Brigadier Martin Bricknell - Enhancing Medical Care through ICT
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The document discusses current and future requirements for Defence health and healthcare information systems. Currently, there is no single IT solution and systems include the Defence Integrated Electronic Health Record (DiEHR), the Whole Hospital Information System (WHIS), and other applications. Looking ahead, the CORTISONE Programme aims to provide an integrated capability through initiatives like REBRACE (future DiEHR), INTERMOLAR (bridge to future), and ACTUARY (future WHIS). This capability will support functions like telemedicine, disease surveillance, health records, patient tracking, and interoperability. Emerging technologies like medical drones and health knowledge commons may also support future information needs.
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Brigadier Martin Bricknell - Enhancing Medical Care through ICT
- 1. HQ Surgeon GeneralPromote, Protect, Restore, ‘Enhancing medical care through ICT’ Defence Health and Healthcare Information Systems Requirements Brigadier Martin CM Bricknell PhD DM L/RAMC Head Medical Operations and Capability HQ Surgeon General
- 2. Promote, Protect, Restore, Expectations? Patient care – clinical access to health records Evidence of quality There were 75 validated clinical unexpected survivors from 1474 trauma cases in the period 02 April 2006 to 30 July 2008. (The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services. Phil. Trans. R. Soc. B 27 January 2011 vol. 366 no. 1562 171-191) Associations between ‘Service’ and health – or not? Integration of Defence health record into individuals’ longitudinal health record Health of the Armed Forces
- 3. Promote, Protect, Restore, Outline Context Current capabilities Future capability requirements Potential technological solutions
- 5. Promote, Protect, Restore, The Healthcare Cycle
- 6. Promote, Protect, Restore, External Context
- 7. Promote, Protect, Restore, CURRENT CAPABILITIES
- 8. Promote, Protect, Restore, Defence Medical Information Capability Programme - DMICP • A networked Defence integrated Electronic Health Record (DiEHR). • A multi-million pound programme over 10 years (2006-16) • Clinical records for primary care, dental, rehabilitation and mental health.. • It covers records for all Regular personnel and occupational health records for the Reserves. • DMICP is a Thin Client application based on a COTS General Practice software application, EMIS PCS. • Business Intelligence (BI) capability is provided by IBM COGNOS tool.
- 9. Promote, Protect, Restore, NCRS NHS Trust PAS JPA Server DEMOGRAPHICS FP-MES DATA DENTAL RECORDS / FITNESS STATES MEDICAL RECORDS / FITNESS STATES/ IMMUNISATION STATES SENSITIVE MH DATA REHAB DATA HQ MANAGEMENT INFO HEALTH TRENDS PERFORMANCE INDICATORS TREND ANALYSIS (EPIDEMIOLOGY) REFERRAL DATA/ PATIENT RECORDS ADMISSION DATA/ PATIENT RECORDS FASTER TREATMENT TIMES Primary Dental Primary Medical DCMH Rehab 2nd Care iHR Server DII
- 10. Promote, Protect, Restore, View of the Consultation Page
- 11. Promote, Protect, Restore, Whole Hospital Information System - WHIS • Deployed hospital Patient Administration System (PAS) with added Clinical Support Tools (CST) • Approx £10M pound over its 4 year expected lifespan • It provides support for patient administration, bed management and hospital management information • Limited links to Laboratory Information System (LIMS) and Imaging (RIS/PACS) Camp BASTION hospital WHIS Lab X-ray DMICP demographics Defence Stats Centre for Defence Imaging
- 12. Promote, Protect, Restore, Other applications and capabilities Central Health Records Library Joint Theatre Trauma Registry (JTTR) Joint Patient Tracking Application (JPTA) Significant Event Reporting System
- 13. Promote, Protect, Restore, Observations No single IT solution to the DMS health and healthcare information requirement Procurement should be based on a spiral acquisition of services NOT an application and hardware SME clinical users are the primary stakeholder The introduction of IS requires x-DLOD organisational transformation.
