Establishment of E-Health Network for Disasters and Healthcare Improvement: Integrated Medical Information Technology System

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Establishment of E-Health Network for Disasters
and Healthcare Improvement Integrated Medical
Information Technology System Partner concept
between Academies and Medical entities Yukako
Yagi University of Pittsburgh Medical Center,
Pittsburgh, PA, USA
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Background Why E-Health Network?

• In March 1, 2001, the Institute of Medicine (IOM)
  stated that
• The American health care delivery system is in
  need of fundamental change. Many patients,
  doctors, nurses, and health care leaders are
  concerned that the care delivered is not,
  essentially, the care we should receive. Health
  care today harms too frequently and routinely
  fails to deliver its potential benefits.
• The difficulty in maximizing the benefits of
  increased clinical and business knowledge and
  advanced diagnostic technologies comes from the
  basic problem of collecting, integrating and
  managing health information in various formats.
  Further, this data is stored in multiple physical
  locations that are often distant and hard to
  access when treating individual patients,
  especially those with critical medical needs.
• use of information technology is key

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University of Pittsburgh Medical Center
4
UPMC has established Telemedicine Network through
the system
Facts and Figures
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Overview Program Description

• looking increasingly towards technology-assisted
  solutions to optimize how they manage and deliver
  health care.
• Non-Civilian Medical Facilities (NCMF) and UPMC
  have created a partnership to collaborate on
  developing technology-assisted solutions to
  real-world medical problems
• The partnership is defined as the Integrated
  Medical Information Technology System (IMITS)
  Program.

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Overview Program Description

• The IMITS program pioneers the application of
  state-of-the-art information management (IM) and
  information technology (IT) solutions, including
  advanced business and clinical decision support
  tools. This initiative brought together vast
  clinical and information technology expertise of
  both institutions and aids in the recognition and
  treatment of many types of medical conditions.
  In addition, the NCMS-UPMC partnership is
  providing new opportunities for enhancing
  expertise, evaluating solutions to technical
  dilemmas, and deploying strategies to address key
  medical issues.

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IMITS Project

• Congressional Special Interest Appropriation
• FY02 8.5M - Establish initial project
  Integrated Medical Information Technology System
• FY04 10.2M - Continue current projects
  expand into Pacific Rim

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Scope

• The initial focus of the IMITS Program was on
  telemedicine and associated advanced
  technologies. The overall program objective is
  the design of new state-of-the-art clinical and
  business models supporting the delivery of fully
  electronic multi-media enabled electronic health
  records. The projects described below will be
  organized under the umbrella of the IMITS Program.

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Scope Multi-specialty Tele-consultation Project

• Situations
• There are many medical facilities in locations
  where specialty medical care is not readily
  available.
• Patients often must travel significant distances
  and taking time off from work.

• Resulting in
• Expense to both the patient and the enterprise
• A delay in the diagnosis and treatment of the
  presenting medical condition

Solutions
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Scope Multi-specialty Tele-consultation Project
Solutions

• Developing and refining computerized medical
  records, enhancing medical information retrieval
  and patient tracking, and creating clinical
  decision support rapidly increases the capability
  to provide high quality cost-effective medical
  care to non-civilian beneficiaries and civilians
  in even the most remote locations.
• To design, build and test a multi-specialty
  teleconsultation system on a common technology
  platform. This system will provide widely
  available, flexible, clinically relevant services
  across multiple medical specialties on a secure,
  stable low cost technology platform utilizing
  asynchronous and synchronous communications.
  This will allow general clinicians and medical
  personnel access to remote expert advice,
  diagnosis and mentoring and in so doing
  contribute to providing a high-quality standard
  of care independent of location.

