Information Science and Technology: A New Paradigm in Military Medical Research

Abstract

The escalating pace of technologies such as computers and mobile communications systems, along with major advances in neurobiology, increases opportunities for military medical problem solving. This convergence of information technology with medicine was new as a core funded program in military medical research, but foundational research had been conducted by the Telemedicine and Advanced Technology Research Center (TATRC) through special congressional interest projects, small business innovative research programs (SBIRs), and other special funding programs in the Department of Defense (DoD) totaling $500 M/year for more than a decade before its inception. Five main thrust areas formed the new funded program supported by the Joint Program Committee 1 (JPC1) to transform military health care to a safer, will-predictive, preventative, evidence-based, and participatory system. These focus areas included medical simulation and training, mobile health (m-Health), open electronic health record and medical systems interoperability, computational biology and predictive models, and knowledge engineering. This modest investment in transformational research stands to produce huge benefits in cost savings in military medicine through improved efficiencies provided with everyday technologies.

Where is the wisdom we have lost in knowledge?

Where is the knowledge we have lost in information?

T.S. Eliot, The Rock, 1934 [1]

1 Introduction

Beginning in FY2010, the Defense Health Program included funding for research and development, specifically in Health Information Technology and Informatics. It was expected that this funding would provide the opportunity to address capability gaps through focused research initiatives and reduce programmatic risks for health care enterprise information technology projects. This funded program was labelled the Medical Simulation Training and Information Science research program (Joint Programmatic Committee 1). This program was consistent with the artificial intelligence and net-centric technological focus of the rest of the military. It also recognized important technological advances affecting information processing and access such as smart phones and high-performance computing. As a medical research domain with no significant investment by any of the Armed Services, this presented an opportunity to create a new program free of legacy laboratories, stove-piped thinking, and traditional lanes in discovery science models. Advances in computing technology and in neurobiology enable this worldwide transformation from discovery science to information science. The transdisciplinary merge of engineering, mathematics, and physics with life scientists and their problem sets has been termed “convergence” and described as the third revolution in medicine, after the advances that followed molecular biology technologies and the human genome project.

The Telemedicine and Advanced Technology Research Center (TATRC) has been uniquely positioned in the DoD to provide a tri-service base for convergence science. Originally established by Colonel Fred Goeringer as the Medical Advanced Technology Management Office (MATMO) to develop technological solutions to health information problems, the organization worked with industry for the first large-scale deployment of a standardized Picture Archiving and Communication System (PACS) in DoD radiology clinics [2, 3] (Fig. 1.1). The Army PACS evolved into the Medical Digital Imaging System (MDIS) which spurred the adoption of the Digital Imaging and Communications in Medicine (DICOM) connectivity standards through a requirement in the MDIS procurement documents to use DICOM. For a decade, under the direction of Air Force Colonel Jeff Roller, TATRC expanded the concept of use-inspired research based on technology implementation experiments. In recent years, the TATRC research model was used as a convergence science approach, especially through cooperative partnerships with the Center for Integration of Medicine and Innovation Technology (CIMIT, Boston, Massachusetts) [4], the Center for Advanced Surgical and Interventional Technology (CASIT, UCLA, Los Angeles, California) [5, 6], the Imaging Science and Information Systems Center (ISIS, Georgetown University, Washington DC) [7], and other important extramural collaborators.

Fig. 1.1

Timeline of health information technology research and development in the DoD, highlighting major milestones and key external influences. TATRC was founded to address a need for a DoD information technology research integration center, beginning with the problem of digitizing radiological images

The research in this JPC1 program was broadly categorized by the following customer and problem focus areas: (a) medical simulation and training systems, (b) mobile health (m-Health), (c) open electronic health record and medical systems interoperability, (d) computational biology and predictive models, and (e) knowledge engineering. These categories are highly interrelated, offering solution sets with soft borders that are characteristic of convergence science. This paper outlines the military’s research needs, implementation challenges, successes and initiatives, and planned program vision that established this program.

2 Research Drivers

The key requirements that were identified for this new area of research in the DoD came from a variety of sources (Table 1.1). Solving problems for military medicine benefits the nation and not just the military. These problems are more likely to be solved if the DoD champions and funds the research now, instead of waiting for an off-the-shelf solution created when someone else discovers a need and a market opportunity. The warfighter becomes an early beneficiary if the DoD is also an early adopter of the research findings. Cooperative agreement grants allow the DOD and extramural organizations to work collaboratively to solve these problems for the warfighters and the population in general.

Table 1.1 Key drivers for JPC1 research

3 Research Challenges

The JPC1 program concept has all the advantages of a new program unburdened by legacy research approaches and infrastructure, but it also faces some formidable challenges, with new approaches needed for research and research management (Table 1.2). Communications and computing technologies are advancing so rapidly that new research designs and evaluation processes must be identified to keep with the advances. The results of randomized controlled trials may be irrelevant by the time they are available because of the short half-life of the technologies evaluated (e.g., smart phone patient-provider interactions rapidly replacing video-teleconferencing center approaches). Standard approaches to peer review hypothesis-driven research may be inappropriate in convergence science efforts addressing a technology implementation and evaluation problem. The laboratory is not a conventional fixed facility wet lab; it is more likely a distributed network of scientists with common access to test environments and shared datasets. Projects require testing in limited microcosms such as regional tests (e.g., within regional health information organizations, RHIOs) and in relevant models with smaller international partners so that potentially innovative advances can be demonstrated before they are steamrolled out of existence in a big bureaucracy (i.e., the Schumacher concept of “smallness within bigness”).

Table 1.2 Challenges and unique needs in military information science research

Research must be conducted in partnership with nonmedical technology communities in the military, in industry, and with the warfighter (e.g., development of an effective electronic health record (EHR) system needs participation of enterprise system managers, information technology specialists, as well as medical users and patients). Because military medicine is lagging behind the rest of the DoD in information science applications, solutions need to take advantage of and not reinvent what has already been established in the nonmedical communities, including intelligence data analyses, military communications protocols and networks, advanced distributed learning co-laboratories, and learning and training methods and metrics.

The military medical community lacks a proponent office for formulation of requirements, policies, and implementations of new capabilities developed out of information sciences (e.g., medical training and curriculum standardization; and telemedicine offices). The only transition paths that were available within the DoD for JPC1 research findings and advanced development were via the Army Program Executive Office (PEO) for Simulation, Training, and Instrumentation (e.g., medical training manikins) and the PEO for Joint Medical Information Systems.

As a new research effort, the JPC1 has the opportunity to be based on a new understanding of the most effective approaches to promoting innovation and maximizing research efficiency. A key aspect of innovation is the recognition that end users, not industry or bureaucratic acquisition models, are the source of most technological innovation [8]. This has been especially true in medicine, with medical care providers promoting the development of the technologies they needed rather than accepting industry models of medical needs (e.g., development of the heart-lung machine). This calls for information science research models that involve participative innovation [9], with user involvement as well as careful consideration given to trends in user and societal adaptation to technological advances. A more specific example is to put new tools in the hands of medics and conduct Joint Capability Technology Demonstration (JCTD)-type experiments to find out how they choose to use or modify, and how they themselves adapt to, the new capabilities.

4 Innovation and Disruptive Technologies

Three key innovators highlight the challenges in information science and technology from three perspectives. Colonel Ronald Poropatich spent an Army career developing telemedicine technology solutions to solve urgent warfighter problems [10]. These range from early efforts in Bosnia on Primetime III medical video teleconferencing and teleconsultation, to later high priority efforts in telebehavioral health based on cell phone connectivity between patients and their case workers in CONUS, as well as extensive telemedicine efforts in Afghanistan and Iraq. These Army-funded demonstration projects provided near-term fixes to real medical information problems, benefitting many soldiers and advancing the use of everyday technologies to solve remote location military medical problems. His greatest challenges were in promoting the adoption of disruptive technologies in a large bureaucracy with an impressive resistance to change. With new affordable technologies and the persistence of a few dedicated scientists, telemedicine was finally being recognized and accepted as equivalent to face-to-face encounters and sought as an effective and needed modality to deliver health care while implementation policies and requirements lag behind.