- 14. Promote, Protect, Restore, FUTURE DEFENCE HEALTH AND HEALTHCARE INFORMATION CAPABILITY REQUIREMENTS
- 15. Promote, Protect, Restore, CORTISONE PROGRAMME to provide a health and healthcare information capability that delivers the right information to the right people, at the right time and in the right format, in order to enable effective delivery of health and healthcare advice, health and healthcare services and medical operational capability, and thus support the Aim of the DMS Aim of the DMS: To PROMOTE, PROTECT & RESTORE the health of the Defence population in order to maximise fitness for role
- 16. Promote, Protect, Restore, CORTISONE Programme Family REBRACE – future DiEHR INTERMOLAR – bridge from present to future ACTUARY – future WHIS
- 17. Promote, Protect, Restore, CORTISONE core capabilities Telemedicine Near Real Time Disease Surveillance Defence Health Records Joint Military Operational Patient Registry Patient Tracking Capability Data integration capability Professional Appraisal and Revalidation Interoperability • NHS • Defence Core Network Services • Other Defence Systems including Joint Personnel Administration and NATO MEDICS
- 18. Promote, Protect, Restore, Network Diagram DCNS REBRACE ARCHIVE FIRM BASE PHC node Deployed nodes ACTUARY PTA JMOPR NHS JPA FIRM BASE Other User Independent Clinician Multinational nodes
- 19. Promote, Protect, Restore, Future Technologies (1) Source: http://www.tactical-life.com/news/israels-fisher-institute-reveals-medical-uav-for-civilian-or-military-use/ X
- 20. Promote, Protect, Restore, Future Technologies (2) Source: http://aic.ncr.vt.edu/?p=321 Source: http://www.nesta.org.uk/news_and_features/13for2013/the_commons_of_health_knowledge
- 21. Promote, Protect, Restore, Summary Context Current capabilities Future capability requirements Potential technological solutions
- 22. HQ Surgeon GeneralPromote, Protect, Restore, Questions
- 23. HQ Surgeon GeneralPromote, Protect, Restore, Information is a critical capability
Editor's Notes
- I am Brigadier Martin Bricknell, Head of Medical Operations and Capability in Headquarters Surgeon General. I am a doctor, qualified in General Practice, Public Health and Occupational Medicine. Alongside the majority of members of the Armed Forces, I have served in both Iraq and Afghanistan. Most recently, in 2010 I was responsible for medical support arrangements in the South of Afghanistan when the UK commanded Regional Command (South). Since then I was responsible for Army medical capability development during the Army 2020 study. I have been in my current appointment as Head of Medical Operations and Capability for one year. Health and Healthcare Information Capability for the Defence Medical Services is one of my areas of responsibility.
- What is expected of a Defence health and healthcare information system?: The first and most vital, is that we need to provide the best possible patient care to Armed Forces personnel wherever they are serving. This requires clinical personnel to have access to an individual’s health record at the time of consultation, wherever they and their patients are serving. This can only be done through an integrated electronic health record. We need to imbibe confidence in the military medical system by proving the effectiveness of medical care provided to sick and injured armed forces personnel. This requires us to capture sufficient data about military patients in the medical system so that we can track their clinical outcomes and compare these outcomes with appropriate external benchmarks. This requires us to be able to aggregate and analyse military health records, consistent with data protection and health records legislation. The MOD needs to be able to analyse possible associations between military Service and effects on health. The heated debate over ‘Gulf War Syndrome’ in the 1990s is a very good example of public expectation that the MOD should be able to record the exposure of Service personnel to threats to their health and relate these exposures to any possible future health outcomes. This requires the ability to retrospectively set up statistical cohorts of military personnel to compare health outcomes between an exposed group and a non-exposed group. Service with the Armed Forces is just one phase of an individuals’ life course. The majority of military personnel will spend most of their life under NHS healthcare, and so the Defence health record needs to capture pre-Service health events in order to inform the recruit selection process, capture health events during Service, and then seamlessly integrate back to the individuals’ health records – possibly several times during an individuals’ life, particularly for Reservists. Finally the military medical information system must be able to present the chain of command with information on the medical fitness of the Armed Forces. This information must be sufficiently sensitive to enable the effectiveness of health promotion and health protection interventions to be measured.
