information designed to give the evacuation personnel an understanding of the situation at the site (for example, radio frequency, site security, method of site marking). Evacuation can occur by ground or air, and is largely determined by the nature of the injury or illness. The end point of the evacuation is also dictated by the severity and capability at different locations. Capability is largely divided into locations that either do or do not have resuscitative surgical assets and whether there is a need for surgical sub-specialization (such as neurosurgery). Documentation and recording care at the point of injury or illness is captured using a mobile device or laptop computer. When communication becomes available, it is transmitted to a central database capable of being viewed by other members of the health care team who will care for the service member as he or she is evacuated.

Battlefield surgery is often referred to as resuscitative surgery or damage control surgery. The far forward surgical elements operate in austere environments with less equipment and less technically advanced tools than would normally be available in trauma resuscitation surgical centers in the U.S. Surgical elements on the battlefield are classified as forward surgical teams (Army--Forward Surgical Teams, Navy--Forward Resuscitative Surgical Systems/Shock Trauma Platoons, Air Force EMEDS/Expeditionary Medical Support) or combat surgical hospitals (Air Force--Theater Hospital, Navy--Fleet Hospitals, Army--Combat Support Hospitals). Forward surgical teams are small teams capable of moving close to the point of injury. Due to their agility, they offer much less capability based on lack of supply and equipment. Combat surgical hospitals offer more capability with an increased number of clinicians but are not capable of making multiple moves on the battlefield to accommodate shifts in the military operation. They are co-located near runways and aerial ports of debarkation. At these hospitals, the clinician's ability to document health care increases based on the number of systems and connectivity offered.

After the service member is stabilized by damage control surgery or initial treatment, he or she is programmed for movement to a tertiary care fixed facility via medical evacuation. The medical evacuation mission employs fixed wing aviation platforms capable of traveling thousands of miles to deliver wounded or ill personnel to hospitals outside of the combat zone. During transport, the staff will document health care using mobile systems capable of storing and forwarding information upon landing and delivery of the patient. The sophistication of the systems employed at this level may be somewhat less than those on the ground at combat surgical hospitals but allow for a continuous record of care.

Injured or ill service members are then transported to tertiary care fixed facilities either at military installations and hospitals abroad or within the continental U.S. These hospitals offer a full range of definitive care and are largely tasked with finishing what may have begun in the combat theater. In order for staff at the tertiary care hospitals to effectively understand what has been done so far, they rely on the information captured from casualty evacuation, initial treatment, and medical evacuation. They incorporate documentation from prior episodes into their care and record information in the garrison EHR. At this stage, a formal divide exists in theater and garrison systems. Definitive care can occur not only at DoD hospitals but also at VHA polytranma hospitals. If the care of the service member is transferred from DoD to VHA, this again precipitates crossing an additional digital boundary facilitated by data-sharing tools required to round out the picture of care.

Conflict and Recording Information About Injuries Sustained and Care Received

Before Operations Enduring and Iraqi Freedom, all military-provided health care was manually recorded and labor intensive (Wilcox & Pugh, 1990). This contributed to the information very seldom being included in the patient's permanent health record, which was evident and became a focal point during determination of the extent of Gulf War Syndromes (Institute of Medicine [IOM], 1996). Continuity of care suffered because no systems were capable of capturing data and records of service members treated in Operation Desert Storm and Desert Shield, and thus, their data could not be fully incorporated into their permanent records.

At the outset of Operation Enduring Freedom several forward-thinking military medical leaders implemented the predecessor to the current suite of systems in the form of a registry (Glenn et al., 2008). Those military medical leaders applied the lessons learned after the implementation of trauma registries in the U.S., and began to build and deploy the Joint Theater Trauma Registry (JTTR). JTTR was sponsored by the U.S. Army Institute of Surgical Research and has subsumed all other efforts to capture data from theater operations. JTTR data were initially extracted from paper documentation. Now, after several iterations and further development, these data are extracted during the process of documentation and captured in such a way that it complements the process and provides very valuable data sets, enabling the adept implantation of the Joint Theater Trauma System (JTTS). The JTTS is an overarching system of care, including a clinical information management scheme, which provides for continuous improvements to trauma care at all levels.

Information Systems

The DoD currently facilitates program management by resourcing program offices. They are tasked with building and delivering health information technology capable of creating health record continuity. Defense Health Information Management Systems (DHIMS) and Medical Communications for Combat Casualty Care (MC4) build, buy, deploy, train, and support the current portfolio of tools both in the combat theater as well as in fixed or garrison locations; this enables the DoD to capture health information and merge those data with care provided by the VHA for the complete picture.

These offices are jointly staffed by health care, information management, acquisition, contract, and program management professionals. The scope of their responsibility is immense. They serve components of the DoD EHR to 120,000 end users that support 10 million beneficiaries (DHIMS, 2012). They communicate with VHA staff and also ensure the effective connection of DoD records with veterans' records through the deployment of bi-directional viewers. Staff on either side of the DoD or VHA can see the information on the opposite side.