Colonel Hon Pak established business models and test and implementation processes to provide transition points, policies, and vital infrastructure for telemedicine research, originally pioneering teledermatology research as a model of telemedicine including a series of studies to consider image quality requirements and other procedural issues [11, 12] and creating the common development environment at TATRC to provide the DoD with their only electronic health record sandbox [13]. The TATRC-sponsored Morningside initiative is an example of the process-organizing efforts for electronic health record data utilization [14]. These efforts helped to move telemedicine and health information technology into a recognized military medical specialty, with its own proponency and as a lead set of solutions to reduce future health care costs and increase patient safety.

Jaques Reifman spent more than a decade promoting the use of mathematical modeling solutions to military medical problems, collaboratively developing decision support, analysis, and planning tools with all interested and capable DoD medical research scientists. The greatest challenge was to gain recognition for computational biology as an important but overlooked research entity rather than to be treated as an afterthought statistics service. Winning rigorously competitive grant awards for high-performance computing applications in the DoD, medical decision support tools, and basic network science investigations, Dr. Reifman brought medical research across the Services into a modern era of convergence science on virtually every important topic of militarily relevant information sciences. He led the development of military medical informatics research strategies and then ensured their execution [15,16,17]. There are three examples of the influential proponents (research zealots) that are required in the advance of almost any major new research idea. They provided a solid foundation for the new JPC1-funded effort.

Disruptive innovations improve a service in unanticipated ways, usually by lowering costs or changing customer access [18]. Examples of disruptive technologies affecting military medicine include smart phones and other personal mobile communications technologies, cloud computing, ultra high-speed broadband networks, high-performance computing, and semantic web technologies. The affected markets include many conventional practices, infrastructure, and research models. Disruptive technologies are new to standard operating procedures, existing plans, and the research requirements established by an earlier generation not raised with the new communications and computing technologies. Truly disruptive processes and technologies in the DoD are typically not synchronized with the military customer or even the requirement processes because revolutionary (rather than evolutionary) advances are unpredictable and provide unanticipated advantages and consequences. Henry Ford reputedly stated that “if I had asked people what they wanted, they would have said faster horses.” This exchange with a military requirements team might have gone further: “why do you want a faster horse?” “To evacuate casualties faster.” “So you don’t necessarily want a faster horse; you want a better way to rescue and transport casualties.” The solution then could be an advanced transportation option or even a particle tele-transporter, if it were available. If we have an alternate solution such as an unaccompanied aerial vehicle casualty evacuation system, we can do other unanticipated things like recover casualties in dangerous and remote settings without a medic [19]. That is disruptive to the current investment in medic force structure and training, but it may lead to greater effectiveness on the battlefield and the advantage should not be dismissed simply because it was not in the 10 year technology forecast.

Disruptive technologies and processes such as the internet could have fundamental effects on how we organize traditional military chain of command because of the change in access to information. Nevertheless, these new approaches provide advantages to an agile and efficient military and net-centric warfare has been embraced by the Army as the way-ahead. For military medicine, this ready access to information empowers patients and has propelled the shift to a more effective patient-centered medicine paradigm, where the individual takes primary responsibility for their health, and a new emphasis is placed on wellness, prevention, and personalized medicine. It also can provide enhanced medical situational awareness, ranging from real-time warning of change in health status to military units and their exposure risks, and providing casualty data for the Joint Trauma Analysis and Prevention of Injury in Combat (JTAPIC) system [20], affecting near real-time adjustments in tactics and procedures. The JPC1 program was intentionally focused on 6.3 and 6.4 late stage research and development and advanced development strategies to embrace these advantages and reduce risk in the implementation.

5 Research Strategy: Current and Projected Research Priorities

Military requirements, external drivers (Table 1.1), and strategic plans largely shape the key research priorities for the JPC1. A summary of mission priorities are listed in Table 1.3. These are enduring needs and problem sets relevant to military medicine, not technology forecasts or specific technologies and systems. Technical workgroups composed jointly of subject matter experts and program managers are best positioned to establish these priorities.

Table 1.3 JPC1 research priorities

Technology roadmaps and strategic plans had been created in this area for more than a decade. Until this program, these were simply research visions without resources and without clear transition partners. The 1994 Army Science and Technology (S&T) Vision and Strategy Review by the ASTAG highlighted Army telemedicine systems that would be completed “within 1–2 years”: personnel status monitor, smart litter/trauma care pod, digital x-ray, electronic dog tag, and interactive telepathology (George Singley, briefing to the ASTAG, October 1993). Of these, only the digital x-ray and telepathology efforts were implemented; the electronic dog tag, personal status monitor, and smart litter were eventually technical successes, but are still not in general use.

In 2001, TATRC sponsored a large strategic planning meeting and published recommendations for strategic research investments in information science [15]. Four of the five thrust areas currently encompassed by the JPC1 were addressed, with medical simulation training included within the computational biology roadmap. Separate strategic planning was conducted for medical simulation training in 2000 [21] and again in 2008 in the larger context of the Hospital of the Future [22]. Other strategic plans were developed and published for knowledge engineering, specifically for medical situational awareness for bioterrorism and epidemic disease threats [17], for soldier physiological monitoring systems [16], the Morningside Initiative [14], and the EHR way-ahead [23]. Action on these strategies was limited not by plans but by resources. TATRC used these plans to shape Congressional special appropriations and other sources of funding to address these priorities to the maximum extent possible [13].

6 The Research Program

Ultimately, JPC1 activity is driven by the available budget. The majority of the initial JPC1 core funding in FY10 and FY11 was allocated for the first of the five mission thrust areas, medical simulation and training. Thus, the major research efforts fall in this portfolio.

6.1 Medical Simulation and Training Systems

Military training systems have been supported by mature research and development programs in each of the military services. This includes the use of sophisticated simulation technologies and advanced distributed learning networks. In sharp contrast to much of the rest of the DoD, medical training simulations lag behind. In the past decade, most medical simulation efforts have been supported only intermittently through special programs (SBIR and congressional special interest) [13]. High visibility interest in reducing the use of animals in medical training accelerated interest in this area in the US as well as numerous NATO partners (this was one of the primary discussion topics for NATO Panel 215, “Advanced Training Technologies for Medical Health Care Professionals”). The overarching goal of the JPC1 effort was to create simulation-based medical education programs for the military that will enhance patient safety, reduce medical costs, and expand access to effective training as well as individual health care empowerment. This involves bringing current technologies involving advanced distributed learning, smart phone and other mobile systems, serious games, and virtual reality into military medical applications. The strategy was to move military medical training to a curriculum-aligned, metrics-driven, objective system to train and assess proficiency of skills. A key part of the research strategy was also to benefit from the lessons learned about interoperability standards and training metrics in the nonmedical community.

In the JPC1 program, a Medical Training Systems workgroup was formed under the leadership of Thomas “Brett” Talbot. This intramural group was composed of medical training and simulations subject matter experts and nonmedical learning and simulation research program managers from across the services. The group evolved a research strategy that centered on three different user communities (prehospital care providers, medical care specialty providers, and beneficiaries) and with a fourth initiative on the development of common simulation developer tools (Fig. 1.2). The Combat Casualty Training Initiative was addressed through a competitive solicitation that resulted in several major university grants to address different parts of the evaluation of simulations for combat casualty care training priorities. These grants and several other funded projects were also intended to investigate the use of simulation for key combat medic skills such as hemorrhage control and airway management, and to evaluate replacement of live animals in medical training for procedures such as cholinergic crisis. Related JPC1 projects addressed specific training simulation options for special forces’ medic training, advanced simulators for massive hemorrhage and amputation, and the Army combat medic training program.

