Use cases. My goodness, is there anything more exciting than creating “To Be” scenarios where major COTS vendors can look at the DHMSM scenarios and can say with a suspicious smile, “Is that all they want, is that all they need?” The features and functionality exist in today’s EHRs. However, the operational and technical architecture to pursue this capture are complex. Not impossible, but complex.
Will a single environment that shares clinical data be enough to support a global clinical data vault? How can any team perfect performance and balance that with improving the delivery of military health? How will synchronization improve and not attenuate data collaboration? Do EMPIs become active participants in providing a variety of global patient identification aliases? Commercial EHR solutions are being deployed each and every day across the United States that meet the DHMSM requirements outlined in acute as well as ambulatory environments. How can we translate those lessons learned in to the psyche of our service integrator / partner / prime?
Now for THEATER. In my experience with beltway software vendors, I can say with a degree of confidence that they cannot design from scratch a theater-worthy solution. These folks seem to think COBOL is cutting edge and that FTP/SFTP transfers are the only conveyance vehicles for data. These are the same folks that design their user interfaces to look like Microsoft Access or a DOS-based Excel worksheet with enough data to push all the data available in the local database. This equates to a single chaotic and cluttered view.
Workflow means something! It really does. It is not just a word on a marketing slick. Understanding how the clinician (I am including down range medics here), technologist, and nurses work. Teams have to take the time to talk to clinicians. Translate those conversations in to a cogent way to view data respective of the clinician’s specialty. Establish when and where it is essential to provide drill-down views — a nurse does not need to have 14 alerts that sourced data pulls from a year ago on a bunion. Data view is about relevance and moving the patient and their care along an uncluttered path. With that lesson in mind, it is my assertion that it is a mistake to assume that a CMMI software development firm could actually provide a salient solution for theater. If you doubt this, take a look at the systems that are put together today.
The smart architects will solution along the lines of repurposing a backbone of an existing patient-centric portable EHR and emergency / occupational health solution(s). Heaven forbid we take a look at solutions that actually have a client base. Low communication and non-communications standalone systems exist – they can provide portable clinical applications that can bridge the combat medic with resuscitative care as well as make the wrinkle in patient timelines affected by airevacs merely a data entry point — a step in patient care. I understand that many believe it is as complex as ear hair removal for men hitting their middle ages, but it is easier to fix than that.
The ultimate theater solution will become an invaluable transfer tool rather than a manual harbinger of medication mis-management and shadow record keeping. Therefore, the theater challenge is keeping data succinct, aligning casualty care with best practices, and an enabler for medics to stabilize data transference in preparation for transport away from harm and to the safe harbors that military medicine can afford. A transfer is a transfer, not unlike moving a patient to a skilled nursing facility or stepping a patient from critical care to a more mundane and therapeutic homeostatic environment. Recovery, therapy, and rehabilitation are the natural progression. Why not assume that the element most needed to evacuate a patient should connect rather than be an island of information that cannot be assimilated and or aggregated after the clinical data is needed?
Clinical decision support requires algorithms and data entry at key intervals in care no matter the monitoring mechanism. Closed loop medication begins with initial care folks! The perfect test bed is to automate the airevac Patient Movement Record. This has to be done and is crucial for survivability and clinical collaboration at the next point of care. Telehealth has a role and cannot only be focused on monitoring, but on collaboration and en route data transference / collaboration. Tc3 needs to add a C for computerization to embed all elements of care allowing intra- and inter-theater transfer of patient-centric data to the folks that need it most. Blood means life, as does airway management, shock management, and the medic’s ability to simplify the medication, pain, and sedation med management.
In a nutshell, it means that the service integrators cannot rely upon CMMI firms to take an innovative approach to the theater solution. These firms lack the fundamental qualifications necessary to understand patient care and the continuum that translates into lives saved. Teams have to marvel at the way military healthcare is provided today in spite of the shortcomings of poorly constructed and non-integrated clinical solutions that have been acquired to date. No finger-pointing, just an observation as a clinical HIT guy.
Perhaps the best place to start is by simplifying and modernizing the medical terms used across all data dictionaries and tables. Design “practical” pathways that can be assumed at the next duty station, base, and post. Data liquidity and actionable analytics can only be realized with a focus on the patient and the care he or she receives. I believe that today data (in the military theater) is deemed as a commodity that needs to be dissected for affect, rather than a kinetic, ever-changing, non-quantifying entity. We have to structure that which is unstructured and assume that sharing clinical data is not a burden, but a directive.
Patient identification is a challenge. We are aware of that. Someone has to lead and state that the axiom “right care, right time, right location” really starts by implementing a uniformed medical language. Patient identification reconciliation is the cornerstone of appropriate care and avoidance of medication errors. Interventions will occur with or without an EHR. Documenting it, though, has everything to do with adherence to standards so care can be provide in a seamless manner. Even if care started in some desolate stretch of land, the care initiation is key – ask any field medic.
What efforts are being made to ensure that we do not design the same menagerie of databases that cannot be deemed as up to date? Are data sources reliable when they were designed to spec to be isolated and un-retrievable? When you manufacture anything, you start with the end in mind. How could any reputable vendor equip any clinician an EHR contributor system without any thought of data integrity to share across the enterprise?
Believe it or not, the longitudinal care record is not a mythological creature. If it was, it would be a unicorn with a bunion and the "As Is" would relegate care to a podiatrist instead of a vet that specializes in equine hoofcare. I fear that many of the beltway firms use archaic technologies and proprietary protocols that effectively eliminate the concept of one patient ,one record.
Understanding down range medical operations as well as the rules constructed to improve survivability means effective transfers of data. This is the only tenable path to measurable outcomes.
I do hope that myopic views will be avoided and that proprietary protocols will become a lessons learned and will translate into improving the way combat care is assimilated in to a viable path to healing.
In spite of ACA legislation, ARRA HITECH investments, and CMS incentives, the commercial EHR market is not expanding, but is instead becoming more and more consolidated. Vendors are trying to compete with strategic service organizations that leverage existing HIT solutions and endeavoring to focus on smarter ways to work, applying analytics to figure out improved ways of deploying service lines that make sense. DHMSM will receive solutions that can address the ever-changing landscape of healthcare and the manner in which clinicians deliver that care. The question is more along the lines of how will teams refine the way data is shared, how liquidity of clinical data can become actionable?
The “As Is” environment is daunting, not the challenge of feature and functionality requirements. Applying the same techniques used in the commercial market segments requires an understanding of how clinicians practice medicine. A great deal of time has been invested in understanding the military enrollment process the deployment systems and even where authoritative data is being sourced. This opportunity will be won — not lost by the way transition and education proliferation is managed, how parallel operations can be kept succinct and orderly.
The transient population of 1.4 million service members is relying on the teams that are pursuing an award, but the eventual winner has to be the troops we serve. This is not a DoD solution. It is an honor to know that the real customer is that lady and that man who wears the uniform of a US service. Sorry for the soliloquy, but this is my way to convey what is on the minds of men and women designing and solutioning every hour, if not on paper or in meetings, but in our minds. Be innovative folks, and do not lose focus on what needs to be done.
I promise next time to throw salted pretzels at primes and vendors. After all, that is why I started my controlled rants.