- My short presentation will: Summarise the context in which military medical information systems must operate Review some of the capabilities of our current military medical information systems Describe our future military medical information systems capability requirement Finally, I will close by highlighting some potential technological solutions to meet the DMS requirements. This is not an invitation to tender, and nothing I will say implies any formal procurement strategy for future systems.
- So, to start, I will consider the context in which a Defence health and health information system has to operate
- The way in which the DMS conducts its business is summarised in this key concept; the Healthcare Cycle. This is the ‘patient-centred’ provision of Health Services Support to the Defence Population at Risk (PAR) throughout their career by the Defence Medical Services. It places the Defence Population at Risk at the centre of our business. Defence medical operations and capability (DMOC) are those activities carried out by Medical Force Elements (Med FE) in order to provide HSS to the Defence PAR deployed on operations. Med FE are Force Generated by the Service Commands (SCs) and are controlled by the Chief of Joint Operations (CJO) through the operational chain of command. The Surgeon General (SG) is the end to end Process Owner for the whole Healthcare Cycle and is responsible for assuring the quality of healthcare delivered to Service and other entitled personnel. The DMOC is shaded in purple. Prior to, and on deployment, the DMS supports the provision of Force Health Protection (FHP) measures to Service personnel from the Defence PAR. Service personnel who become operational patients are supported by the seven capabilities of operational healthcare (defined below) and, if necessary, are medically evacuated from the theatre of operations. Patients are accepted into the NHS under the Reception Arrangements for Military Patients (RAMP) and are usually admitted to the clinical unit of the Royal Centre for Defence Medicine (RCDM). Those that require specialist rehabilitation are transferred to the Defence Medical Rehabilitation Centre (DMRC); those requiring less specialised rehabilitation will be managed at regional rehabilitation units (RRUs) within the Defence Primary Healthcare (DPHC) organisation. Mental health support is provided by Departments of Community Mental Health. In all cases, after completion of care within the DMOC, Service personnel return to the Defence PAR under the purview of DMS Firm Base medical activities and capability; administration is undertaken by their own unit, or through Personnel Recovery Units or Centres (PRUs and PRCs) that form the Defence Recovery Capability (DRC). Firm Base clinical services are provided on a Joint basis through Defence Primary Healthcare (DPHC), Defence Dental Services (DDS) and Defence Healthcare Commissioning. A health and healthcare information system must be able to capture all clinical information arising from clinical interactions with Armed Forces personnel around the Healthcare Cycle and present it to whoever has a legitimate use for that information.
- This slide is a collage of images taken from Google related to searches for ‘Defence medical information’ and ‘NHS Information’. The Defence health and healthcare information requirement was first fully codified under a programme titled the ‘Surgeon General’s Information Strategy’. This was primarily driven by the political impact of issues concerning Gulf War Syndrome and the challenge of managing a paper-based healthcare records system. Concurrently the NHS has been trying to develop a UK national healthcare information system under the NHS IT programme. This evolved into Connecting for Health but the overall strategy has not delivered the single unified and transferable health record for UK citizens. The pace and range of IT innovations are making long-term strategic procurement choices extremely difficult – even if the aspired for outcome seems tantalisingly obvious.
- So what I am going to do now is to summarise some of the DMS current health and healthcare information capabilities.
- The Defence Medical Information Capability Programme (DMICP) is the current Defence integrated Electronic Health Record. This is an approximately £200M programme running from 2006 to 2016. It provides clinical records for primary care, dental care, rehabilitation and mental health for services provided by the MOD. It covers the whole record for Regular personnel and will provide occupational health records for the Reserves. It is a thin client application based on commercial-of-the-shelf on a General Practice software application, EMIS PCS, but heavily adapted for the military requirement. It is supported by a Business Intelligence Tool, COGNOS, that allows interrogation and analysis of the whole database.