Fig. 1.2

Four research thrust areas in the DoD medical simulation and education program, with findings and solutions integrated through the Armed Forces Simulation Institute for Medicine (AFSIM)

A solicitation for the “Medical Practice Initiative” focused on the problem of specific skills degradation in redeployed providers. This research supported the larger strategic goal of developing a comprehensive system of automatic monitoring, evaluation, and training sustainment through the military lifecycle of care providers (“Continuous Observation of Medical Records for Advanced Doctor Education”, COMRADE) that would eventually link EHR data with an intelligent assessment and tutoring system for individual providers. Many previous TATRC workshops were exclusively centered on the topic of surgical skills development and assessment for physicians, especially with the visionary leadership of Rick Satava [24]. This was a logical starting point for medical training simulation research, especially for technology-enabled surgical procedures such as those involved in laparoscopic surgery that could be readily simulated, provide similar views and haptic feedback compared to the actual procedures, and could be scored through the motions of the manipulators. The JPC1 moved to a broader strategy to serve medical training priorities in the DoD and not be limited to surgical specialties where certification of skills is already governed by national specialty boards and societies.

The Patient-Focused Initiative was intended to enhance user interfaces and interactive technologies for patient medical training empowerment, including education, access, and rehabilitation. This initiative also continued funded efforts in the development of virtual human technology at the Institute of Creative Technologies, in collaboration with CAPT Russell Shilling’s “Detection and Computational Analysis of Psychological Signals (DCAPS)” DARPA program on behavioral cues from facial expressions, posture and activity, voice stress and speech content, sleep patterns, social interactions, and online activities that may lead to diagnostic aids and also provide more realistic virtual humans for training and other applications (http://www.darpa.mil/Our_Work/I2O/Programs/Detection_and_Computational_Analysis_of_Psychological_Signals_(DCAPS).aspx). The TATRC investment in ICT’s SimCoach (interactive avatars that are expected to be used as patient-focused behavioral health advisor tools and trainers) continued with expansion of natural language processing capabilities for a more realistic personal interaction with an avatar (Fig. 1.3). A project with the Armed Forces Medical Museum explores interactive technologies for public education in neuroprosthetic and brain-machine interface technologies being developed by the DoD.

Fig. 1.3

Bill Ford, one of the sets of virtual human prototypes developed for the military, is designed to attract and engage soldiers and family members with the goal of empowering them to take responsibility for behavioral health and to break down barriers to seeking available diagnostic and therapy resources. This is an example of research under the Patient-Focused Initiative education and training effort. Illustration courtesy of Dr. Skip Rizzo, Institute of Creative Technologies, University of Southern California

The US Army Medical Institute of Chemical Defense (USAMICD) has been a DoD leader as an end user of simulation for specialized curriculum enhancement. This laboratory pioneered significant advances in serious games training technologies to create “activated” learning. For example, Nerve Academy was a multimedia curriculum for nerve agent education that includes live animation demonstrations, a virtual instructor, and dynamic exploratory exercises. This covered principles of nerve conduction, effects of nerve agents, nerve agent casualty treatment, and advanced topics in nerve agents and included self-assessment tests. Nerve Academy was a semifinalist for the 2009 AdobeMAX award. SIMapse 3.0 was a nerve agent pharmacology simulator that kinetically portrays the behaviors of nerve agents, effector organs, and antidotes in a free-play live simulation. It accurately depicts all major unclassified nerve agents and a wide variety of antidotes used throughout the world. It included speech capability, live classroom demonstrations, and a scenario authoring tool using the TOXIC scripting language. Also included was a full laboratory book containing a curriculum of 28 progressive lessons designed to instill graduate level knowledge in nerve agent pharmacology. Other novel simulators provide specific chemical defense training (USAMRICD Cynanide Casualty Simulator; Chem Squares 2.0). CBRNE GAME (Breakaway Ltd.) was an online multiuser mass casualty simulator for civilian chemical casualties modeled after the USAMRICD Hospital Management of CBRNE incidents course to allow real-time simulated CBRN casualty events.

A fourth initiative, Developer Tools for Medical Education, supported development of a tri-service open platform for simulation at USUHS, building on the previous research efforts at the National Capital Area Medical Simulation Center (NCAMSC), as well as developing open source physiology models to drive training simulations (Fig. 1.4). One goal of this effort was to have an effective multiplayer distributed training system for team training in medical procedures (an international military demonstration project was planned within the NATO HFM-215 panel).

Fig. 1.4

Virtual cricothyroidotomy and unified surgical simulation platform for medical readiness training created by Alan Liu at the National Capital Area Medical Simulation Center (NCAMSC). This demonstrates a simple medical procedure involving psychomotor skills that can be trained with a common platform involving a computer and haptic manipulators. Illustration courtesy of Dr. Alan Liu (http://www.simcen.org/cric.html)

Training simulations require scientifically based metrics for design and evaluation of effectiveness. Standardized metrics were developed through a series of workshops organized by the Office of Naval Research with academic partners at the National Center for Research on Evaluation, Standards, and Student Testing (UCLA) on behalf of the JPC1. The first workshop focused on the individual measures and technical quality components for simulation performance assessments; subsequent workshops target practice and certification issues and team competencies.

A major investment in basic research was made from the FY10 budget to study the role of olfaction, emotion, and learning plasticity at the Monell Chemical Senses Center (Philadelphia, PA). This began to address a fundamental gap in understanding the significance of olfaction in neurological health and learning and the use of odorants in enriched environments and training, including medical simulations.

All of the medical simulation training efforts were coordinated through the Armed Forces Simulation in Medicine (AFSIM) center at TATRC, including execution and integration of many of the JPC1-funded projects in this portfolio. Major capabilities for military medical training simulation test and development included the Anderson Simulation Center at Madigan Army Medical Center (Tacoma, WA), a significant tri-service presence in Orlando in modeling and simulation RDT&E (including RDECOM), the Institute of Creative Technologies (an Army University-Affiliated Research Center in Los Angeles, CA), and the consortium established under the DARPA DCAPS program.

Other successes were supported through DoD SBIRs and Congressional Special Interest funding. These earlier projects generally fell into four categories of training technologies: personal computer-based interactive multimedia, digitally enhanced manikins, virtual workbenches, and total immersion virtual reality. Of the 175 medical simulation projects that had been funded by TATRC in the previous decade, the majority of the projects were industry-led and focused on technology development [25]. The new core-funded program was able to move from pure technology development to a longer-term strategic plan addressing fundamental issues such as interoperability, metrics, curriculum, and user interfaces.

Through the CIMIT program in Boston, Massachusetts, manikin trainers were developed, including a smallpox inoculation training system; VIRGIL, the chest trauma training simulator; and COMETS, a next generation autonomous manikin. VIRGIL was a physiologically realistic mannequin designed to train first responders to perform chest tube insertion and prevent a leading cause of battlefield deaths (Fig. 1.5). One of the Army’s Greatest Inventions in 2004, it was also used to demonstrate what was possible in medical simulations in a 2008 Wellcome Trust Museum exhibit on War and Medicine. It was compared favorably in a pilot test of USUHS medical student performance in chest tube instruction with live pigs (Col. Mark Bowyer, personal communication, 2008). The VIRGIL technology became a component of the COMETS manikin. COMETS technology was licensed by the Army to CAE and marketed as CAESAR, an interactive, full body-trauma casualty system that behaves autonomously to provide realistic training for Army medics and civilian first responders. The autonomous features are intended to reduce the instructor training load and the system can be adapted to changing training requirements. COMETS was developed out of a multiyear project at Massachusetts General Hospital/CIMIT with joint TATRC and Combat Casualty Care funding [26, 27]. The manikin provided medical simulation training for massive hemorrhage, pneumothorax, limb amputation, airway management including cricothyrotomy, and had realistic skin and eyes, multiple pulse points, and intravenous access. Another JPC1 project expanded the craniofacial simulation with emphasis on an ophthalmic trauma trainer with an embedded assessment of competency.