Theater Systems

The systems used by the DoD start with technology at the lowest level. The DoD employs hand-held technology designed to be the first responder's EHR. Armed Forces Health Longitudinal Technology Application (AHLTA-Mobile) captures information at the point of care. It is designed to store and forward information to the other applications and data sources at higher echelons of care. Data captured at this level are incorporated into the patient's record and are immediately available in data sources that provide commanders with medical situational awareness. It becomes the digital gateway for the remainder of the service member's record of care.

Beyond point-of-care documentation tools, clinicians in austere locations use AHLTA-Theater (AHLTA-T), which is designed so the user interface mimics EHRs the clinician uses while at home station. AHLTA-T is the primary documentation modality at the first levels of care with resuscitative capability (such as Forward Surgical Teams, Combat Support Hospitals). Because network connectivity at this level can be tenuous, AHLTA-T is designed to store and forward information when a connection becomes available. It is primarily used with an outpatient focus, whereas the Theater Medical Information Program Composite Healthcare System Cache 2 (TC2) is used to record inpatient care. When an Armed Forces service member remains at a location after resuscitative surgery awaiting transport to the next higher level of care, clinicians will use TC2, which enables computerized provider order entry (CPOE) with laboratory, pharmacy, and radiology ordering. This system is also capable of storing and forwarding information in a case where connection is not immediately available. All components of the system listed above also include maritime modules, providing a documentation suite for shipboard health care.

Garrison Systems

In garrison, clinical users primarily use a suite of three applications to record health care (AHLTA, Composite Health Care System [CHCS], Essentris). AHLTA and CHCS are used in the outpatient setting, and Essentris is used in the inpatient setting. Each application allows the user to document health care, and data flow to a central database the clinical data repository (CDR).

AHLTA and CHCS both allow for clinical documentation and laboratory, pharmacy, and radiology CPOE. Both rely on data that are kept locally and from the CDR to provide a comprehensive picture of a service member's health care. AHLTA is the clinician end user. User interface serves as the primary documentation tool. CHCS is based on interfaces developed with laboratory instrumentation, pharmacy systems, and radiology information systems to serve as the backbone of the CPOE capability in DoD-fixed facilities. Both extensively use templates to provide for structured documentation, which allows the user to take advantage of standard content enabling the introduction of the most current clinical practice guidelines. These systems incorporate the entire spectrum of health care by facilitating data capture for pre-deployment and post-deployment health screening, as well as routine outpatient care when service members are not deployed. Both systems, while primarily focused on capturing the health information of service members, also serve as the documentation system for family members, including several tools that capture pediatric and obstetric care.

Data Sources

Each application and system listed in the previous sections feed data to centralized data repositories that both enable worldwide data availability and a significant source of data for analysis and clinical decision support. On the garrison side, the CDR provides a large cache of data available for analysis and to complete the health care picture. The CDR contains the health information of nearly 10 million DoD beneficiaries and is the largest health care database in the world. The CDR enables information dissemination around the globe almost instantaneously. On the DoD side, the CDR has a complement on the VHA side named the Health Data Repository (HDR). Together, data are represented via the Central Data Repository/Health Data Repository (CDHR), which is an exchange of both DoD and VHA data. This combination of data provides for data integration and interoperability through a variety of techniques. If a service member's health data are updated and recorded on the CDR, the information becomes available in the combination of the two data sources--CHDR--enabling for better clinical decision making on the VHA side.

Information captured in the pre-hospital setting or in the field hospitals by AHLTA-Mobile, AHLTA-T, or TC2 feeds the Theater Medical Data Store (TMDS) and JTTR. TMDS represents all data captured in theater, whereas JTTR is specifically designed to serve the interest of the JTTS. Both systems capture all theater data and provide a Web-based viewing application where clinicians and administrators can see data from across disparate sources in a consolidated manner. For instance, while the U.S. maintained military operations in both Iraq and Afghanistan, clinicians at the point of care would enter data using AHLTA-Mobile or AHLTA-T, and after a certain period of time, that information was available for review using TMDS or JTTR. These data were available worldwide and could be viewed by clinicians in hospitals in Germany and the continental U.S. All data represented in TMDS or JTTR are eventually forwarded to CDR.

Case Study

The following, fictitious case study describes the system from the battlefield to a VHA hospital.

On the morning of July 24, 2012, a Marine lance corporal, while conducting dismounted patrol with Fox Company of 2/3 Infantry, steps on an improvised explosive device (IED). He is thrown several feet, and it is immediately apparent that he has serious injuries. A Navy corpsman responds when he knows the situation is safe. He administers First Aid and informs leadership of that company about the lance corporal needs immediate evacuation. The lance corporal has suffered a partial amputation of the right lower leg and penetrating injuries to the perineum. While the company awaits air evacuation by U.S. Army Air Ambulance, the Navy corpsman documents the care he gave using his AHLTA-Mobile hand-held device.