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Scope

• The Multi-specialty Tele-consultation
  Demonstration Project was divided into the
  following areas
• Distributed Radiology Imaging Demonstration
  Project The design and implementation of a
  distributed radiology imaging system utilizing
  the Stentor platform at a medical facility in
  Dayton, Ohio. The system was connected to UPMC
  linking the radiology departments for education
  and service opportunities.
• Pathology Tele-consultation System Demonstration
  Project The design and implementation of a
  telepathology system at a facility in
  Mississippi. The system is connected to UPMC
  linking the pathology departments for education
  and service opportunities.
• Behavioral Health Tele-consultation System
  Demonstration Project - The design and
  implementation of a behavioral telehealth system
  at a facility in Texas. The system connects to
  UPMC linking the behavioral health resources for
  education and service opportunities.
• Pediatric Cardiology Tele-consultation System
  Demonstration Project

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Approach/Strategy

• A high-level project work plan will be included
  in the individual scope of work documents. The
  main focus of the program will be on the
  implementation of tele-consultation applications.
  The tele-consultation implementation work plans
  have been developed based on a standard
  implementation methodology and are organized into
  seven major segments with corresponding
  activities as follows

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Approach/Strategy
I. Project Set-Up Confirm project governance and
organization structure. Confirm project roles and
responsibilities. Confirm communication
structures. Confirm methodology approach.
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Approach/Strategy
II. Analysis Conduct application education and
training. Document functional and technical
requirements. Assess hardware, interfaces and
network. Document software requirements,
conversion decisions, and data standard
initiatives. Identify training needs and sites.
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Approach/Strategy
III. Design Complete system design. Develop
conversion specifications and interface
specifications. Identify data standards and file
setups, customizations, and security requirements.
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Approach/Strategy
IV. Development Complete system build. Begin
programming conversions, interfaces, and
customizations. Develop new policies and
procedures. Develop menus, forms, reports and
screens.
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Approach/Strategy
V. Testing Define testing scope and
approach. Identify testing team. Develop
integrated and product specific test
plans/scenarios. Conduct testing system
acceptance, unit, application, integration,
stress, security and network/communications
testing.
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Approach/Strategy
VI. Training Develop training plan and
materials. Schedule and conduct user training.
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Approach/Strategy
VII. Conversion/Post-Live Support Develop
go-live plan. Identify support team for
go-live. Determine conversion downtime
requirements and system freeze dates. Prepare
contingency plans. Perform conversion. Identify
post-live issues team. Initiate post-live support
and transition.
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FY 01-02 IMITS
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FY 01-02 IMITS

• Business Problem
• Shortage of specialty physicians
• NCMF high priority Radiology
• Goal
• Improve access to care and provide quality
  healthcare services to individuals regardless of
  location

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FY 01-02 IMITS ProgramImplementation Overview

• Extended period to move money and negotiate
  agreement
• Pre-award implementation of Radiology project to
  meet NCMF requirements to replace legacy systems
• Rigorous security requirements that necessitated
  adjustments to project timelines

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IMITS ProgramDistributed Imaging

• Dayton, OH
• Installation of Stentor iSite COTS
• UPMC customizations for NCMFs workflow, global
  hub and spoke strategy
• Replaces legacy PACs system
• Establishes footprint for global NCMF image
  distribution infrastructure
• Evaluation of provider acceptance and satisfaction

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FY 01-02 IMITS ProjectsDistributed Imaging

• Current Status
• July 1, 2003 - Technical go-live
• August 27, 2003 - Clinically live on private
  subnet
• November 14, 2003 Notified of impending final
  security accreditation
• November 24, 2003 Move from private subnet to
  live radiology network
• January 20, 2004 Clinical go-live
• February 2004 Begin UPMC customization
• March 2004 UPMC Radiologist wrapper installed
• May 2004 Clinician wrapper installed
• June 2004 STE for upgrade to iSite v3.2

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IMITS ProgramTelepathology

• Biloxi, MS
• Installation of UPMC Static Telepathology
  (Mississippi, Florida, California)
• Installation of dynamic telepathology for
  educational purposes (Mississippi, Florida,
  California)
• RD on whole slide imaging (Mississippi,
  Pittsburgh)
• Progressive technology for imaging and storage of
  pathology specimens
• Evaluation of provider acceptance and satisfaction