Fig. 1.5

The VIRGIL chest tube trainer developed in the Steve Dawson simulation laboratory at CIMIT/Massachusetts General Hospital. This demonstrates a part task trainer involving a PC-based graphical interface that tracks the internal position of chest tubes during training, providing a repeatable training experience superior to the use of live animals (Mark Bowyer, unpublished research results). Basic concepts of the VIRGIL system have been incorporated into the more comprehensive autonomous COMETS, now CAESAR, human manikin. Illustration courtesy of Dr. Steve Dawson

Other examples of projects include the development of a DVD trainer to instruct deploying physicians on compartment syndrome management, funded from the TATRC innovation program as an urgent warfighter need, and a compartment syndrome training simulator. The Wiser Institute (Pittsburgh, PA) continued a large challenging longitudinal study to assess the skill levels for management of the three most prominent battlezone injuries for combat medic trainees and of veteran combat medics at the Medical Education and Training Campus (METC) (http://www.metc.mil/). From this evaluation, recommendations were made for the use of simulations in medic training. Examples of the many efforts that have been funded in this portfolio have been summarized in a previous TATRC Report [13] and in a careful portfolio analysis [25].

Other related efforts have moved into preventive medicine training for individuals such as the internet-based weight management system developed at the Pennington Biomedical Research Center and included a longitudinal study now being tested with the Louisiana National Guard [28]. Similar technologies including the use of the online tips, encouragement, and reminders have been extensively tested by COL Vigersky in the WRAMC diabetes program [29, 30]. A joint NIH-TATRC-sponsored symposium was held on the use of virtual reality technologies for research and education in obesity and diabetes [31] and this was also highlighted in an international workshop in Warsaw, Poland, several months before. Simulation technologies and health information technologies carry huge potential as enablers in health risk communications research and related preventive medicine strategies currently pioneered in nursing research and other allied health sciences.

A unique opportunity in advanced distributed learning that spans several JPC1 portfolio areas was an FY10 awarded Coalition Warfare Program (CWP) project on Mobile Learning Environment (MoLE). This TATRC-supported, and later JPC1-supported, project was led by Naval Forces Europe/Africa and included more than 20 international partners in an effort to deliver mobile medical courseware such as just-in-time training and refresher training in support of humanitarian relief mobilization efforts. The CWP project included technical trials of the leading smart phone and other operating systems, development of integrated mobile learning capability, evaluation of mobile courseware by DoD and international partners, and identification of technical challenges to cross-cultural adoption of m-learning. This project could implement features of the GuideView project, a program jointly supported by TATRC and NASA to develop just-in-time medical training and decision support on mobile devices [32]. The concept was also expanded with JPC1 support to produce a state-of-the-art electronic version of the Special Forces medic handbook for SOCOM.

6.2 Mobile Health (“M-Health”) and Telemedicine

Telemedicine support to Operation Joint Endeavor in Bosnia in 1996 (“Primetime III”) marks the start of TATRC proof-of-concept telemedicine field demonstrations. Primetime III explored the use of communications technologies in medical consultation and the efficient transfer of radiological images between medical providers [33, 34]. Expansion of telemedicine capabilities in subsequent deployments was supported through the Army Operational Telemedicine Program under the leadership of Colonel Ron Poropatich [10]. In 15 years, technology advances, along with the public embrace of increasingly affordable and useable electronic devices, moved telemedicine from unwieldy, expensive, operationally complex systems that originally imposed an unacceptably large deployment footprint to an enabler with clear advantages demanded by a new generation of medical providers (e.g., email, cell phones, smart phones, webcams) (Fig. 1.6). The technology implementation had been limited primarily by security, privacy, and procurement issues and policies. These issues were each addressed in subsequent demonstration projects and experiments. The major JPC1 research questions involved evaluation of the quality of the medical encounter, access to care, and capturing data from the encounter in the medical record.

Fig. 1.6

Mobile Health (m-Health) is ubiquitous, with important applications in theater, in garrison, and in international and humanitarian operations. In the TATRC m-Health testbed, all of these interactions are tested collaboratively with the Army’s Medical Communications of Combat Casualty Care (MC4), the Army Battle Command Battle Lab-Gordon, and the Communications-Electronics Research, Development and Engineering Center (CERDEC)

Using the existing Army Knowledge Online secure email system, the teleconsultation program was initiated for remote dermatology consults in 1994 [35]. The concept was simple, allowing email requests with attached JPEG images to be sent by a remote provider into the unencrypted system (no personal identifying information included in the text or the images). These requests are answered by an on-call specialist within 6 h for urgent requests and 24 h for routine requests. This program has expanded to more than 19 medical and seven dental specialty services and currently include heaviest use in dermatology (43%), infectious disease (8%), orthopedics (7%), and neurology (6%), with a total of 9285 consults to theater serving more than 2292 deployed provider users since its inception (personal communication, Francis McVeigh, July 2011) [36, 37]. Consults have been answered in an average of 5 h and 8 min by a rotating call roster of providers spanning multiple time zones. One fourth of the consults have been requested by Air Force and Navy providers. Teleconsultation referrals have resulted in prevention of more than 110 unnecessary evacuations (estimated cost avoidance of $4 M) and facilitation of 415 cases of appropriate evacuations. AKO teleconsultation services were extended to all NATO forces in 2008 and are available to all NATO sites in Afghanistan [38].

The operational telemedicine research program supported medical communications demonstration projects in each of the Combatant Commands (COCOMs), including the previously discussed Coalition Warfare Program Mobile Learning Environment (MoLE) project, and vitally important theater telebehavioral health efforts. At the start of the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) deployments, limited medical bandwidth was addressed with a Joint Urgent Operational Needs Statement (JUONS) request, following TATRC experiments with the Army Communications Battle lab. This permitted projects such as the first demonstration of in-theater surgical telementoring by T. Sloane Guy in 2009 in Iraq. He used a system with adjustable camera and laser pointer attached to an overhead surgical light with integrated audio. This was initially developed and tested in teleproctoring of three clinical scenarios in collaboration with San Francisco VAMC [39]: a penetrating right ventricular injury, an open tibial fracture, and a subdural hematoma requiring craniectomy. Telebehavioral health projects were well-received by in-theater users and standardized across Afghanistan, Iraq, and Kuwait with over 80 sites providing VTC connectivity via Secure Internet Protocol Router Network (SIPRNet) to remote patients and providers to improve access to behavioral health care. Encounters were documented through the Armed Forced Health Longitudinal Technology Application-Theater (AHLTA-T). Evaluations indicated savings accrued in reductions in travel through remote medication management and combat stress management (personal communications, COL Ron Poropatich, July 2011). The most important discoveries from these experiments were the overwhelming acceptance and the user innovations in improving access to care, confirming the truism that end users are the ultimate innovators. This included factors such as improved patient willingness to use behavioral health services because of a reduction in social stigma and easier access to providers, and improved efficiency in extending the reach of a limited number of behavioral health providers. These findings directly led to General Chiarelli’s successful request to Congress to legislate the STEP Act, permitting DoD telebehavioral health services across state lines.

Research and development in military medical logistics addressed telemedical maintenance, medical supply tracking systems, and deployable medical communications units. Telemedical maintenance of CT scanners in theater began as a TATRC-funded experiment that has resulted in comprehensive “virtual engineering” maintenance support in Iraq, Afghanistan, and Kuwait, connected to Landstuhl Army Medical Center. Other efforts include support of teleradiology solutions including the Theater Image Repository (TIR), addressing the lack of centralized acquisition of all in-theater images. Tracking of medical logistics was a major challenge again in the Haiti earthquake relief effort. The Rugged Mobile Logistics System (RMLS) (VerdaSee Solutions, Inc., West Langhorne, PA) was a combination of hardware- and software-integrated solution developed into a GPS-enabled system for medical communications including locating RFID tags on medical supply pallets. This was one of the families of sophisticated medical asset tracking systems managed by TATRC.

