By Bob Brewin
June 27, 2007Two Defense Department medical agencies have attempted to stall the deployment of a popular Internet-based health records system in favor of pursuing their own systems costing hundreds of times as much, according to congressional sources and documents furnished to Government Executive.
Defense's Military Health System and the Army Medical Department have tried to keep Army clinicians in Iraq and health officials at the Veterans Affairs Department in the United States from using the Joint Patient Tracking Application system and the Web-based Veterans Tracking Application system. The two systems provide doctors and other clinicians with real-time access to a soldiers' electronic health records, from the moment a clinician at a combat hospital enters health information on a wounded soldier until the soldier is released from care in the United States.
No such combination of systems existed before, which was one of the primary reasons the Army was criticized this year for the poor medical care it provided soldiers at Army hospitals. The most prominent case involved failures at Walter Reed Army Medical Center, where lost documents left soldiers waiting for weeks to receive medical attention.
In an effort to stop the deployment of the patient-tracking systems at other VA hospitals and clinics and in Iraq, officials at MHS and AMEDD have transferred the systems' primary developer and supporter, Lt. Col. Mike Fravell, to another job. Fravell developed the patient-tracking system in 2003 when he was chief information officer at the Landstuhl Regional Army Medical Center in Germany, and created a Web-based version this past year, when he was on a fellowship at VA.
MHS officials transferred Fravell this month from his VA post in to the agency's headquarters just outside Washington, which a congressional source called "bureaucratic Siberia."
The transfer was in retaliation for Fravell's public criticism of the two Defense health agencies, the congressional source said. At a hearing in May of the House Veteran Affairs Committee, Fravell spoke highly of the two patient-tracking systems he developed and criticized MHS' reluctance to work with VA on the two systems. "I think on the DoD side, things are very territorial," Fravell told the committee.
The transfer occurred despite widespread praise for Fravell's systems. Army Chief of Staff George Casey said this month they provided the Army with "improved visibility on location, medical status and progress of soldiers' care." David Gorman, executive director of Disabled American Veterans, said, "The ability to transfer electronic medical information between DoD and the VA is critical to providing the highest quality health care to the men and women who have been wounded in combat or otherwise require medical care after serving in the military."
Still, MHS and AMEDD recently ordered clinicians in Iraq to use only standard Defense electronic health records systems, including the Theater Medical Information Management Program, software fielded by the Army's Medical Communications for Combat Care program office, and battlefield versions of the Armed Forces Health Longitudinal Technology Application, a Defense electronic health records system, according to congressional sources.
At stake are billions of dollars. Through fiscal 2006, AHLTA alone cost Defense $775 million to develop and deploy. The system's fiscal 2007 budget is $392 million. By comparison, the Joint Patient Tracking Application system cost less than $1 million to develop and $2 million a year to maintain.
In addition, the Web-based patient-tracking systems are more useful to doctors, according to a paper prepared by a team of combat clinicians serving in Iraq. The system "is the only record that has visibility throughout the evacuation chain," according to the paper. "It is easy to access anywhere that we have Internet, it is easy to enter key progress [notes, X-rays, lab and operation] report data in a quick read stream that answers most coordination of care issues at a glance."
Field surgeons in Iraq said of the MHS systems, "It is time to say, 'The emperor has no clothes.' These systems do not answer … the critical issues [that there is] no easy way to capture vital trauma data, [and they] lack real-time visibility of clinical data across the evacuation spectrum and to command and control medical elements."
Before the transfer, VA had petitioned MHS and AMEDD to extend Fravell's fellowship at the agency for another year, congressional sources said. But the Defense health agencies had started the process to transfer Fravell to South Korea. They abruptly stopped June 15 after Reps. Bob Filner, D-Calif., and Steve Buyer, R-Ind., respectively the chairman and ranking member of the House Committee on Veterans Affairs, wrote a letter dated June 1 to Pete Geren, acting secretary of the Army. The letter highlighted the importance of Fravell's systems to the Defense and VA missions to provide "the highest quality health care to active-duty service members who have been wounded in combat."
Filner and Buyer also wrote in the letter that they understood Fravell had been ordered to South Korea and added, "Given the critical importance to our wounded service members of the work Fravell has been doing, we believe that Fravell is needed here in Washington."
Army Medical Department spokeswoman Cynthia Vaughn declined to answer questions about Fravell's current assignment, saying the command does not address personnel issues. Military Health Systems officials have not replied to a query on Fravell's status filed more than a week ago.
Robert Foster, acting CIO at MHS, said his command has "no issues with the use of [the Joint Patient Tracking Application] and it is a viable alternative" as an interim electronic health record until his agency can field its own systems to Iraq. Foster added that MHS has heard the message from battlefield users on the merits of the system and the flaws of other health record systems "loud and clear," and is working to satisfy their concerns.
While the Armed Forces Health Longitudinal Technology Application currently captures only outpatient information, Foster said MHS is working to deploy in Iraq later this summer a version of that health system that will capture battlefield inpatient information in what is known as the Theater Data Medical Store. By April 2008, MHS plans to connect that system to the Armed Forces' health system's Clinical Data Repository, which contains the medical records on more than 9 million active-duty and retired service members and their families, Foster said.
In September, clinicians at all VA hospitals and clinics will see patient information in the Theater Data Medical Store through the use of a Defense-VA health information system, Foster said. A congressional source said he was familiar with this plan and said he considered the timeline ambitious.
In the meantime, support for Fravell and his patient tracking systems continues. Ken Jordan, appointed by President Bush to the Veterans Disability Commission, said IT systems that support the transition of veterans between Defense and VA health care systems are essential, and MHS told the commission it will not have such standard systems in place until 2014 to support transitioning soldiers between the two departments.
Disabled American Veterans' Gorman said, "It would be a decided loss to veterans if this important work were to be interrupted."
Besides the ease of access that the Web-based capability of the patient-tracking systems, clinicians in Iraq said the systems are easier to work with. The systems operated by MHS and AMEDD do not have the capability to capture trauma data, and clinicians must print out hard copies of patient charts on a daily basis and scroll through long lists of text data fields to obtain the information they need. The battlefield version of the Armed Forces Health Longitudinal Technology Application system is "impossible to use in a serious inpatient setting because of the requirement to open each note individually. … The only feasible way to use it for inpatient care would be to print out every note," according to the combat clinicians' paper.
Steve Robinson, director of veterans affairs with the organization Veterans of America, said Defense should continue to back the Web-based patient tracking systems until it fields a system with capabilities equal to Fravell's systems. Medical information on combat wounded -- including their mental health problems -- is critical throughout the continuum of care, said Robinson, a former Army Ranger who worked at MHS from the late 1990s through 2001.
For example, detailed information contained in the patient-tracking system can alert clinicians in the United States to mental health conditions, which, if not addressed, could lead to suicide, Robinson said. That information "can mean the difference between life and death," Robinson said.
By Bob Brewin
June 27, 2007