Army Dustoff arrives, and the Navy corpsman and the Army flight medic exchange information about the patient's current condition. The flight medic assumes care, and the patient is loaded and transported to an Army Forward Surgical Team (FST). While en route, the flight medic performs an assessment and several interventions. Upon arrival to the FST, the trauma team assumes care, performs trauma resuscitation, and prepares the lance corporal for immediate surgery. The flight medic documents the patient's care using AHLTA-T at the FST using a structured template. During the entire course of the lance corporal's stay at the FST, health care providers document his condition and care using AHLTA-T. The leg injury is debrided and washed out. The lance corporal has also suffered a penetrating injury to the external genitalia. Scrotal exploration and repair of a testicular injury were performed, and the testes were salvaged. The patient is stable and recovered by the FST.

Evacuation to the next higher level of care is arranged, and an Air Force Critical Care Air Transport Team (CCATT) arrives and assumes care of the patient. The CCATT prepares the patient for transport to Landstuhl, Germany, and takes off. While en route, the CCATT documents the care performed and the several assessments made using AHLTA-T. During the patient's entire course in theater, clinicians at Landstuhl receive updated clinical information via TMDS and align the appropriate resources in anticipation of the patient's arrival.

The patient arrives and is transferred from the CCATT to the critical care team of the ICU at Landstuhl Regional Medical Center and the urologic surgeon. The surgeon arranges review of the patient's course via TMDS information and matches that with his assessment. The patient is treated, and the information is documented in AHLTA, CHCS, and Essentris. As the information is captured, it is written to the CDR. The patient is stabilized, and his leg and scrotal injury are treated accordingly. Arrangements are made to transfer the patient to the continental U.S. Another CCATT arrives and transports the patient to a team at the Walter Reed National Military Medical Center in Bethesda, Maryland. While the CCATT team is transporting the patient across the Atlantic, the team at Walter Reed National Military Medical Center is reviewing the patient's information using TMDS and information captured at Landstuhl Regional Medical Center in garrison systems available by the CDR.

The patient arrives and is treated. His care is documented again using the garrison systems, AHLTA, CHCS, and Essentris. With each new note written and saved, more information becomes available in both CDR and CHDR. The patient's injuries are treated by an orthopedic and urology team at Walter Reed National Military Medical Center. They communicate with counterparts on the VHA side by completing documentation that will be available to the VHA polytrauma center in Minneapolis, Minnesota. The patient's course is unremarkable, and he is healing well. He is transferred to Minnesota, where his care is assumed by the team of experts. All clinicians at the VHA polytrauma center are able to review records dating back to the very piece of information saved by the Navy corpsman who served as the first responder when the Marine was injured. The patient's record is comprehensive and allows his health care team to see the nuances of each step in the process. The patient makes a full recovery without undue sequel.


Military health care is provided through multiple episodic encounters across a vast continuum of teams and organizations, and is designed to facilitate the effective care of service members after injury or illness. Care starts on the battlefield and moves through stages of evacuation, resuscitative surgery, and movement to definitive levels of care. All care on the DoD side complements eventual transition to the VHA.

In order to capture the health care provided to service members, a sophisticated system of electronic tools is required. These tools are all designed to complement the level of care where they are used, and they feed data to CDRs that enable worldwide visibility. The systems are largely divided into theater or deployed systems and garrison or fixed-facility systems. All systems enable clinical documentation and CPOE, and facilitate a coordinated approach to health care.

Because the nature of specialized urologic care is complex, clinicians need information systems that allow for better care. Better care can be delivered when the team has a thorough picture of the entire course of a patient's injury or illness. In addition to providing better care based on better documentation, when the documentation produces structured data, it facilitates performance improvement. Service members have reaped the rewards of performance improvement initiatives carried through to fruition. With a better understanding of wounding patterns through data captured in the health care process, the DoD has been able to field specific protective technologies to reduce the incidence of urologic injury (Paquette, 2007; Waxman et al., 2009).

Much of what has been discussed in this article reflects the experience of the DoD and the current state of the system. Due to the sheer number of systems, as well as solution and disparate data sources, there is significant room for improvement. The Military Health System is currently involved in building a consolidated EHR for both the VHA and the DoD. The integrated electronic health record (iEHR) will replace legacy systems, and provide a consistent look and feel across several planes, including an emphasis on consistency between garrison and deployed environments.


Care of the military service member is complex and requires an integrated system of tools capable of capturing and effectively communicating health care. When members of our Armed Forces suffer complex urologic injuries in the performance of their duties, it requires skilled clinicians who will take care of this highly specialized injury to visualize their entire course from blast to recovery. The systems and solutions that the DoD and VHA use enable clinicians to connect the dots and provide better care and focus on enhanced outcomes. The interrelated system that allows this health care process to occur and the eventual move to the iEHR demonstrate a clear commitment by the DoD, VHA, and private sector team for the greater good of military members.

doi: 10.7257/1053-816X.2013.33.2.73


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Benjamin Eli Seeley, MSN, RN, CPHIMS, CEN, is a Major, United States Army, and a Chief Nursing Information Officer and Chief of Clinical Systems Support, Walter Reed National Military Medical Center, Bethesda, MD.
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Title Annotation:General Clinical Practice
Author:Seeley, Benjamin Eli
Publication:Urologic Nursing
Article Type:Report
Geographic Code:1USA
Date:Mar 1, 2013
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