In 2008, a new focus on traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) provided funding through TATRC to initiate the Army tele-TBI program. Three initiatives were launched: develop an Army Medical Department (AMEDD) Tele/TBI/health network; deploy transcranial doppler capabilities to Army medical centers; and develop a cell phone secure messaging system (mCare) to communicate with Community-Based Warrior Transition Unit (CBWTU) soldiers, their platoon sergeants, and their case managers. Francis McVeigh, O.D., oversees these three initiatives and directly manages the teleTBI/health network program from TATRC. The teleTBI/health network initiative provided equipment and personnel for the regional medical centers and their medical treatment facilities to establish and sustain telehealth video teleconferencing. This AMEDD TeleTBI/health Network includes 60 sites throughout five regional medical commands involving 76 support personnel who provide telehealth encounters in 22 medical specialties (behavioral health, echo-cardiology, dermatology, TBI, neurosurgery, pain management, and others). Greater than 75,000 telehealth encounters have been performed since FY10 (personal communication, Francis McVeigh, September 2011). Ongoing evaluation of the program estimates at least $5 M in cost avoidance by reducing travel and other costs, more rapid access to care averaging up to 30 days sooner in some locations, better leveraging of resources across regional medical commands, and greater than $2 M/year return on investment just from Northern Regional Medical Command’s neurosurgery teleconsultations [40]. Telehealth network initiatives used the Extension for Community Health Care Outcomes Model for telepain and teleTBI. This model used a team of subject matter experts at a hub who reach out to rural/remote clinics via video teleconferencing modalities. The remote/rural providers presented multiple cases and received consultative advice and continuing education during the sessions. This method increased rural/remote providers’ medical knowledge, promoted standardization of care, and reduced unnecessary travel for providers and patients. The Transcranial Doppler program (TCD) supported neurotrauma management to detect and treat cerebral ischemia from severe TBI-associated vasospasm. The program provided over 1376 TCD studies as of August 2011, contributing to pharmacological management of 72% of the patients and necessary follow-up procedures for 18% (personal communication, Francis McVeigh, September 2011).

The mCare Initiative was a significant demonstration effort that was elegant in its deceptive simplicity. There was an identified need to increase communication between soldiers who are spread out among multiple states in civilian communities with their case managers and their platoon sergeants. mCare connected injured warriors with their case workers at the Community-Based Warrior Transition Units (CBTWUs) utilizing the Soldiers’ personal cell phones by sending secure messages (Fig. 1.7). mCare was recognized as one of the Army’s Greatest Inventions of 2010. The project demonstrated that personal cell phones could be used as a secure bi-directional Health Insurance Portability and Accountability Act (HIPAA)-compliant messaging system within the military health care system, managed by a central, secure web portal. Over 138,000 secure messages were sent (personal communication, Holly Pavliscsak, September 2011). Messages remind patients of appointments and disseminate administrative, health, and wellness information. mCare also assists case managers by gathering important information about patients and providing real-time alerts for critical issues. The challenges in this demonstration project were to ensure open architecture and software that would operate on all major cell phone systems, address issues of internet security and patient privacy, and address changing regulatory and bureaucratic requirements such as the Defense Business Certification process approval to expand the project beyond prescribed monetary limits.

Fig. 1.7

The mCare program connects military providers and patients by secure messaging on the soldiers’ personal cell phone, increasing access to care and extending the reach of a limited number of medical providers. This program was recognized as one of the 2010 Army’s Greatest Inventions

A JPC1-funded study conducted by the National Center for Telehealth and Technology (T2) (Fort Lewis, WA) explored barriers to in-home telebehavioral health patient encounters that would allow a soldier to conduct a virtual clinic visit with a provider by personal webcam from their own home. The purpose of this capability was to improve nonstigmatizing patient access to mental health resources. Barriers to implementation included establishing the quality of telehealth encounters and unattended patient safety, as well as communications security and privacy issues, recording the encounter for the medical record, and interstate licensing issues for providers.

Multiple studies on store-and-forward approaches were conducted, with many specialties involved, ranging from TATRC-funded projects on pediatric telecardiology, e-ICU efforts [41, 42] in the Pacific rim, to teledermatology, to telepsychiatry through the Walter Reed telehealth services center [43]. These studies were concerned with cost-effectiveness compared to current standards of care and reliability when used in military applications. Telepathology was an early TATRC telehealth demonstration project that has since been implemented as a standard of practice [44]. Large investments over more than a decade in remote diabetes monitoring and management, including telediabetic retinopathy, have been a model of chronic disease management through telemedicine. A web-based chronic disease management and communication system called MyCareTeam was developed at the ISIS Center at Georgetown University. Clinical studies of MyCareTeam showed statistically significant improvements in glycosylated hemoglobin (HbA1c) for patients who used the technology compared with those who chose not to use it [45, 46]. The studies also showed that personal and frequent communication between provider and patient resulted in frequent patient use of the technology and a significant improvement in HbA1c [47,48,49]. A large series of projects by COL Robert Vigersky explored simple technology aids such as cell phone reminders, patient decision support tools, and cell phone dietary management with food photography to improve diabetes care and prevent costly hospitalization readmissions [29, 30, 50, 51]. A TATRC workshop in 2007 explored the application of these technologies in a potential Hawaii and Pacific Islands telehealth model in a remote geographically distributed population [52], and outreach studies for similarly remote and underserved populations such as native American veterans were explored, including cultural generalizability of neuropsychological tools.

Point of injury casualty data acquisition and medic decision support systems have been the topic of various high visibility telemedicine efforts for more than 20 years, notably the electronic dog tag (“EIC” and “WEIC”), a handheld medical data collection system (“BMIST”), and multiple versions of casualty physiological monitoring systems (“WPSM”). These systems developed by TATRC were named Army’s Greatest Inventions, but, for various reasons, these early efforts have not gained traction as medic tools. Eventually, the TEMPUS Pro system was selected as a candidate technology for the Joint Forces Command (JFCOM) and Joint Medical Distance Support and Evacuation (JMDSE) JCTD. This was intended to be used by combat medics for casualty monitoring, point of injury data acquisition, and telementoring. The system generated a digital Tactical Combat Casualty Care Card record of patient encounters, provided voice, physiological data, and still photo or video transmission for telementoring, and transmitted medical information over secure tactical networks from forward deployed medics to supporting medical treatment facilities and ultimately to update AHLTA and Theater Medical Data Store (TMDS) (Fig. 1.8). Following use in field training environments, the 1/25th Stryker Brigade Combat Team (BCT) submitted an operational needs statement to use the system during deployment to Afghanistan. Secure tactical radio integration was also demonstrated in Net Modernization exercises, and the system was nominated for evaluation in an Army Network Integration Exercise. The Tempus system was championed by United States Army Special Operations Command (USASOC) and the Marine Corps Warfighter Laboratory and development continued with JPC1 support [19]. This effort continued as a JPC1-funded Warrior Medical Network (“MedNet”) project to develop standards-based data capture from medical devices at the point of injury with storage in AHLTA-Theater (Fig. 1.9).

Fig. 1.8

The Tempus-Pro system was identified as a point of injury medical monitoring system through downselection of candidate technologies in a JCTD and in subsequent field studies and network integration experiments, resulting in early technology adoption by SOCOM and the Marine Corps Warfighter Laboratory. The system generates a digital TCCC record of patient encounters, provides voice, physiological data, and still photo or video transmission for telementoring, and transmits medical information over secure tactical networks from forward deployed medics to supporting medical treatment facilities and ultimately to update AHLTA and Theater Medical Data Store (TMDS). Experiments now are focused on how to acquire and collect minimally intrusive point of injury data and monitor a casualty through evacuation

Fig. 1.9

Concept of medical information flow from the point of injury to combat support hospital and CONUS facilities. This highlights a test utilizing 3G/4G smart phone communications of physiological status information from first responders, collected through a monitoring system (e.g., Tempus-Pro), and transmitted into the AHLTA-T medical record. Illustration courtesy of Dave Williams/Carl Manemeit

6.3 Electronic Health Record and Health Information Systems

The advantages of an electronic health record (EHR) over paper records are accrued through the information that can be garnered from aggregated patient data, in addition to all the advantages to the individual patient and providers that come from convenient access to complete medical records. The EHR is a disruptive technology since it changes so many current practices regarding medical information access, empowering patients and providers in ways previously unimagined. The Office of the National Coordinator (ONC) for Health Information Technologies (HIT) was established in 2004 to promote and standardize an electronic health information use and exchange. TATRC worked in close coordination with the ONC and supported the PEO-Health Information Technology at Tricare Management Activity (TMA), with Army-funded support for demonstration projects and by leveraging Congressional special appropriations. The Armed Forces Health Longitudinal Technology Application (AHLTA) is the world’s largest EHR, supporting over 9 million beneficiaries in treatment facilities around the world, including deployed environments and on-mobile devices to support real-time medical record keeping. This offers massive power in early detection of new deployment health threats, adverse drug responses (e.g., pharmacovigilance program), or for refining cost-effective standards of care. As the system improves, it will meet the Army Surgeon General’s (TSG’s) key objectives to provide timely, accurate, and actionable information for providers and the medical health system.

