U.S. Department of Defense (DoD) Initiatives
- 1 U.S. Department of Defense (DoD) Initiatives
- 1.1 DoD EHRs
- 1.2 Defense Healthcare Management System (DHMS)
- 1.2.1 DOD Healthcare Management System Modernization (DHMSM)
- 1.2.2 Joint Operational Medicine Information Systems (JOMIS)
- 1.2.3 Enterprise Intelligence and Data Solutions (EIDS)
- 1.3 Telehealth
- 1.4 Defense Medical Logistics Standard Support (DMLSS)
- 1.5 Resources Information Technology Program Office (RITPO)
- 1.6 Expense Assignment System IV (EAS IV)
- 1.7 Third Party Outpatient Collection System (TPOCS)
Composite Health Care System (CHCS)
- Composite Health Care System (CHCS) is a MS-DOS like interface developed in 1988 for use in DoD. It worked in a module-based system, with access rights limited by module. Modules included: RAD (radiology), LAB (Laboratory), PHR (Pharmacy), PAS (Patient Appointing & Scheduling), MCP (Managed Care Program; used to support TRICARE enrollees by enrolling them to Primary Care Managers), PAD (Patient Administration): MRT (Medical Records Tracking), MSA (Medical Service Accounting) medical billing, WAM (Workload Assignment Module), DTS (Dietetics), CLN (CLinical: Nursing, Physician, and Allied Health), DAA (Database Administration), ADM (Ambulatory Data Module) Medical Coding of outpatient visits, and TOOLS (FileMan). CHCS is still widely used for order entry as it has more flexibility and is significantly faster to use then AHLTA. LAB and RAD functions are also heavily used by primary care again for simplicity and speed of use.
AHLTA while seen as the CHCS replacement is still heavily dependent on CHCS, many process from AHLTA are passed and run through CHCS instead of AHLTA itself, which further leads to providers ‘removing the middle man’ and using CHCS directly. Patient booking, clinical appointment scheduling, booking templates, and Patient Administration (creation and maintenance of records) are still done in CHCS and the data from these modules is used to populate AHLTA. Effectively, AHLTA in it’s current form can not function without CHCS, which fed directly some of the difficulties in the MC-4 deployed AHLTA record system.
- Armed Forces Health Longitudinal Technology Application (AHLTA) is a Department of Defense (DoD) Electronic Health Record (EHR). It was built off of a backbone of the Composite Health Care System (CHCS) which is still used as both standalone and as a supporting back-end to AHLTA. Fielding of AHLTA began in 2004, and is currently still in operation. AHLTA does not have a capability for inpatient records, in some small pockets CHCS is still used ofr that function but as of 2007 Essentris was purchased and deployed as the DoD inpatient EHR. Currently the two record system to not share data beyond what is passed through back-end support of CHCS; meaning there is no way to view records or data in one system from the other.
DoD and VA records are managed on different system despite sharing the same patient population, as such AHLTA (and VistA) contains and additional module called Joint Legacy Viewer (JLV) allowing the viewing of records information from the other system, however DoD Essentris inpatient record system is not included in this capability. Through joint DoD VA efforts the development and testing of AHLTA predecessor MHS Genesis has begun and initial fielding and testing started at DoD facilities in Washington state in 2017.
Further information on AHLTA is present in it's own Clinfowiki page.
- Military Health System Genesis (MHS Genesis) began as a concept in 2013 when SECDEF Leon Panetta and SECVA Eric Shinseki announced plans to increase interoperability of their health systems. At this point in time VA announced plans to continue using MUMPS based VistA as it’s EHR core, while DoD began perusing commercial solutions for replacement of AHLTA. Contract for MHS Genesis was award in 2015. OHSU’s own Dr. Vishnu Mohan participated in the efforts.
In 2017 MHS Genesis went live in the Pacific Northwest. Initial adoption had issues, including CAC card (DoD Id card with smart chip for digital Auth) implementation and capability gaps, inadequate training, trouble ticket backlog and prolonged issue resolution processes. Despite these issues the rollout saw significant improvement in EMRAM and oEMRAM scores. Rollout was delay to allow more time to address issues and the next phase began in 2019 and continued through 2021 with deployment of MHS Genesis to DoD facilities located in California. In late 2021 deployment to Hawaii and other Pacific based location began.
Initial contract request for proposals was reported as having included a requirement for the EHR to operate in a deployed environment with strict cyber defense capabilities and the ability to still deliver service in a delayed/disconnected, intermittently-connected, low-bandwidth (DIL) environment. During initial fielding MHS Genesis was found to be unable to survive in even a basic level of cyber contested environment. Additionally, Cerner reported an inability to deliver a full functional version of Genesis that could operate in a DIL environment on a laptop with to without local DIL server support. As such DoD is now exploring (through TATRC and JOMIS) deployable EHR solutions for the DIL (combat) environment. Likely yielding a two EHR system as they had before.