- The DMICP network diagram is shown here. The system uses the application hosted in a data warehouse in Bridgend, South Wales. Each setting of clinical care uses the same personal clinical record but only has access to the relevant section or module. DMICP exchanges demographic and medical classification data to JPA, the Defence personnel records system. DMICP is being integrated into the NHS Choose and Book hospital referral system. Better than the NHS, it allows a clinician at any DMS clinical setting to access the clinical record of any person registered as a patient on DMICP. It integrates all of an individuals’ DMS clinical records and occupational records into one dataset. It supports DMS level clinical and organisational performance management. It does not provide an inpatient hospital record as hospital care for Service personnel is provided by the NHS or a contracted third party, though externally provided clinical information can be imported into an individuals’ clinical record.
- DMICP uses a complex software application. The introduction of DMICP has been a transformational process that is really only achieving full operating capability at this stage in the programme – with less than 3 years to run. The key challenge is training and education for all of the users of the system.
- The significant information management challenge posed by running the UK led hospital in Camp BASTION has been partly solved by the introduction of the Whole Hospital Information System – WHIS. This provides a patient administration system with a number of clinical support tools. It was procured as a Urgent Operational Requirement specifically for OP HERRICK. Its primary role is to provide information support for the management of the deployed hospital, mainly patient administration and archiving of core management data. It provides limited support to laboratory services. In addition our deployable field hospital laboratories have an electronic Laboratory Information Management System linked to the laboratory test machines that provides an electronic register of all tests and results undertaken. This is particularly important in the compatibility testing and tracking of blood products given during massive transfusion resuscitation of the severely injured. The imaging departments of our field hospitals have a similar system for capturing and archiving digital x-rays and other diagnostic images. This links back to the Centre for Defence Imaging within the Royal Centre for Defence Medicine to provide access to specialist analysis of these imaging.
- We also manage a range of other health information applications nested within other medical capabilities. This slide lists a number of these. The Central Health Records Library is the primary archive for Defence health records. This is based in Shoeburyness in Kent and comprises a small warehouse and an electronic archive of scanned copies of health records for members of the Armed Forces. In addition it holds old electronic patient record systems from closed down military hospitals. Clinical information on casualties treated on operations is collated onto the Joint Theatre Trauma Registry managed by the Defence Analytical Services and Advice under the clinical direction of the Royal Centre for Defence Medicine. This records a range of clinical information on all UK trauma cases since 2003 and is used for retrospective research. The Joint Patient Tracking Application has been developed to track patients evacuated from Afghanistan through their care pathways to minimise the friction in managing their care between a combination of MOD and NHS healthcare providers. The Significant Event Reporting System has been developed to track the reporting of clinical significant events in order to track the implementation of organisational changes to either reduce the likelihood of adverse events being repeated or to scale up examples of high quality practice.
- So from this list of health and healthcare information applications, which is not complete, it is apparent that there is no single IT solution to the DMS health and healthcare information information systems requirements. No single factor is constant, not the requirement, nor the software solution, nor the hosting architecture, nor the user. Thus we need to base our procurement on spiral acquisition of information services not single applications and hardware. This is complex, and requires deep understanding of the business of health, healthcare and the Ministry of Defence across the procurement process. We must ensure that the subject matter expert clinical user is recognised as the primary stakeholder. They are the the primary users as the ones who provide clinical care to members of the Armed Forces, and so they are the ones who will input the majority of the data. Health and healthcare information systems must support them in the performance of their role, not inhibit or skew it. Finally, it needs to be acknowledged that the introduction of new information systems requires organisational transformation across all of the Defence Lines of Development of which, two, concepts and doctrine plus training are the most important. We need to describe to our users what the information system is going to do to improve the overall performance of the DMS, we need to ensure that we have codified how this is going to be done and then we need to train our users to use the system. Much easier to say than actually do.