TATRC has been involved in this HIT research domain from its inception, dealing with early issues around transferring and archiving radiographs. A wide range of Congressional Special Interest (CSI) projects, Army Advances in Advanced Medical Technology Initiative (AAMTI) projects, and Small Business Innovative Research (SBIR) programs explored many aspects of electronic data acquisition, analysis, archiving, retrieval, display, and dissemination and utilization for modeling and simulation, data extraction, and visualization. Annual TATRC investments in health IT research over 5 years (through FY10) averaged $25 M per year.

The TATRC Common Development Environment (CDE) was a laboratory tool developed exclusively with Army funding for early-stage research support to developers responsible for integrating with and building military health systems (Fig. 1.10). The CDE supported Composite Health Care System (CHCS), AHLTA, Nationwide Health information network (NwHIN), and mobile health systems development. It provides a state-of-the-art software development and testing platform for numerous platforms (Windows, Unix, Red Hat Linux, and VMS) easily accessible to MHS, Industry, and Academia. The CDE allowed for easy collaboration on early-stage Research and Development (R&D) efforts. The Patient Ancillary Web Services (PAWS) platform for network-enabled patient data retrieval was developed by TATRC using the CDE. The CDE was also used to demonstrate the ability to transfer a standardized medical record between VA, DoD, and Kaiser Permanente Health Care through the standard Federal health Architecture (FHA) gateway and agency adapter. This was a first step in the development of the Presidentially mandated Virtual Lifetime Electronic Record (“VLER 1a”) (Fig. 1.11). A new version of the CDE with expanded capabilities such as a mobile Health test component, the Early-Stage Platform, has gained support through the JPC1 program.

Fig. 1.10

Organization of the TATRC ESP (formerly the Common Development Environment, CDE), showing platforms currently supported, the user environment interfaces, and supporting IT structure. This capability has been vital to development of programs such as PAWS and provided the test environment for VLER1a and other interagency experiments in Health IT. Illustration courtesy of Tom Bigott

Fig. 1.11

Flow of information in the Nationwide Health Information Network (NwHIN) for an initial Virtual Lifetime Electronic Record (VLER) demonstration project that successfully transferred a C32 medical record between agencies. This was demonstrated using the TATRC ESP capability

The new JPC1 effort (FY10+) was directed by a technical workgroup composed of DoD Chief Information Officers and Chief Medical Information Officers (CIOs and CMIOs), led by Steve Steffensen. This group was responsible for technical leadership of the JPC1 research in Health Information Technology (HIT), including the open EHR, m-Health/telemedicine, and medical device interoperability. The initial assessment of the workgroup concluded that early-stage HIT R&D was fragmented and unpredictable. It was based on programs whose funding was irregular and unpredictable (e.g., SBIR, CSI, service-funded programs) and the MHS-funded enterprise R&D projects did not fully benefit from early-stage R&D (Fig. 1.12). This resulted in significant amounts of directed R&D funding spent without linkage to military needs and without a strategy to use the research findings to evolve health IT knowledge; major investments in health IT were made within the TMA program offices without the benefit of early-stage R&D funding to explore options and mitigate programmatic risk. In FY10, the group established a plan to execute early-stage R&D that supported Health Affairs (HA)/TMA and military services. This was coordinated across organizations and funding sources, mitigated risk for enterprise systems, identified technology insertion and/or transition process, provided an environment for collaboration of health IT R&D stakeholders, aligned with the MHS Information Management/Information Technology (IM/IT) strategic plan, and strengthened the technical infrastructure for collaborative R&D. Four projects were supported with the limited first year (FY10) funding to address data analysis, display, and utilization research gaps (described below).

Fig. 1.12

Interrelationship of projects representing early development of Military Health System health IT research that have been supported through Congressional special interest funding prior to the establishment of the new JPC1 core-funded research program. Future SOA services can be developed to support additional use cases for both the NHIN and the MHS. These components plug into the standard-based enterprise service bus to rapidly provide new functionality

There was no tool in the MHS that has made aggregated health data in the EHR accessible and useful to clinicians, administrators, or researchers. This gap was addressed in studies with Clinical Looking Glass, a commercial application that allows clinicians and researchers to build dynamic complex patient cohorts at their desktops for real-time statistical analysis of health outcomes. Originally developed and demonstrated at Montefiore Hospital in New York, NY, this tool provided meaningful access to clinical data for quality improvement, IRB-approved research, and clinical education [53]. The application, adapted to the MHS, was used to support more than 20 studies and was piloted in the Walter Reed National Military Medical Center (WRNMMC) Medical Home. It enabled quality assurance (QA) and comparative effectiveness studies, the publication of research studies, and the validation of research findings in military facilities with military data. This showed value in improving quality of care for chronic care patients, such as those with diabetes, kidney failure, and heart disease, and in reducing costs associated with readmissions.

Predictive modeling tools are critical to the care and long-term outcomes of injured warfighters. The Knowledge Management Repository (KMR) developed by CAPT Emory Fry at the Naval health Research center in San Diego, California, and related distributed decision support system were novel tools to predict increased workload from mental health issues for returning warfighters. This was based on a scalable predictive model using statistical and machine learning algorithms to develop models for resource planning and capacity management of posttraumatic stress disorder (PTSD) patients in a resource-constrained environment. The infrastructure and tools can be configured and generalized for other resource planning requirements. The goal was to embed these models in a new health care planning tool designed to investigate how population characteristics and operational data influence demand forecasting under a variety of risk profiles, as defined in the TATRC-sponsored 2007 Morningside Initiative [14]. The KMR platform was adopted as the reference middle tier for the Nationwide Health Information Network (NwHIN) to provide its services across diverse infrastructures. The open source code developed was contributed to the Federal Health Architecture (FHA) as a reference analytic platform for use by the CONNECT community. This DoD contribution by Dr. Steve Steffensen and CAPT Emory Fry to enable the conversion of agency-specific data elements to standardized sharable information in the NwHIN was recognized with a ComputerWorld Honors Award in 2008.

A variety of visual dashboards and heads-up displays of patient conditions were explored in DoD research including systems for the Operating Room of the Future pioneered by investigators in the CIMIT program (Boston, Massachusetts) and by the Parsons Institute for Information Mapping (PIIM) (New York, New York). The PIIM prototyping continued with JPC1 funding in support of the Program Executive Office (PEO)-Health IT at TRICARE Management Activity (TMA), to design a dashboard using standardized visual styles (e.g., typography, graphics, iconography) to support views for various personnel in the clinical environment. The PIIM Visualization Toolkit (PVT) streamlined engineering of prototypes while retaining a deployment-ready technology stack. This effort used the Patient Ancillary Web Services (PAWS) platform for network-enabled, patient data retrieval and compliments these technologies with PIIM-developed write-back functionalities. PIIM also investigated innovative ways to visualize patient health information and patient health histories, creating “Intelligent Iconography” from existing health information to provide snapshot visualizations of patient health and histories. This method would compress complex and historical patient and public health data into single, comprehensive, and portable visualizations. PIIM’s work showed that better visual displays, more intuitive user experiences, and easy-to-use tools are crucial to a successful EMR.