- Program Executive Office (PEO) Defense Healthcare Management System (DHMS) usually shorted to just DHMS is the current DHA function responsible for healthcare information exchange and management inside DoD and with the VA. It has 3 Subordinate offices each managing different aspects of modernization and health information. DHMS is the current evolution (as of 2017) of Defense Health Information Management System, which itself was the successor to CITPO in 2008. DMHS offices and their responsibilities:
- Supervises deployment and acquisition of MHS Genesis the currently being fielded EHR for DOD. Manages Defense Medical Information Exchange (DMIX) the DoD health information exchange. They also support Joint Longitudinal Viewer (JLV) a read only tool for VA's VistA and DoD's ALHTA allowing cross viewing of information from within the EHR and without need for account logins with the other Department.
- Responsible for sustaining the Theater Medical Information Program-Joint (TMIP-J) products, and leading acquisition of a deployable solution of MHS Genesis. Manages Theater Medical Data Store (TMDS) which a clearing house for health information from multiple other DoD databases, and is specifically intended for access and use in the deployed environment. They are currently working to develop a Medical Common Operating Picture (MedCOP) that is effectively a map overlay for DoD planning solutions allowing visualization of medical assets, their capabilities, and patient load. In addition to tracking evacuations, combat injuries, and Disease non battle injury/illness (DNBI) data.
- Enterprise Intelligence and Data Solutions (EIDS) is responsible for decision making support, and timely delivery of that information. They have five main focus areas: Legacy Data Consolidation, Workflow Applications, Information Portals, Analytics Workbench, and Data Science Laboratory.
Historical departments or programs circa 2006 moved or consolidated under DHMS
CITPO is an acquisition office for centrally managed MHS clinical IT systems that support the delivery of health services throughout the MHS. The following are CITPO projects: the Military Electronic Health Record AHLTA (formerly known as CHCS II), Composite Health Care System Legacy, Clinical Information System (CIS), Preventive Health Care Application (PHCA), Encoder Grouper (EG), Special Needs Program Management Information System (SNPMIS), TRICARE Online (TOL), Nutrition Management Information System (NMIS), and Veterinary Services Information Management System (VSIMS).
The Composite Healthcare System II (CHCS II), now called AHLTA, is a computer-based patient record for the U. S. miltary (Harmon BJ, Wah R, Inae T. Theater Style Demonstration of the Composite Health Care System II the Miltary Health System Computer-Based Patient Record. AMIA Symposium Proceedings. 2003: 1068). This system provides an "integrated clinical graphical user interface", a clinical data repository, and a "migration architecture" to allow upgrades in the system without changing the user interface. It can be used when troops are deployed away from their home base. This system can be used in conjunction with the DMSS and birth defects registry to monitor hazardous exposures of military members in the field.
The DMSS (Defense Medical Surveillance System) is the central source for medical data on the U.S. armed forces. There are also links to 27.6 million serum specimens (as of 2002) (Ruberton MV, Brundage JF. The Defense Medical Surveillance System and the Department of Defense Serum Repository: Glimpses of the Future of Public Health Surveillance. American Journal of Public Health. 2002; 92(12): 1900-1904). The U.S. Department of Defense also maintains a birth defects registry (Ryan MA, Pershyn-Kisor MA, et al. The Department of Defense Birth Defects Registry: overview of a new surveillance system. Teratology. 2001; 64 suppl 1: S 26-29). This registry is being used to monitor active duty women due to concerns over potential and actual hazardous exposures. Both of these resources are critical for monitoring the health of active duty military personnel including concerns regarding infectious disease exposure (natural or due to biological weapons).
Theater Medical Information Program (TMIP)
- TMIP provides a seamless, interoperable medical information system to support theater health services during combat or contingency operations within and across all echelons of care. The primary goal is to provide a global capability linking theater medical information databases and integration centers that are accessible to the warfighter anywhere, any time to support the mission. TMIP includes the following programs: Composite Health Care System in the Theater of Operations (CHCS NT), Composite Health Care System II - Theater (CHCS II-T), TRANSCOM Regulating and Command and Control Evacuation System (TRAC2ES), Defense Medical Logistics Standard Support Assemblage Management (DMLSS-AM), Medical Analysis Tool (MAT), Shipboard Non-Tactical Automated Data Processing Program Automated Medical System (SAMS), Medical Surveillance System (MSS), and Defense Blood Standard System (DBSS). Note from a clinician whose guys use this system: at least aboard ships, this system is fairly unreliable, but when it works, you can then pull up those encounters in AHLTA, which is nice.