- The authority for the DMICP programme runs out in 2016, so there is significant urgency in designing our procurement strategy for our future Defence health and healthcare information systems.
- Our future system will be procured under the banner of the CORTISONE programme. We are an early stage in developing the programme, with a Programme Implementation Team having been set up in Feb 2013. The aim of the programme is provide a health and healthcare information capability that delivers the right information to the right people, at the right time and in the right format, in order to enable effective delivery of health and healthcare advice, health and healthcare services and medical operational capability, and thus support the Aim of the DMS. It is nested within the DMS Strategy and must align to the 3 objectives of the DMS, namely: Promoting health within the Armed Forces through understanding threats to health, influencing healthy lifestyles, developing physical and psychological resilience, and preventing and mitigating the effects of ill-health. Protecting the health of the Armed Forces community through providing specialist medical advice and generating medical capability. And finally Restoring health through ensuring excellence in the provision of safe, effective, seamless, resource-efficient and evidence-based healthcare across Defence to meet the needs of our patients and Defence.
- At this stage we know that the CORTISONE Programme will have to consist of at least the following projects: Project REBRACE will acquire the future Defence integrated Electronic Health Record that holistically captures the entire clinical story of member of the Armed Forces whilst under the clinical care of the Ministry of Defence. However, both the NHS and MOD electronic architectures are sufficiently uncertain that Project REBRACE cannot be delivered by 2016. Therefore Project INTERMOLAR is designed to provide a bridge between the current capabilities represented by DMICP and Project REBRACE. The current WHIS is not suitable for contingency operations. Project ACTUARY will be the fully scale-able deployed hospital informational capability that includes support for patient administration, imaging, laboratory support, clinical information, medicines management and an internal and external communications architecture. This will also need to include a mechanism for archiving the whole hospital record. As the analysis for the CORTISONE Programme matures, it may be necessary to develop further subordinate projects.
- Embedded within the defined projects, CORTISONE will need to deliver the following capabilities. The first, Telemedicine. As defined by the World Health Organisation, this is “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”. This is exactly the challenge faced by the Defence Medical Services, and so CORTISONE must deliver a health and healthcare information architecture that enables Telemedicine. This is likely to be focussed on developing the Centre for Defence Imaging into a Defence Centre for Telematics and providing an electronic referral pathway into accessing clinical support from RCDM. This might be as simple as a video conference between a deployed clinician and advisory group supported by electronic data and images through to some form of robotic assisted surgery in a field hospital operating theatre. Health data from all clinical activity will be contemporaneously compiled into health surveillance database that will be able to produce near-real time reports on health status and ill-health outcomes by time, place, person and causation. This will require a heuristic decision support system that can analyse clinical information without being constrained by diagnostic coding that can also capture the time and place of the clinical consultation against the defined population at risk. All data concerned with the provision of clinical care will need to be captured and retained in accordance with the Defence Health Records policy. This will need to archived, retrievable and exploited to meet the needs of patients, their representatives and the MOD. This will also need to be future proofed against changes in technology or degradation of media. The JTTR will need to be developed in the Joint Military Operational Patient Registry to capture the health record of all patients cared for by the Operational Patient Care Pathway. This will need to collate all the data generated from point of injury through to discharge from medical care, possibly including accessing their longitudinal healthcare record if medically discharged and receiving care from the NHS or third parties. The JTTR will need to import data from the REBRACE and ACTUARY Projects. The existing Patient Tracking Application will need to be incorporated into CORTISONE but to increase access and enable patients to be actively engaged in their own pathways of care. This will extend into the NHS Choose and Book system and also provide management information to line managers and the Wounded Sick and Injured Management Information System so that sick and injured Service personnel can be actively supported through their recovery pathway. The health and healthcare data within the CORTISONE family of projects will need to be integrated into a health and healthcare performance management information system, probably providing health ‘dashboards’ to the chain of command and aggregating performance indicators for the DMS from unit level all the way up the chain of command to enable the Surgeon General to report the health of the Armed Forces to the Defence Board. All healthcare professions are rapidly transforming clinical performance management from tracking CPD activities to annual professional appraisal and periodic re-validation by professional bodies. The majority of the evidence that individuals need to need these requirements is based on evidence of satisfactory clinical performance. Therefore the CORTISONE programme will need to incorporate, and provide information management support to, DMS professional appraisal and re-validation. Finally CORTISONE will need to be interoperable with a significant number of other communications and information systems. Interoperability with the NHS is the most important clinical relationship to ensure that DMS patients are able to access NHS services at least equally to other UK citizens, independent of where they are located. CORTISONE is most likely to remain hosted within the Defence information architecture and therefore will need to be compatible within the replacement to DII, DCNS. CORTISONE already has significant information exchange relationships with JPA that will need to be maintained within any future MOD personnel administration system. Finally CORTISONE will need to be compatible with military command and decision support systems, notably the future NATO medical system, MEDICS.
