Imagine one of the busiest clinics you've ever seen; then change its medical specialty every few months. Next haul the clinic to a different location around the world every few weeks or months. Now try to keep and maintain records of all the clinical events for every patient that enters that clinic" until they die.
Welcome to the world of the clinicians, medical information officers, information technology managers and commanders responsible for attending to the healthcare of personnel aboard a United States Navy ship. US Navy Commander Melanie Merrick is a typical member of that high-pressure corps.
"I can give you 20 minutes," she said. "I've got a helicopter full of Haitian kids arriving and I've got to make sure I'm there when they land."
Merrick is the senior medical officer aboard the USS Bataan, a multi-purpose amphibious assault ship that includes medical and surgical facilities, which was stationed off the coast of Haiti in February, providing relief to earthquake victims. "There were a lot of people waiting on the beach when we arrived, much more than we expected," she said about why her time was short.
The Navy is called upon to play a multitude of roles these days: besides providing security on the high seas and supporting combat operations, it also extends medical attention to citizens of developing countries and provides to relief victims of natural disasters.
Navy vessels like the Bataan, or the USS Kearsarge, which was recently docked at its home port of Norfolk, VA, are equipped to one degree or another to take advantage of health IT capabilities such as electronic medical records and telemedicine. But capabilities differ depending on the ship and the circumstances.
The Navy envisions a day when all of its vessels will make ubiquitous use of electronic health records through a worldwide, bidirectional system. But achieving a vision in which shipboard EHRs will be able to call up medical data in real-time will require upgrades to the fleet's information systems and supply of bandwidth"its available data communication resources.
And that's easier said than done. Maintenance priorities are dictated by the ship's captain, so overhauling weapons, navigation and command and control systems, or the galley and hull are likely to take precedence. At an industry briefing this spring, Charles Campbell, the chief information officer of the Military Health System, which supports all three military services, described the challenge of outfitting a perpetually moving, tightly scheduled customer like a Navy ship.
"How do you get EHR systems onto ships? We can't just go out to a ship while they're en route," Campbell said. "Ships are very secure; they do things a certain way and if you don't follow their specific rules, you're not getting onto their ship. You have to wait until they're back in port and ready for retro-fitting; that's absolutely vital to them."
At this point, an updated medical record system has been installed on 19 of the Navy's hundreds of ships. Several more are scheduled to be outfitted by the end of this year. In the meantime, medical personnel aboard vessels like the Bataan and the Kearsarge must make due with a medical record patchwork which includes paper records as well as systems which provide some connectivity some of the time to central databases.
Changing hats
Medical personnel on vessels like the Bataan must change hats depending on the type of mission they are pursuing. Earlier this year, Merrick and her staff were helping Haitians; when deployed to theater, they are treating wounded warriors; when in port, their main role is to see to the medical readiness of the Bataan's crew.
The Department of Defense's effort to establish a unitary electronic medical record system"AHLTA"connected to the military's central medical database" the Clinical Data Repository (CDR)" is intended to benefit members of the armed services and other beneficiaries of the Military Health System.
So data on Haitian patients receiving critical care aboard the Bataan is recorded on a spreadsheet, which can then be shared with other medical providers aboard other vessels, such as the USNS Comfort, a Navy hospital ship, which includes after-care capabilities.
"We record the name, age, injury and disposition," said Merrick. "Once we treat them, they are either referred to the Comfort or returned home." Providers on the Bataan and the Comfort also chat online about patients they have in common.
When not occupied with humanitarian aid, Merrick and her team are focused on the medical readiness of the Bataan's crew. "We maintain readiness with anthrax and smallpox vaccinations and we take care of injuries that may have been incurred in battle or in port," she said.
Merrick has access to patient histories and lab results on a read-only basis, over shipboard communications systems. "This information may have been entered in AHLTA anywhere in the world," said Merrick. "But we don't have access to sufficient bandwidth so that we can input our information. There are many other uses for bandwidth on board ship."
Immunization data on the Bataan's crew are inputted into Shipboard Automated Medical System (SAMS), but laboratory reports and encounter notes are still recorded on paper and "do not get recorded in AHLTA," said Merrick. "These are not necessarily reproduced in the electronic record if someone had to look for it."
Hodgepodge history
Navy ships host a hodgepodge of standalone systems and connecting networks characterized by redundant hardware and software which limit bandwidth and slow communications. The Navy has embarked on a program, the Consolidated Afloat Networks and Enterprise Services (CANES), to consolidate and streamline shipboard systems. But that program is still in its developmental stage and will take years before it is eventually completed and deployed.
SAMS is a Navy-specific system that was originally developed to track Navy medical supplies. "SAMS was originally part of the Navy supply system and had a basic medical module which was available only on ship," said Rear Adm. Thomas Cullison, the Navy's deputy surgeon general. "If we wanted to exchange data, we had to put it on a floppy disk."
Cullison, a Vietnam veteran, held several medical command positions before being appointed to his current post in 2007.
Developed in 1986, SAMS was first used in an era when each of the US armed services was developing its own electronic health record for deployed forces. The Air Force developed the Global Expeditionary Medical System (GEMS), while the Army focused on the development of the Theater Medical Information Program (TMIP).
SAMS eventually became absorbed into TMIP, and TMIP became a program of the Military Health System. MHS is responsible for the development of AHLTA, which has been designated as the service-wide EHR.
SAMS is in the process of being updated to make it more "AHLTA-like," said Cullison. "What has evolved over the years through TMIP is a Navy system which is more like AHLTA, so that they can be used in an integrated fashion, but not exactly AHLTA." The updated Navy system is still called SAMS, so that there are actually two SAMS systems being used by the Navy: "legacy SAMS" and "new SAMS." The Bataan and the Kearsarge have not yet been updated to the new system.
Evolution to AHLTA
The legacy SAMS is composed of three modules: patient encounters, radiology and medical logistics, explained Col. Claude Hines, program manager at the Defense Health Information Management System (DHIMS), the agency which is charged with the development of the new SAMS.
"We are in the process of upgrading SAMS to the MHS applications," said Hines. "The patient encounter module is done" a