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IMITS ProjectsTelepathology

• Current Status
• Feb 2003 Version 1 Security Documents submitted
  for approval
• July 2003 Updates to Version 1 submitted
• Sept 2003 Version 2 Security Documents
  submitted for approval
• Oct 2003 Initial lab certification at DSI
• Nov 2003 Awaiting report of certification
  testing
• Jan 2004 Certification re-test
• Feb 2004 Awaiting IATO
• April 2004 IATO obtained
• May 2004 Awaiting CTO
• June 2004 CTO obtained
• August 2004 Final STE scheduled

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IMITS ProjectsPediatric Tele-echocardiography

• Current Status
• Dec 2003 Installation equipment at all bases
• Jan 2004 Equipment installed
• Mar 2004 Awaiting ISDN re-install
• May 2004 Clinically live
• Jun 2004 Beta cases

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IMITS ProgramPediatric Tele-echocardiography

• Biloxi, MS
• Implementation of Pediatric Tele-echo system
  modeled after Childrens Hospitals in Florida
• Clinical implementation and support
• Evaluation of parent and provider acceptance and
  satisfaction
• No security requirements

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IMITS ProgramEmergency Services

• Emergency Communication Database
• Demonstration project using international
  healthcare facility database in UPMC Command
  Center
• NCMF identified additional required information
  in database
• UPMC collecting data on health care facilities in
  South America
• NCMF will evaluate via secure web access
• Opportunity for future business relationship

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FY 01-02 IMITS ProjectsEmergency Services

• Expeditionary Medical Support (EMEDS)
• NCMF forward deployed treatment facilities
• Portable tents
• Large IT footprint
• Hard wired
• Subcontract with MountainTop Technologies
• Conduct needs assessment
• Make recommendations for wireless solution

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IMITS Program Discontinued Projects

• Telemental Health
• Internal NCMF issues
• Change in leadership Wilford Hall Medical Center
• Administrative changes in TRICARE
• Teleradiation Oncology
• Difficulty finding suitable site
• IMRT requires specific equipment on linear
  accelerator

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FY 04 IMITS (Sept, 2004)

• 10.2M Congressional Appropriation
• Congressional intent to expand into the Pacific
  Rim
• Pacific Telehealth and Technology Hui
• University of Hawaii
• Expanded relationship with Wilford Hall Medical
  Center

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FY 04 IMITS (Sept, 2004)
Extracorporeal Membrane Oxygenation (ECMO)
Platelet Gel Therapy
Telepathology
Simulation and Training
Teleaudiology
IMITS
Telemental Health
Evaluation
Distributed Imaging and Workload Balancing
Teleophthalmology
Education
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FY 04 IMITS ProjectsECMO

• Extracorporeal Membrane Oxygenation
• Invasive procedure for maintaining oxygenation of
  the blood when lungs and/or heart are failing
• Requires specialized equipment and specially
  trained individuals

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FY 04 IMITS ProjectsECMO

• ECMO programs generally found in urban academic
  medical centers.
• 145 ECMO centers in the world
• 112 in the US
• Only 2 NCMF in Texas
• No centers located in the Pacific

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FY 04 IMITS ProjectsECMO

• Interest in establishing a regional ECMO Center
  for the Pacific in Honolulu
• Senator Inouye
• Non Civilian Medical Center
• Kapiolani Womens and Childrens Hospital
• Pacific Telehealth and Technology Hui
• University of Hawaii

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FY 04 IMITS ProjectsECMO

• FY 04 ECMO project is feasibility and planning
  study
• Evaluation of existing resources
• Requirements
• Budget
• Deliverable will be a plan for implementation of
  the center with the support of FY 05
  appropriations sponsored by Senator Inouye

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FY 04 IMITS Projects Distributed Imaging and
Workload Balancing

• NCMF experiencing a severe shortage of
  radiologist
• 160 billets (FTE) as of July 1, 2004 only 60
  filled
• Need to maximize resources and distribute
  workload
• Hub and spoke teleradiology model no longer
  useful
• Symmetrical load balancing model more appropriate