- Whilst not authoritative, a future network diagram might look something like this. The whole Defence health and healthcare services information system would be hosted on the DCNS network. The active Defence integrated Electronic Health Record would be hosted within REBRACE with active two-way information exchange between the NHS, Joint Personnel Administration, Patient Tracking Application (PTA) and the Joint Military Operational Medical Record (JMOMR). REBRACE would be fed as synchronous live exchange from Firm Base PHC nodes and Firm Base other users (including mental health, dental health, rehabilitation). ACTUARY would be a live feed from operations linked to a deployed server. Deployed nodes would have asynchronous information exchanges, due to the complexity of establishing and maintaining a permanent live link. The deployed system would include ‘lighter weight’ technologies such as tablets and smartphones. Some deployed systems would be run from deployed servers, and some would be independent practices that synchronise the electronic health record on a periodic basis through exchange of hardware. All systems would host the office and general CIS functionality of DCNS including VOIP, CHAT and file sharing. All systems would be capable of importing all forms of electronic media into the Defence iEHR.
- So what might the future look like? I don’t see injured soldiers being put into the back of armoured vehicles in suspended animation with robots inside and medics conducting operations from remote workstations. The actual delivery of healthcare to injured and sick Armed Forces personnel is a messy, dirty business requiring humans to provide immediate, hands on decision-making and clinical interventions.
- I do see us much better able to capture the multiple sources and media of existing medical information into a unified electronic format that will be hosted onto a single Defence integrated electronic health record that is designed to be retrievable and archived to use when and where needed after creation. I see us using bluetooth and cloud services to enable devices and users to communicate with each other. I see the hardware being targeted to the user, both in terms of the clinical record keeping interface and the use of decision support tools. I see us using electronic communication to improve ease of communication between the patient and clinicians. I see us exploiting Big Data analytics to enable us to understand the meaning of the mass of health information that the MOD will own. Our biggest challenge will be to link the procurement system to the technical subject matter experts all though our procurement and in-service management system to ensure that we get the best return on investment for our patients.
- So I hope that my presentation has: Summarised the context in which military medical information systems must operate Reviewed some of the capabilities of our current military medical information systems Described our future military medical information systems capability requirement And in closing, has highlighted some potential technological solutions to meet the DMS health and healthcare information requirements for the future.
- I am very willing to take any questions. Please could you state your name and the organisation that you represent.
- This slide illustrates the medical capability development process. Emanating from Defence policy and strategy, medical staff in the chain of command define the medical capability and capacity required to support the Armed Forces and define the Joint Medical Operational Requirement. The medical task is a component for the Defence Capability titled ‘Sustain’. Medical command and information systems, Med CIS, is one of the 7 capabilities of operational health care. From this, using the Defence Lines of Development, DLODs, medical force elements are developed by the Services and held at an appropriate level of readiness to deploy on operations. Information is one of the DLODs. Thus, Information and Medical Command and Information Systems, are critical capabilities of the DMS health and healthcare system.