- The EI/DS program provides timely, accurate, and appropriate decision information supporting the TRICARE Management Activity (TMA) and DoD MHS mission. The EI/DS program currently consists of a data warehouse and several operational data marts supporting nearly 3,000 system users, providing a robust database and suite of decision support tools to empower the effective management of MHS health care operations. The EI/DS systems support decision making by senior MHS personnel and post-decision monitoring of the effects of decisions. EI/DS products include: MHS Management Analysis and Reporting Tool (MHS MART), Managed Care Forecasting and Analysis System (MCFAS), Population Health Operational Tracking and Optimization (PHOTO), Medical Surveillance, TMA Reporting Tools (TMART), CHAMPUS/TRICARE Medical Information System (CMIS), CHAMPUS/TRICARE Utilization Reporting and Evaluation Systems (CURES), Care Detail Information System (CDIS), and Patient Encounter Processing and Reporting (PEPR).
- Telehealth has significant adoption in the DoD. It was initially introduced in 1992 by the Army as a way to deliver supporting specialty care to remote operational areas. It was first used in 1993 in Somalia, again in 94-95 in the Balkans, and based on those successes it began garrison (home station) use in 1995. The Global War on Terrorism (GWOT) saw significant expansion of the program and a large growth in specialties added to the system, as well as improvement in the capabilities. Outside of the operational benefits, mental health continues to be the largest use of Telehealth in garrison. As it provides a way for service members to receive care without the military culture stigma of seeking mental health care, and allowed small bases or remote areas with low utilization to still provide a vital service.
By 2010 digital photos and what can effectively be described as a ‘drop box’ were providing around the clock access to deployed providers in an exceptionally bandwidth limited environment. Consulting providers would place PII into the Telehealth log for appropriate specialty, provide a short consult request, then globally providers of that specialty could login in during their normal workday to answer the Telehealth queue. This provided around the clock access, without need for direct video or phone support, something not always available on the battlefield, while also allowing specialist to answer the need during their normal clinical day.
Telemedicine and Advanced Technology Research Center (TATRC) began in the 1990s as a joint research effort between the Army and AirForce to develop mobile imaging system, the Navy joined this effort a few years later and in 1998 this effort was formally named TATRC. TATRC is currently part of the US Army Medical Research and Development Command (USAMRDC) which itself is part of Defense Health Agency (DHA). While the hierarchy is Army, the effort is joint (Tri-service). TATRC manages the development of Telehealth for DoD (in additional to other focus areas) and works to push the capabilities, whether it’s remote use of Da Vinci surgical robots from continents away, or delivering expertise like ventilator management to ground medics in the field. DoDs adoption of Telehealth continues to grow.
The COVID-19 pandemic saw even more significant adoption of Telehealth in everyday care for the DoD. To meet this demand and deal with unrelated internal restructuring DoD has contracted with GlobalMed and award an Authority to Operate (ATO). GlobalMed will integrate into the new DoD EHR system (MHS Genesis) and provide services not only to service members, but their families as well. The ATO covers garrison operations as well as supplementing or completely supporting overseas, ship based, and combat operation support.
- DMLSS replaces aging military departments' (Army, Navy, and Air Force MilDeps) specific legacy medical logistics systems with one standard DoD medical logistics system. DMLSS also manages Joint Medical Asset Repository (JMAR), Customer Support on the Web (CSW), Facility Management (FM), Customer Area Inventory Management (CAIM), Equipment & Technology Management (E&TM), Stockroom/Readiness Inventory Management (SRIM), Assemblage Management (AM), Universal Data Repository (UDR), Prime Vendor Program (PV), DMLSS - Wholesale (DMLSS - W), Customer Demand Management Information Application (CDMIA), National Mail Order Pharmacy (NMOP), Readiness Application (RMA), Medical Electronic Customer Assistance (MECA), Distribution and Pricing (DAPA) Management System (MS), Defense Blood Standard System (DBSS), and Electronic Catalog (ECAT).
- The RITPO initiative is a project that consists of a family of capability-specific applications/systems that support the MHS "Manage the Business" and "Access to Care" and information technology requirements. The RITPO project scope includes providing information technology support for MHS personnel, scheduling, workload forecasting, and patient safety initiatives. The following are RITPO projects: Defense Medical Human Resources System - internet (DMHRSi), Central Credentials Quality Assurance System (CCQAS), Enterprise Wide Scheduling and Registration (EWS-R), Enterprise Wide Workload Forecasting (EWF), Patient Safety Reporting (PSR), Defense Occupational and Environmental Health Readiness System (DOEHRS), and Patient Accounting System (PAS).
Expense Assignment System IV (EAS IV)
- EAS IV is a standard DoD cost accounting/assignment information technology system that consists of a cost-assignment application and a data repository. The system receives information electronically from a variety of DoD financial, manpower, and workload systems, and allocates this expense information to Medical Treatment Facility/Dental Treatment Facility (MTF/DTF) direct and indirect work centers.
Third Party Outpatient Collection System (TPOCS)
- TPOCS is the MHS information system used to bill for ambulatory services.
--Original contributions by Michael 15:30, 17 April 2006 (CDT)
--Updates by Marshall 11:51, 22 April 2022 (MDT)