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Distributed Imaging and Workload Balancing

• UPMC implemented distributed workload model one
  year ago
• Shared worklist
• Radiologists read films from facilities other
  than the one they are assigned to for the day
• Same model implemented
• Shared worklist
• Appropriate cases for civilian readings

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Distributed Imaging and Workload Balancing

• Designated Non Civilian Medical Center
• Scale up model developed for the hospital in OH
• Attempt to keep readings within the US Gov

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Distributed Imaging and Workload Balancing

• IMITS 04 project scope
• Assess the current workflow at NC Medical Center
• Recommend changes based on UPMC workflow model
• Implement a prototype system

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Teleaudiology

• Cochlear implants are utilized to improve hearing
  in severe to profound hearing loss
• Once implanted the devices require monitoring and
  adjustment
• This must now be done in person

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Teleaudiology

• UPMC and NCMF both have cochlear implant programs
• Only one MTF that has a cochlear implant program
• NCMF treats patients globally
• Interested in developing a means to remotely
  access and adjust implants

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Teleaudiology

• FY 04 deliverables
• Feasibility study
• Vendor evaluation
• Determine regulatory impact in civilian world
• Plan for technology development
• Pilot project

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Teleophthalmology

• Joint project with Type 2 diabetes
• NCMF requested that retinal screening images
  captured for the diabetes project be stored in a
  DICOM archive
• Consistent with newly released ATA guidelines
  Telehealth Practice Recommendations for Diabetic
  Retinopathy

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Teleophthalmology

• UPMC Radiology Informatics has done work with
  visible light images
• Image archive for melanoma photographs
• Customized viewer

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Teleophthalmology

• FY 04 IMITS Teleophthalmology Deliverables
• Create DICOM object with associated metadata from
  acquired image
• Transport the DICOM object form point of
  acquisition
• Store image in a DICOM archive irrespective of
  vendor

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Telemental Health

• A major component of dealing with catastrophic
  events is Post Traumatic Stress Disorder
• Victims of disasters
• Critical incident stress management has been
  unsuccessful in management of PTSD
• Cognitive Behavioral Therapy has been show to be
  successful

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Telemental Health

• FY 04 Project
• Initial data collection and assimilation for
  analysis
• Partnership with simulation center in San Diego

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Telepathology

• Three initiatives under this heading
• Telepathology Needs Assessment Pacific Rim
• Development of Whole Slide Imaging Capability
• Incorporation of pathology images in enterprise
  image archive

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TelepathologyPacific Rim Needs Assessment

• Telepathology needs of the Pacific Rim differ
  from CONUS
• Static vs. dynamic
• Multiple time zone changes, international date
  line
• Staffing at MTFs
• FY 04 Deliverables
• Needs assessment and feasibility study for
  telepathology in the Pacific Rim

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TelepathologyWhole Slide Imaging

• Technologies that allow rapid and automatic
  imaging of entire slides at high resolution,
  storage of the image and display
• Equipment developed but technology has not been
  integrated into clinical practice
• FY 04 project
• Development and implementation of a fully
  integrated WSI clinical application at UPMC

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TelepathologyImage Archive

• Native telepathology images are not in DICOM
  format
• File size for WSI is rather large
• FY 04 project
• Leverage work done to date at UPMC with visible
  light images for melanoma and ophthalmology to
  integrate pathology images into a DICOM archive

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Simulation and Training

• Three initiatives under this heading
• Wilford Hall Simulation Center
• University of Hawaii Simulation Center
• UPMC Nursing Injury Prevention Program
• All projects will involve WISER

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Simulation and TrainingWilford Hall Simulation
Center

• Wilford Hall has simulation capabilities
  distributed in various departments throughout the
  MTF
• Wants to consolidate existing capabilities and
  build a Simulation Center
• FY 04 deliverable
• Assessment of current capabilities and
  recommendations for an integrated simulation
  center

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Simulation and TrainingUH Simulation Center

