JOMIS Will Take E-Health Records to the Frontlines
The Defense Department Military Health System Genesis electronic health records (EHR) system went live last October at Madigan Army Medical Center (Wash.), the biggest step so far in modernizing DOD’s vast MHS with a proven commercial solution. Now comes the hard part: Tying that system in with operational medicine for deployed troops around the globe.
War zones, ships at sea and aeromedical evacuations each present a new set of challenges for digital health records. Front-line units lack the bandwidth and digital infrastructure to enable cloud-based health systems like MHS Genesis. Indeed, when bandwidth is constrained, health data ranks last on the priority list, falling below command and control, intelligence and other mission data.
The Joint Operational Medicine Information Systems (JOMIS) program office oversees DOD’s operational medicine initiatives, including the legacy Theater Medical Information Program – Joint system used in today’s operational theaters of Iraq and Afghanistan, as well as aboard ships and in other remote locales.
“One of the biggest pain points we have right now is the issue of moving data from the various roles of care, from the first responder [in the war zone] to the First Aid station to something like Landstuhl (Germany) Regional Medical Center, to something in the U.S.,” Navy Capt. Dr. James Andrew Ellzy told GovTechWorks. He is deputy program executive officer (functional) for JOMIS, under the Program Executive Office, Defense Healthcare Management Systems (PEO DHMS).
PEO DHMS defines four stages or “roles,” once a patient begins to receive care. Role One is for first responders; Role Two: Forward resuscitative care; Role Three: Theater hospitals; and Role Four: Service-based medical facilities.
“Most of those early roles right now, are still using paper records,” Ellzy said. Electronic documentation begins once medical operators are in an established location. “Good records usually start the first place that has a concrete slab.”
Among the changes MHS Genesis will bring is consolidation. The legacy AHLTA (Armed Forces Health Longitudinal Technology Application – Theater) solution and its heavily modified theater-level variant AHLTA-T, incorporate separate systems for inpatient and outpatient support.
MHS Genesis however, will provide a single record regardless of patient status.
For deployed medical units, that’s important. Set up and maintenance for AHLTA’s outpatient records and the Joint Composite Health Care System have always been challenging.
“In order to set up the system, you have to have the technical skillset to initialize and sustain these systems,” said Ryan Loving, director of Health IT Solutions for military health services and the VA at General Dynamics Information Technology’s (GDIT) Health and Civilian Solutions Division. “This is a bigger problem for the Army than the other services, because the system is neither operated nor maintained until they go downrange. As a result, they lack the experience to be experts in setup and sustainment.”
JOMIS’ ultimate goal according to Stacy A. Cummings, who heads PEO DHMS, is to provide a virtually seamless representation of MHS Genesis deployed locations.
“For the first time, we’re bringing together inpatient and outpatient, medical and dental records, so we’re going to have a single integrated record for the military health system,” Cummings said at the HIMSS 2018 health IT conference in March. Last year, she told Government CIO magazine, “We are configuring the same exact tool for low-and no-communications environments.”
Therein lies the challenge, said GDIT’s Loving. “Genesis wasn’t designed for this kind of austere environment. Adapting to the unique demands of operational medicine will require a lot of collaboration with military health, with service-specific tactical networks, and an intimate understanding of those network environments today and where they’re headed in the future.”
Operating on the tactical edge – whether doing command and control or sharing medical data – is probably the hardest problem to solve, said Tom Sasala, director of the Army Architecture Integration Center and the service’s Chief Data Officer. “The difference between the enterprise environment and the tactical environment, when it comes to some of the more modern technologies like cloud, is that most modern technologies rely on an always-on, low-latency network connection. That simply doesn’t exist in a large portion of the world – and it certainly doesn’t exist in a large portion of the Army’s enterprise.”
Military units deploy into war zones and disaster zones where commercial connectivity is either highly compromised or non-existent. Satellite connectivity is limited at best. “Our challenge is how do we find commercial solutions that we cannot just adopt, but [can] adapt for our special purposes,” Sasala said.
MHS Genesis is like any modern cloud solution in that regard. In fact, it’s based on Cerner Millennium, a popular commercial EHR platform. So while it may be perfect for garrison hospitals and clinics – and ideal for sharing medical records with other agencies, civilian hospitals and health providers – the military’s operational requirements present unique circumstances unimagined by the original system’s architects.
Ellzy acknowledges the concern. “There’s only so much bandwidth,” he said. “So if medical is taking some of it, that means the operators don’t have as much. So how do we work with the operators to get that bandwidth to move the data back and forth?”
Indeed, the bandwidth and latency standards available via satellite links weren’t designed for such systems, nor fast enough to accommodate their requirements. More important, when bandwidth is constrained, military systems must line up for access, and health data is literally last on the priority list. Even ideas like using telemedicine in forward locations aren’t viable. “That works well in a hospital where you have all the connectivity you need,” Sasala said. “But it won’t work so well in an austere environment with limited connectivity.”
The legacy AHLTA-T system has a store-and-forward capability that allows local storage while connectivity is constrained or unavailable, with data forwarded to a central database once it’s back online. Delays mean documentation may not be available at subsequent locations when patients are moved from one level of care to the next.
The challenge for JOMIS will be to find a way to work in theater and then connect and share saved data while overcoming the basic functional challenges that threaten to undermine the system in forward locations.
“I’ll want the ability to go off the network for a period of time,” Ellzy said, “for whatever reason, whether I’m in a place where there isn’t a network, or my network goes down or I’m on a submarine and can’t actually send information out.”
AHLTA-T manages the constrained or disconnected network situation by allowing the system to operate on a stand-alone computer (or network configuration) at field locations, relying on built-in store-and-forward functionality to save medical data locally until it can be forwarded to the Theater Medical Data Store and Clinical Data Repository. There, it can be accessed by authorized medical personnel worldwide.
Engineering a comparable JOMIS solution will be complex and involve working around and within the MHS Genesis architecture, leveraging innovative warfighter IT infrastructure wherever possible. “We have to adapt Genesis to the store-and-forward architecture without compromising the basic functionality it provides,” said GDIT’s Loving.
Ellzy acknowledges compromises necessary to make AHLTA-T work, led to unintended consequences.
“When you look at the legacy AHLTA versus the AHLTA-T, there are some significant differences,” he said. Extra training is necessary to use the combat theater version. That shouldn’t be the case with JOMIS. “The desire with Genesis,” Ellzy said, “is that medical personnel will need significantly less training – if any – as they move from the garrison to the deployed setting.”
Reporter Jon Anderson contributed to this report.