Computing a Cure
On the hot seat over soldiers' medical care, the Army and Veterans Affairs find answers in their own backyard.
Walter Reed Army Medical Center and the Veterans Affairs Department found that coincidence can be the mother of invention as they scrambled earlier this year to streamline clinical care and benefits processes for troops wounded in Afghanistan and Iraq.
Soldiers at Walter Reed complained in the media and in congressional hearings about balkanized paper-based systems that frustrated their attempts to obtain clinic appointments and transition between the Military Health System and the VA health and benefits systems.
Staff Sgt. John Daniel Shannon, who ended up at Walter Reed due to a head wound in Iraq that resulted in loss of his left eye and a traumatic brain injury, was among those who became lost in the paper trail.
In March, Shannon told the House Committee on Oversight and Government Reform that he spent a couple of weeks sitting in his room waiting for appointments and "wondering when someone would contact me about my continuing medical care." After numerous phone calls, he tracked down his case manager. She "was somewhat distressed" she had not been able to locate him, Shannon said, and immediately started to schedule clinic appointments. But the paperwork he had submitted for a medical review and discharge was lost. Shannon had to start over.
Under intense public criticism, which caught the attention of President Bush, Walter Reed and VA officials worked to to automate processes. During a visit to Walter Reed in March, Bush told wounded soldiers that the problems at the hospital "were caused by bureaucratic and administrative failures. The system failed you, and it failed our troops. And we're going to fix it." He added that the administration, the Defense Department and VA would work to ensure that transfers between the two health care systems are "smooth, and that there's not bureaucratic delay or obstacles in the way of making sure that we can report to our fellow citizens that [soldiers] are getting the best possible health care."
The solutions, it seems, already were in the works. Coincidentally, both VA and Walter Reed fielded automated patient tracking systems on April 23, a little more than two months after the scandal over the care of combat-wounded soldiers surfaced.
Last year, VA turned to Lt. Col. Mike Fravell, a medical service corps officer on fellowship at the agency, to modify for its use a patient tracking system he helped develop for the Army. Fravell had led the team that created the Joint Patient Tracking Application for Landstuhl Regional Army Medical Center in Germany, where he was chief information officer.
The system was designed to track patients from Afghanistan and Iraq to Landstuhl and then to stateside hospitals. "Between 400 and 500 patients a week arrived and departed Landstuhl, and it was hard from an overall hospital perspective to keep track of them," Fravell says. Working with Col. Richard Jordan, who ran the Landstuhl Deployed Warrior Medical Management Center, Fravell launched the Web-based application to manage the massive flow of patients, which some days peaked at 100 arrivals from the battlefield.
When the Army system was fielded in January 2004, it did exactly what was intended, Fravell says. The database provided a quick view of every combat evacuee in the hospital, down to the ward and bed level, including the number of the nearest phone to that bed. Battlefield medics also could access the system to determine the location and status of personnel transported from the battlefield by medevac.
Before, "commanders would call all areas of the hospital trying to find their personnel and status," Fravell says. The system also made it easier to connect patients with family members who called the hospital.
In 2005, Fravell helped upgrade the Army's system to allow clinicians in Iraq to store notes from their rounds and surgeries. Now deployed to 21 military hospitals, the system provides a snapshot of treatment through the continuum of care, often starting with notes entered into a hand-held computer on the battlefield.
Clinicians at four VA facilities gained access to the system in September to help care for polytrauma patients, but the Defense Department's Military Health System cut off access early this year for lack of a formal data sharing agreement that would safeguard patient privacy.
Another fear of opening the database to other users is that it contains sensitive information about battlefield units, says Tommy Morris, director of deployment health systems for the Military Health System.
After Sen. Daniel Akaka, D-Hawaii, chairman of the Veterans Affairs Committee, and ranking member Sen. Larry Craig, R-Idaho, sent highly publicized letters to Defense, Military Health System officials restored VA access in February.
VA rolled out its own version of the system, known as the Veterans Tracking Application, in April, and clinicians will be able to access medical information in the Defense system. To protect patient privacy, access is limited to authorized personnel.
Clinicians and case workers at VA's 154 hospitals and more than 800 clinics will get access to Defense medical records. Support for VA case managers was one of the key modifications made to the Army's system, Fravell says.
Daniel Cooper, VA's undersecretary of benefits, told the Senate Veterans Affairs Committee in May that the Veterans Tracking Application and other joint VA/Defense systems will help support the seamless transition of patients from active duty to veteran status. It will allow case managers to ensure that the records of patients transferred from military hospitals to VA facilities indicate the need for a particular course of treatment, such as the fitting of a prosthetic device, says Dr. Edward Huycke, VA's chief Defense Department coordination officer. The Veterans Benefits Administration also will use the tracking system to help manage the claims process from active duty through veteran status. It is the first application ever fielded by Defense and VA that provides clinical information at the earliest stages of a combat event. As a result, Veterans Affairs will be able to "review and update information in real time for the same individual in each stage of transition from the DoD to the VA," says VA spokeswoman Josephine Schuda.
Sen. Craig says the Veterans Tracking Application is a positive step toward developing a joint Defense/VA electronic medical record system. But, he adds, "What is needed in the long run is a fully integrated electronic medical record that includes the service member's entire medical record."
The Paper Chase
Walter Reed faced a less complex but still daunting patient-tracking task-streamlining a paper-based process that left wounded soldiers in a bureaucratic limbo as they tried to make clinic appointments and wend their way through a medical review process that would determine whether they would stay on active duty or be discharged. Officials tapped Col. David Jones, an internal medicine specialist and chief of health plan management, to adapt the Patient Appointment System he developed for Walter Reed commanders, case managers and clinicians.
Wounded soldiers were frustrated by hospital processes that relied on paper forms and digital information stored in stovepipe systems, says Col. Francis McVeigh, head of Walter Reed's optometry service and clinical informatics division. He knew he could not fix the Military Health Service's systemic problems, so he focused on automating processes at Walter Reed. Mc-Veigh sought a way to adapt the appointment system to help clinicians and case workers better manage clinical care.
The result is the Walter Reed Military Medical Tracking System, a Web-based dashboard that pulls information from three electronic patient record systems: Defense's Armed Forces Health Longitudinal Technology Application, Walter Reed's Clinical Information System and the Medical Evaluation Board Internal Tracking Tool.
The dashboard provides clinicians and case workers all the relevant medical information on a patient at a glance and features an automated clinical appointment system accessible by authorized users of the 8,000 computers on the hospital network.
Jones says Walter Reed's system also provides a window into the workload at various clinics in the hospital, so administrators can zero in on a potential overload. If the orthopedics clinic is overwhelmed, for example, the hospital could increase staffing there so soldiers don't have to wait weeks for appointments. Col. Franklin Rowland, Walter Reed's CIO, says the system is a good candidate for deployment across the Defense Department.
The quick development and deployment of the Military Medical Tracking System shows that "top down sometimes may not be as efficient as bottom up," says McVeigh. In fact, Walter Reed and VA might not have met immediate requirements to smooth patient tracking by starting from the top down.