Various graphical user interfaces (GUIs) were developed as workarounds for providers to obtain information from different systems, connecting the Veterans Health Information Systems and Technology Architecture (Vista) and DoD’s Composite Health Care System (CHCS) information into a common view. Janus was an example GUI application developed to provide a common view for dual beneficiaries. This effort started under the leadership of Stan Saiki in 2003 as a demonstration at Tripler Army Medical Center (TAMC), where VA and DoD services are collocated and dual beneficiaries can access both services. Providers needed a way to access information from two completely different health information systems, including pharmacy orders and laboratory results; a bi-directional pharmacy ordering interface was also developed as a first of its kind in the US. In 2009, JANUS was upgraded to include the ability to share the different systems’ PACS images. The changeover between different systems was an even larger issue for the transfer of records from the DoD to the VA (or the Indian Health Service) when soldiers left the service. TATRC explored numerous projects in the transfer of information between medical organizations through bidirection health information exchange networks (BHIE), as well as developing an immediate fix to the problem of medical record transfers between DoD and VA polytrauma centers when this became an urgent issue in OIF (personal communication, MAJ Frank Portals, 2007).

The CIMIT program involving a consortium of the major medical research organizations in Boston, Massachusetts, supported the Medical Device “Plug-and-Play” Interoperability program led by Julian Goldman. This program grew with direct TATRC support and also secured a National Institute of Biomedical Imaging and Bioengineering (NIBIB) multi-institutional quantum grant focused on full integration of medical equipment and electronic health record systems into smart networks through the Integrated Clinical Environment (ICE) framework. This included development of software tools and simulation environments to accelerate innovation in clinical applications and produce error-resistant medical device systems (i.e., ICE-compliant equipment for military and civilian care). The requirements for this research were outlined in national strategy meetings [54].

In March of 2008, Seong Ki Mun and COL Hon Pak convened the National Forum on the Future of Defense Health Information Systems (National Forum) at Georgetown University to address major themes in the development and implementation of the longitudinal health record (LHR) [23]. This TATRC-sponsored forum brought together experts from government, industry, and academia to focus on longitudinal health records, systems architecture, knowledge management and discovery, and interoperability. The results from this forum were published in a special supplement to the Journal of Military Medicine. A summary of the high-level recommendations from the forum is summarized in Table 1.4.

Table 1.4 Key recommendations from the National Forum [23]

Current JPC1 investment in development of recommendations for a framework for aspects of the electronic health record research effort includes policy (RAND), data standards and interoperability approaches (MITRE), and modeling and simulation efforts (SEI). These collaborative efforts with Federally Funded Research and Development Centers (FFRDCs) were intended to address strategic focus areas as a foundational activity. The developmental activities over a decade were largely shaped by rapidly changing external forces such as deployment experiences (e.g., 1990/1991 Gulf War mystery illnesses and medical documentation), technology advances, and funding opportunities (Fig. 1.1). JPC1-funded experiments target near-term MHS research concerns in identity and registry management to test policies and procedures regarding who can access medical data and how to regulate it. Agile development processes were a key aspect of testing the roadmap. This called for clinical user community involvement throughout the development (i.e., Pasteur model of use-inspired research), instead of “waterfall” development involving the intended user only at the beginning and end of the project. Foundational researches on policy, interoperability, data standards, and clinical modeling and simulation were keys to solving problems with patient safety, medical care efficiency and cost reduction, and rapid implementation of innovation. This research effort was intended to develop concepts and products up to the level of “enterprise capable” and then hand them off to operator testing and development of “enterprise ready” systems by the TMA/DHIMS (Table 1.5).

Table 1.5 Significant accomplishments of the Joint Technical Coordinating Group 1 (JTCG1)

Future interoperability for the EHR, as well as other cloud computing and database applications, will depend on interoperability standards and semantic web technologies. TATRC supported foundational work in this area, especially through the CIMIT program and Massachusetts General Hospital for the creation of national and international standards led by Julian Goldman [54] and the semantic web technologies in the TexShield program led by Parsa Mirhaji [55]. The Morningside Initiative outlined an approach to manage collaborative knowledge sharing with clinical decision support to include genomics and to involve public and private sector participation [14].

6.4 Computational Biology and Predictive Models

In 1999, Harold Varmus received recommendations on information science and technology from an expert panel whose observations were also relevant to other federal agencies: “Increasingly, researchers spend less time in their “wet labs” gathering data and more time on computation. As a consequence, more researchers find themselves working in teams to harness the new technologies. A broad segment of the biomedical research community perceives a shortfall of suitably educated people who are competent to support those teams… What is needed is a higher level of competence in mathematics and computer science among biologists themselves” [56]. The DoD also recognized this critical need [57]. For at least a decade, Jaques Reifman led computational biology in DoD medical research, with a mandate to collaboratively develop these capabilities in military medicine. As one example, he promoted the use of DoD high-performance computing resources to solve medical research problems in biological defense. With support of a multiyear grant from a DoD High-Performance Computing office, his team developed and implemented 14 software applications for research on diagnostic assays and to identify drug and vaccine candidates (Fig. 1.13). These tools provided significant advantages in time and efficiency for military lab researchers with virtual screening for drug discovery, potentially reducing months or years of work to days. One of the most widely used applications, the Docking-based Virtual Screening (DOVIS) software, developed for screening of small molecule drug candidates based on receptor-ligand interactions, was downloaded by over 1000 users in the research community [58]. Another application, the Protein Structure Prediction Pipeline (PSPP), provided a tool that could be used on any high-performance system to conduct sophisticated analysis of three-dimensional protein structures from known sequences, including rapid examination of thousands of models assembled using energy functions and other rules [59]. Such tools complement traditional laboratory methods to determine protein structures, providing a major advance in the ability to analyze potential binding partners and active sites and to support efficient in silico drug screening. The work accomplished under this initiative addressed research gaps identified in the 2001 TATRC strategic plan for biomedical informatics, including all of the near and mid-term gaps [15]. The longer-term strategic objective expanded the effort to a sophisticated information management system that could process an unknown sample [60], match its characteristics to related known chemical or biological threats, and produce relevant threat management recommendations (drawing on the worldwide database of relevant existing studies).

Fig. 1.13

Schema of biospecimen analyses addressed by high-performance computing applications developed by the BHSAI. The development of these software applications came about from intramural laboratory collaborations and was funded through a competitive grant from the DoD High-Performance Computing Modernization Program. Illustration courtesy of Dr. Jaques Reifman

Jaques Reifman’s Biotechnology High-Performance Computing Software Applications Institute (BHSAI) had a large network of collaborations, including tri-service research laboratory participation. In addition to the development of analytical tools, the BHSAI modeled biological processes from algorithms and tools that advance physiological monitoring systems [61] to human sleep physiology studies [62] and thermal strain predictions [63] to in silico replication of metabolic networks for drug discovery (that help reduce reliance on animal testing) [64]. Systems biology problems were addressed in blood coagulation [65], traumatic brain injury, PTSD, and glucose regulation for closed loop system regulation [66, 67]. A key limitation to advances in the widespread application of such computational methodologies is often the limited access to datasets. New data sharing requirements pioneered by the NIH and new concepts of immediate data sharing to accelerate scientific discovery [68] help to remedy this problem.

Sensor data fusion with a physiological underpinning has been a key shortfall in soldier monitoring for more than 30 years since this was seriously considered. The personal status monitor described in Heinlein’s Starship Troopers was the conception for a system that would permit a commander to have full intelligence on the performance readiness status of troops and would help medics and support casualty evacuation [16, 69,70,71] (Fig. 1.14). Many versions of monitoring devices have been proposed including the Army’s WPSM (Fred Hegge, personal notebooks), NASA’s Lifeguard [72], and a wide variety of commercial products. The challenge has not been in the engineering of smaller measurement devices, but in the management of the information from a minimal combination of sensors to predict outcomes of interest (performance impairment from fatigue, life-threatening hemorrhage, likelihood of death, impending environmental injury, etc.). Commanders and medics may not find raw physiological data of use with elevated heart rate signifying activation for combat or life-threatening hemorrhage. Meaningful interpretation of the signals are not trivial problems, yet have been largely overlooked except for a few efforts such as those of Reed Hoyt at USARIEM [73,74,75] and Jaques Reifman at the BHSAI [76, 77]. True decision support systems are necessary when there are billions of options, and informatics and computing technologies now make this feasible in complex integrative multi-scale models.

