After a series of news reports in March about conditions at Walter Reed Army Medical Center and other government health care facilities, President Bush convened a presidential commission to examine why injured service members and veterans are not receiving proper care.

Bush asked the President's Commission on Care for America's Returning Wounded Warriors to recommend steps to ensure the quality of care for wounded troops from the battlefield through military health care facilities and back into civilian life.

The commission's report, released at the end of July, made six recommendations. They included creating individual recovery plans, streamlining the disability and compensation systems, treating post-traumatic stress disorder and brain injuries, reinforcing family support systems, and recruiting health care professionals to work at Walter Reed.

The sixth recommendation will likely be the most difficult to follow: The commission asked the military to "rapidly transfer patient information between the Defense and Veterans Affairs departments."

That will be easier said than done. DOD and VA have been working on interoperable patient record systems for several years. So far, they have had limited success.

Military officials face two colossal challenges: eliminating redundancy along the health care supply line and integrating services that are unique to one department - such as combat medical care, a DOD specialty.

"What DOD and VA are striving for strategically is a true, seamless sharing of information across this entire wounded-warrior life cycle," said Robin Portman, a vice president at Booz Allen Hamilton, which was recently awarded a contract to study the feasibility of having the two departments use the same electronic medical record system.

One soldier, one record
Since the beginning of recent U.S. military operations in Iraq and Afghanistan, DOD and VA have treated thousands of wounded troops. Today, an injured soldier might receive treatment at five or more facilities while moving from a medical station near the battlefield to a VA hospital for physical therapy after discharge from active duty.

A single patient record that can be retrieved and annotated at each stage of care, regardless of its location or hosting agency, is vital to ensuring quality of care, military health information technology officials say. It guarantees that costly or painful procedures are not repeated unnecessarily. A single record also ensures that life-threatening allergy and prescription drug information is instantly available for doctors who must make emergency care decisions
.
"For providers to be able to provide proper treatment, they need to have access to that medical record, to all of that patient information," said Charles Campbell, assistant chief information officer at the Veterans Health Administration. "There is a lot of sharing that has to be done, both in the long term for veterans as well as in the very short term for severely injured service members."

Central to the plan is a shared inpatient record system linking two systems with deep roots in each department's respective health care cultures: DOD's Armed Forces Health Longitudinal Technology Application (AHLTA) and VA's highly regarded Veterans Health Information Systems and Technology Architecture (VistA).

To explore connecting the two systems, DOD and VA recently awarded the first of two six-month contracts to Booz Allen Hamilton to "determine the feasibility of having a common electronic medical record system and what it would look like," Portman said. She added that the departments' information-sharing efforts are not solely focused on medical records but also encompass the processes for determining disabilities and the provision of benefits.

VA and DOD have called the study a first step in creating
joint inpatient electronic medical record.

"We should get some early information
during those first six months that can begin to shape the development," said Charles Hume, deputy CIO at the Military Health System. "Then perhaps we'll begin to do development or procurement. We don't know which way we're going yet."

Dual consumers
Both departments have also been busy forging data repositories and data-transfer systems to manage the terabytes of information that would flow through the new system. Two of these - DOD's Clinical Data Repository and VA's Health Data Repository - give physicians access to outpatient pharmacy and allergy data.

The databases are linked through a Clinical Data Repository/Health Data Repository interface, abbreviated as CHDR, which enables physicians in both systems to share information. DOD recently awarded Northrop Grumman a $10.3 million contract to help deploy CHDR, which by its nature focuses on dual consumers - those who receive care at DOD and VA facilities, said Les Westberg, a senior software architect and engineer at Northrop Grumman IT.

CHDR's emphasis on allergy and pharmacy data will soon expand to include lab data. In one scenario under consideration, DOD will identify a dual-consumer patient and make a request to extract allergy and prescription data from the VA system. That data will be stored in AHLTA and flagged as coming from VA, Westberg said. Conversely, VA might request data from AHLTA and have that data extracted and stored on VistA.

Northrop Grumman is also working on a project to develop an interface for CHDR and the Bidirectional Health Information Exchange (BHIE), which orchestrates the sharing of viewable health data between DOD and VA. In contrast, CHDR provides for the exchange of computable health data. The BHIE read-only system "allows us to open up more data types" more quickly, Westberg said, adding that the integration of computable data takes longer.

The CHDR/BHIE interface recently went live with medication, allergy, radiology and chemistry lab data. The system lets physicians at VA check to see whether DOD has data on a given patient, or vice versa, using identifiers such as patient name and Social Security number.

In-theater care
Work on sharing and storing data focuses on applications that are common to both departments' health information processes. But DOD entirely owns a critical piece of the military's health care system: in-theater care, often delivered in the bloodiest and riskiest battlefield locations.

"There is no question that the DOD has a mission that we don't have," said Dr. Paul Tibbits, VA's deputy CIO for enterprise development. "And that is medical support of forward-deployed military operations."

Whether the military chooses to buy a commercial system, develop its own tools, or adapt AHLTA and VistA, the final solution must support medical care in combat zones.

"One of the key requirements that we'll have to deal with is the DOD's requirement to have a version of the system that they can put in combat support hospitals," Hume said. "That will introduce some unique requirements to the system that will have to be addressed."

The military has already adapted AHLTA for use in combat environments. Medical professionals use AHLTA Theater (AHLTA-T) at the point of injury and combat support hospitals. They can enter critical medical data on service members at the injury site, the forward operating base's medical station where they were stabilized before evacuation, and the combat support hospital where they first received surgery.

"It's an older version of AHLTA, but it's basically the same system to the layman who looks at it," said Lt. Col. Roderick Whit