• University of Hawaii will be opening a new
  Medical School Building in 2005
• One floor dedicated to advanced simulation and
  training
• UH interested in WISER applications
• FY 04 deliverable
• Development of a collaborative partnership and
  implementation of a WISER pilot at UH

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Simulation and TrainingUPMC Nursing Injury
Prevention

• Work related injuries are a significant issue for
  nursing
• Simulated situations can assist with assessment
  and prevention of injuries
• FY 04 project
• UPMC Nursing in collaboration with WISER will
  develop and implement a work related injury
  prevention simulation

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Platelet Gel Therapy

• Wound healing therapy
• Creation of platelet rich plasma that enhances
  wound healing and decreases healing time
• Applicability to non-healing diabetic ulcers
• FDA approved
• Not reimbursed by Medicare or private insurers

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Platelet Gel Therapy

• Additional studies needed to validate efficacy
• FY 04 project
• Planning and development of multi-center clinical
  trial comparing platelet gel therapy to standard
  wound care treatments
• Literature review
• Protocol development
• Vendor negotiations
• IRB approvals

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Education

• Three initiatives under this heading
• Nursing Leadership training
• Nursing Magnet Program
• Type 2 Diabetes Education in Italy

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EducationNursing Leadership

• UPMC and the NCMF have similar objectives for
  leadership training
• UPMC has established the Beckwith Leadership
  Institute
• FY 04 project
• Review Joint Leadership Core Curriculum to
  determine synergies between NCMF and UPMC
• Make recommendations for joint curriculum
  development

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EducationType 2 Diabetes Italy

• Incidence of type 2 diabetes increasing in Italy
• Need Diabetes Self Management Tools
• Partner with the hospital in Italy and
  Mediterranean Institute for Transplantation and
  Advanced Specialized Therapies (UPMC)
• FY 04 project
• Initiate an on-line diabetes education program
  for type 2 diabetes

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Evaluation

• Leadership from Center for Biomedical Informatics
• Conduct rigorous and professional evaluation of
  the IMITS projects
• User acceptance
• Technology integration

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Evaluation

• Oversight of all evaluation activity
• Protocol development
• Protection of humans subjects
• IRB approvals
• Federal and state regulations

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Conclusions

• 1. The civilian counterparts, particularly in
  developing countries are interested in
  implementing information technology that
  eliminates inefficiencies, increases utilization
  and improves quality of care, while also lowering
  administration costs. Given the limited manpower
  and resources facing the military non-civilian
  and private sectors, improved information
  technology and management will be the foundation
  for quality health care.

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Conclusions

• 2. University of Pittsburgh Medical Center has
  also some other partnership models and close
  cooperation with Italy, Czech Republic, Brazil
  and China and is looking forward to cooperate
  with Arab Region as well
• 3. One of these models of partnership between
  the university and medical entities can be
  applied in case of Arab nations region.

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Background

• The IOM committee believes the development and
  application of information systems is essential
  to enhance quality and improve efficiency.
  Information technology must play a central role
  in the redesign of the healthcare system if a
  substantial improvement in quality is to be
  achieved over the coming decade.
• These problems are even more acute when applied
  to a military service population for a number of
  reasons. First, service men and women and their
  families are among the most mobile members of our
  society. Second, due to their exposure to
  diseases and environmental factors in a multitude
  of geographic locations, they are subject to a
  wider variety of difficult-to-diagnose medical
  conditions. Complicating this is the likelihood
  that relevant medical data is stored in
  incompatible health information systems increases
  with the time spent deployed outside CONUS. In
  addition, the drawdown in military forces and the
  closure of medical treatment centers in the 1990s
  has resulted in a reduction in funding and
  staffing for medical care applied against a
  stable but aging population of beneficiaries.
• Like its civilian counterparts, the Air Force is
  interested in implementing information technology
  that eliminates inefficiencies, increases
  utilization and improves quality of care, while
  also lowering administration costs. Given the
  limited manpower and resources facing the
  military and private sectors, improved
  information technology and management will be the
  foundation for quality health care.