Fig. 1.14

The Warfighter Physiological Monitoring (WPSM) concept, first articulated by Dr. Fred Hegge in 1996, includes wear and forget sensors that provide intelligence to commanders on soldier readiness and convert to a medical monitoring mode when a casualty event is detected and through medical evacuation. Development of computational biology models to accomplish sensor data fusion and create actionable (useful and reliable) information has been the rate limiting step in advancing WPSM decision support systems. Illustration reconfigured from Friedl, NATO technical workshop HFM-151, 2007

Even before decision support tools are validated and approved for medical interventions, these models can provide near-term casualty monitoring benefits and could be integrated into the same systems that medics will bring to the casualty starting at the point of injury. Andy Reisner developed an automatic processing system for assessment of injury severity using full-automated diagnostic algorithms that analyze vital signs patterns of trauma patients transported by Boston Medflight using an innovative plug-and-play computing platform [78]. The longer-term goal from the 2001 strategic planning meeting included developing a computer-based medic aid for triage of unforeseen injury conditions. This would run on a smart phone type of device or perhaps on a medic-borne medical monitoring device also connected into the health IT network such as experiments that were conducted in the JCTD.

Closed loop regulation of glucose and volume control in casualties was a near-term goal of the same modeling efforts, with national research efforts and standards driven by Robert Vigersky and David Klonoff [79, 80]. A productive Army collaboration produced a universal data-driven model to predict subcutaneous glucose concentrations, made possible by the availability of important patient datasets to develop and test this model [66]. High reliability predictive algorithms will be useful for interpretation of new continuous glucose monitoring technologies as well as in closed loop systems including the military trauma pod of the future.

The medical community has an important role in developing models of human tolerances and damage risk criteria for military materiel developers to be able to conduct their human factors and safety planning for new materiel and systems, including personal protective equipment and survivable systems [81] (Fig. 1.15). Comprehensive biomedical models can provide developers with an in silico prototyping capability that would be especially powerful when combined with any of the many other military human systems models [82]. This supported the Secretary of Defense’s objective to increase use of prototypes to ensure that programs are ready for subsequent phases of development (Robert Gates, testimony before the SASC, January 27, 2009). Such virtual prototyping tools of human limits assist materiel and combat developers in considering human health and performance from the very start of a new program. Physiological models for health hazards assessment and prototyping of better soldier protection have been conducted for more than a decade for problems such as blast, auditory, and inhalation toxicology exposure limits [83,84,85]. However, these individual hazard assessment models have never been combined in militarily realistic comprehensive models (e.g., effects of blast exposure combined with inhalation of fire gases, or brain injury outcomes affected by head impact in combination with metabolic status, hemorrhage, psychological trauma, etc.). The complexity of such modeling tends to be underappreciated and requires considerably more experimental data input, collaboratively developed with the modelers, than a single animal or cadaver experiment. For example, a significant modeling effort on blunt impact risk could provide important insights into effective lighter weight body armor. Developing a new scientifically based evaluation system that could replace an antiquated clay deformation test involved finite elements modeling (FEM) of pig and human torsos based on CT images, a series of animal blunt trauma tests with CT images, measurement of chest wall motions and lung pressures, and pathology data, and then scaling of the human FEM to simulate equated frontal and side human subject impacts [86]. An Army and Marine Corps collaboration was initiated to develop a comprehensive model of load carriage for mission planners and materiel developers. This was supported by JPC1, in close coordination with JPC5 (Military Operational Medicine).

Fig. 1.15

Damage Risk Criteria have been developed from physiological models such as the three examples illustrated in this figure. Each of these computational models, critically important to nonmedical materiel developers, was developed by Jaycor/L-3, San Diego, Californa. Illustration courtesy of Mike Leggieri

6.5 Knowledge Engineering

To make the growing body of biological data available as an organizational memory, there is a critical need to develop methods of knowledge conservation (storage and curation), retrieval, and analysis. There is extraordinary power that comes from accessing the growing electronic database cloud and this information will become increasingly accessible through the development of semantic systems tools. The possibilities for global medical disease monitoring using information already available in disparate databases were epitomized by the work of Rita Colwell in the prediction of cholera outbreaks 6 months in advance of the event based on oceanographic and meterological data [87]. Useful information can be derived from widely disparate sources of data. Even massive multiplayer games have been used to gain new insights into human behavior during a lethal epidemic, as was observed by the peculiar rush into danger by players during the inadvertent spread of an infection in the Worlds of Warcraft game [88]. Medical situational awareness systems were explored by TATRC and the potential was illustrated by early experiments by the ISIS Center (Georgetown University) with Project Argus. The Argus experiment explored early detection of biothreat events based on automatic detection of combinations indicators of social disruption, such as changes in the use of medical services and other public behaviors in a region [89]. Patterns and content of communications between soldiers may identify behavioral health issues or provide automatic indicators of unit cohesion and stress. Automatic knowledge generation through algorithms, models, fuzzy logic associations, and tools such as those produced by Google were important for useful conversion of data to information and knowledge. In an earlier collaboration with TATRC and the 1994 Defense Women’s Health Research Program, Fred Hegge conceived the Army Medical Knowledge Engineering System (AMKES) for automated access to medical knowledge based on storage of information “nuggets” (generic knowledge objects, GEKOs), each containing values for rule-based utilization [90]. The application to providing women with current breast cancer information was recognized with a Computerworld Award. The shortfall in this system was the labor-intensive creation of the structured knowledge elements. The DoD pharmacovigilance system led by Colonel Trinka Coster in collaboration with the FDA has explored the use of powerful data mining programs to identify drug associations with adverse events in the clinical data repository [91]. Current efforts with specific registries such as the Joint Theater Trauma Registry have provided immediate value to the current deployment combat casualty care. Using this database, many trauma care issues were identified and addressed through education or changes in clinical care, including the development of 27 evidence-based clinical practice guidelines. The damage control resuscitation guideline was associated with mortality decrease in massively transfused from 32 to 21% [92]. The JTAPIC system combined medical casualty data with information about personal protective equipment, vehicles, and contextual information such as tactical situations to produce vital intelligence changing threats to soldiers and effectiveness of protective equipment against those threats [20]. The WDMET database was an early attempt at such a database. Started late in the Vietnam War to retrospectively investigate effectiveness of protective equipment, the investigators lacked modern computational tools that would have made this feasible and essential to agility in modern warfare [93].

Emerging technologies such as semantic web technology will make these fixed data element standalone registries unnecessary with push-of-the-button access to all relevant data derived from existing medical records and other data systems. Semantic web technology development was a critical investment area for JPC1. An effective EHR eliminates the need for any future “registries,” any of which could be established with a few key strokes. Ultimately, modeling depends on data. For researchers developing new knowledge, national data sharing is critical to the speediest advance of knowledge creation. New breakthrough data sharing models such as the national Alzheimer’s Disease Neuroimaging Initiative (ADNI) have already produced unanticipated benefits across the board in accelerating interpretation and utilization of this important information to advance industry and academic efforts in disease monitoring and drug development [68]. Semantic tools to facilitate sharing of important data from the massive military investment in TBI and PTSD research are urgently needed.

7 Conclusions

The soft boundaries for JPC1 research were drawn around the main objective of the research. Within the military medical funding domain, if the intent is to develop information technologies or test the efficacy of the tools in their applications, it fell to JPC1. If the primary intent of the research was to solve a key question in prevention, diagnosis, treatment, or rehabilitation of dengue infection, PTSD, TBI, or vision loss, it would probably fall to other specialty programs such as JPC2 (Infectious disease research), JPC5 (Operational medicine research), JPC6 (Combat casualty care), or JPC8 (rehabilitative medicine). The boundaries were very soft for JPC1 because of the cross-cutting nature of information science. It would be reasonable to expect the JPC1 to subsume the majority of the military medical research investment within a few years, as the research world transform science to information science. At that point, it would represent a common basis for convergence science and would no longer need a distinct specialty program, with full integration in all the other research areas. At its start, the new JPC1 program was composed of relatively small demonstration projects that were beginning to form the interconnections of larger consortia and comprehensive efforts spanning disciplines and organizational boundaries. The JPC1 program should lead the convergence of information science, cyber infrastructure, and biomedical research in military medicine with multi-scale multimodal multisite science.