Clash Over Casualties

Battlefield medics resist push to stop using joint patient tracking system.

Despite evidence that the low-cost Web-based Joint Patient Tracking Application eases transfer of medical records on wounded soldiers from the battlefield to hospitals, military officials have stifled its use and further development, according to congressional sources and combat medical personnel in Iraq.

The system "is the only record that has visibility throughout the evacuation chain," combat surgeons in Iraq wrote in a talking paper. "It is easy to access anywhere that we have Internet," they wrote, and the system also makes it easy to enter data about patient progress, tests, notes and operations.

JPTA allows medical personnel to easily and quickly update commanders in Iraq on the status and location of patients, eliminating hours required to track them down through phone calls and e-mails, according to the paper.

The Army earlier this year directed combat medical units to use standard Defense Department systems, including the Theater Medical Information Program fielded by the Army's Medical Communications for Combat Casualty Care (MC4) program office, and battlefield versions of the Armed Forces Health Longitudinal Technology Application, which has cost

$1.2 billion to develop and deploy through fiscal 2007. JPTA cost less than $1 million to develop and $2 million a year to maintain, according to congressional sources and Lt. Col. Mike Fravell, the system's developer.

The Army's 3rd Medical Command, which oversees units in Iraq, directed clinicians to use the Theater Medical Information Program, not JPTA. The April order bluntly stated that "JPTA is not a TMIP-authorized alternative means of documenting evacuation and tracking purposes of the patient."

Combat clinicians say they are ignoring the directive. If it is enforced, "casualty care info and data collection will suffer greatly," they said, because among other problems there is "no easy way to capture trauma data into MC4."

One combat surgeon, who requested anonymity, said the requirement to paste MC4 notes into JPTA makes no sense because they would be unreadable. The clinicians added that the Armed Forces Health Longitudinal Technology Application "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 in-patient care would be to print out every note."

"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 data, the surgeons said.

JPTA appeared to have high-level backers in June when Army Chief of Staff Gen. George W. Casey Jr. supported the system. But at the same time, Defense officials were working to sideline Fravell, congressional sources say. Fravell had launched JPTA at the Army's Landstuhl Regional Medical Center in Germany in 2003 and later adapted it for use at VA.

Daniel Cooper, VA's undersecretary for benefits, told the Senate Veterans Affairs Committee in May that the Veterans Tracking Application 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.

Despite requests to extend Fravell's fellowship at VA for another year to continue work on the system, the Army transferred him to South Korea and then to Military Health System headquarters just outside Washington. A congressional source equates the assignment to "bureaucratic Siberia." Some say Fravell's transfer was in retaliation for his frank assessment of the Military Health System's reluctance to work with VA. At a House Veterans Affairs Committee in May, Fravell said, "I think on the DoD side, things are very territorial."

The Army stopped Fravell's transfer to South Korea in mid-June after Reps. Bob Filner, D-Calif., chairman of the House Committee on Veterans Affairs, and Steve Buyer, R-Ind., the committee's ranking member, wrote to Pete Geren, secretary of the Army. But Fravell's new assignment at MHS still removes him from any further work on the patient tracking systems, according to the congressional source. Fravell was sidelined because he posed a threat to standard Defense electronic health care systems, according to the source. The Army and Military Health Service declined to comment about his status.

Veterans can't wait another five years for the two departments to "plod along" with system development, says Gerald T. Manar, deputy director of the National Veterans Service for the Veterans of Foreign Wars. If Fravell has developed even a partial solution, it should be encouraged, he adds.

"It would be a decided loss to veterans if this important work were to be interrupted," says David Gorman, executive director of Disabled American Veterans. MHS says it will not have systems in place until 2014 to support transitioning soldiers between the two departments, says retired Marine Col. Kenneth Jordan of the Veterans Disability Benefits Commission. "Something should be done right now," he says.

Robert Foster, acting chief information officer at MHS, says his command has "no issues with the use of JPTA, and it is a viable alternative" as an interim record until MHS can field its own systems in Iraq. Foster says he has heard the message from battlefield users on the merits of the system and the flaws of others "loud and clear," and the agency is working to satisfy their concerns.

The Armed Forces Health Longitudinal Technology Application captures only outpatient information, but MHS is working to deploy a system in Iraq later this summer that will capture inpatient information in the Theater Data Medical Store. In September, clinicians at all VA hospitals and clinics will be able to see patient records in that database through a Defense-VA health information system, Foster says. A congressional source familiar with the plan says that timeline is ambitious. By April 2008, the agency plans to connect that system to the clinical data repository, which contains medical records on more than 9 million active-duty and retired service members and their families.

The Defense Department should continue to back JPTA until it fields a system with equal capabilities, says Steve Robinson, director of veterans affairs with Veterans for America. Medical information on combat wounded is critical throughout the continuum of care, he says. Mental health conditions, for example, if not addressed could lead to suicide, says Robinson, a former Army Ranger who worked at MHS from the late 1990s through 2001. That information, he adds, "can mean the difference between life and death."