Healthcare Informatics- January 1, 2001, “Patient Records_ Military Health Goes Global”

After four years of designing and testing, operational pilots of the Composite Health Care System II (CHCS II) will begin in early 2001 to fine-tune the system and begin the linking process between facilities, according to Capt. David Snyder, M.D., program manager of clinical information systems, Defense Department.

Once the final testing phase passes the approval of the Army Test and Evaluation Command, the project will have the nod for gradual worldwide deployment--planned to begin late this summer.
A global scope was necessary: The Military Health System has 100,000 providers and about 8 million patients worldwide. And the system must deliver care to covered members wherever they are, at home or abroad.

Integic Corp., formerly Universal Systems Inc., Chantilly, Va., is in charge of integrating the imposing project, for which the Defense Department has planned about $4 billion spread over the next six to 10 years.

The project planners considered using multiple regional servers to store and exchange health information but decided to employ the existing network of the Defense Information Systems Agency (DISA), which provides the primary information infrastructure for the business end of military operations. The current plan is to use DISA as a vast virtual private network and to store all medical records in one almighty clinical data repository. "We're using their preexisting megacenters to act as the physical repository and to provide the pipes to connect the various facilities," says Larry Albert, Integic's senior vice president, healthcare practice.

Another challenge was how to integrate the medical record information that the military already has stored in CHCS I, a Massachusetts Utility Multi-Programming System (MUMPS) already running at 104 military treatment facilities. Each CHCS I installation is slightly different, resulting in 104 mini-legacy systems that couldn't communicate. The new interfaces built into CHCS II will allow access to data in all CHCS I systems, and DISA's connectivity will allow record sharing among all networked facilities via the central data repository.

The Care Innovation suite from 3M Health Information Systems, Murray, Utah, won the bid for the clinical record foundation. VASCO Data Security International Inc., with U.S. headquarters in Oakbrook Terrace, Ill., is providing the security and access control features at each individual site through its SnareWorks system.

SnareWorks already included roles-based access controls and public key infrastructure-enabled architecture but had to be tweaked a bit for healthcare, explains Jonathan Chinitz, VASCO's vice president and general manager. "We have an access control system today that gives the professionals the access rights to data based on rules. But one of the big things is that you have to be able to grant that ability to the patient."

The project planners were unable to find a satisfactory desktop user interface on the commercial market, so they designed their own, based on input from an international team of physicians.

"It's not just a simple technical implementation where you develop a system and then train users how to operate it," says LTC William Lang, M.D., chief of clinical information requirements, Defense Department. "There's a functional implementation because this is so intimately involved in the clinical process of patient care. You don't want to have the system drive the clinical process. The users have to mold the system. It's very different from most systems we deploy in the military."

CHCS II managers intend to start with the physician record encounter and add pharmacy and specialty components later. "We plan to add additional functionality as we go along with frequent, small releases rather than trying to get the ultimate, perfect system and field it two years after it's obsolete," Snyder says.

The beauty of the CHCS II system is its deliberate reliance on commercially available components whenever possible. Unlike in the old days, now even the Defense Department is getting into managed care contracts and outsourcing, so it's no accident that the project sought more open-market solutions. "Where we've gotten in trouble in the past is if we built to 'mil spec,' where it would only serve the military," Snyder explains. "It became harder to maintain and more expensive to do so. It's important for us to have an approach, and ultimately even maybe a product, that our civilian colleagues can use as well. It's another reason to drive a convergence rather than a divergence."

Albert admits that most of the grunt work is on traditional problems: interfaces and tweaking at the desktop. "There was a lot out there from vendors, but it didn't exactly fit. A big part of the integration job is to maximize the utilization of what's already out there."

"We're building interfaces to a lot of the old MUMPS systems for CHCS II, but there are a lot of other military organizations that can use the same interfaces to accomplish their integration jobs," he adds. "And I think there's a high degree of transferability over to the civilian world."
CHCS II also is a key step toward the government's G-CPR (government computer-based patient record) concept: medical information sharing that crosses agencies as well as continents. "Once the systems are in place, we'll be able to share information as a patient moves through the agencies--as a recruit, through active duty service and into the VA system," Snyder says. "We'd like to have fully longitudinal, coordinated healthcare."

What's good for the military will benefit everyone in the long run. The existence of a composite clinical data repository will present the Defense Department with new possibilities for outcomes analysis, population health studies, and wellness management and simultaneously create a vast storehouse of data for public research, Albert notes. "After this system is up and running for a couple years, think of the data we're going to have in the clinical repository to start doing research. Having everything online will position us to start embracing real population health management."

For more on CHCS II, visit the Department of Defense section at HIMSS 2001.

Read more about VASCO's Healthcare Information Security.