U.S. ARMY MEDICAL RESEARCH

1
U.S. ARMY MEDICAL RESEARCH MATERIEL COMMAND MG
Eric B. Schoomaker, Commanding
MEDICAL MATERIEL DEVELOPER Protect the Warrior
Sustain the Force!
Deputy for Advanced Technologies COL Karl Friedl,
MC, USA Director, Telemedicine Advanced
Technology Research Center (TATRC) LTC (Dr) Hon
Pak, MC, USA Chief, Advanced Information
Technology Group
2
Disclosure

• Chairman, Standards and Guidelines of ATA
• Deputy Chair, Telemedicine Taskforce, American
  Academy of Dermatology
• President-elect and Board of Directors, American
  Telemedicine Association (ATA)
• Teledermatology Consultant, Army Surgeon General
• Chief, Advanced Information Technology Group,
  TATRC

3
MISSION

• Apply physiological and medical
  knowledge, advanced diagnostics, simulations,
  and effector systems integrated with information
  and telecommunications for the purposes of
  enhancing operational and medical
  decision-making, improving medical training, and
  delivering medical treatment across all
  barriers.
• The program scope is to identify,
  explore, and demonstrate key technologies and
  biomedical principles required to overcome
  technology barriers that are both medically and
  militarily unique.

Department of Defense, Joint Warfighting Science
and Technology Plan, Chapter IX, Joint Readiness
and Logistics, 1999
4
TATRC Programs

• Congressional Special Interest RDTE (70
  Programs)
• Office of the Surgeon General AMEDD Advanced
  Medical Technology Initiative (AAMTI) (70
  Projects)
• SBIR/STTR Small Business Innovative
  Research/Small Business Technology Transfer (50
  Projects)
• Telemedicine
• DARPA Programs (25 Projects)

5
Integrating Telehealth Technologies Into DoD EHR
Network
6
Agenda

• Current telemedicine investments
• Arrival of AHLTA- our EHR
• The gap of EHR
• Convergence of EHR and telemedicine

7
Theater Teleradiology Business Process
A Theater Approach to Soldier Health Care
Teleradiology
ERMC LRMC Germany
WRMC MAMC
18th MEDCOM 121st General Hospital
Air Force MEDCENS
NARMC WAMC WRAMC
Afghanistan
PRMC TAMC
Baghram
NAVY MEDCENS
Kandahar
Salerno
GPRMC BAMC
SERMC DDEAMC
Kabul (Projected)
Iraq
Balad (Army Air Force)
Kuwait
Baghdad
Arifjan TMC (Army Navy)
Mosul
Beuhring
Cropper
Ali Al Salem (Air Force)
Bucca
Bahrain (Navy)
Talil
Tikrit
8
Army Telepathology Program

• 13 new virtual slide scanners - 800K
• Infrastructure upgrade for AFIP Telemed - 250K

9
(No Transcript)
10
Tele-Health Initiatives
Tele-Echocardiology

• Availability of echo depends on access to
  sonographer, equipment and cardiologist
• Digital echo and telemedicine technology bridge
  the gap to specialty diagnostic imaging
• All echos are read at BAMC
• Cost savings for MEDDAC
• Civilian cardiologist office echo plus
  interpretation 600 to 1000
• Our contractor read cost is 73
• 434.4K funded as Venture Capital (ROI) on FY06
  resource summary transitions to base in FY07
  (452.2K)

Jan 2002 Jun 2006 10,746 exams Purchased
care would have cost 3,544,454
11
AKO.Consult Program Summary

• burntrauma.consult_at_us.army.mil
• Managed by the Institute for Surgical Research,
  Ft Sam Houston
• cards.consult_at_us.army.mil
• Managed by BAMC Cardiology
• derm.consult_at_us.army.mil
• 4 Call Teams BAMC, Walter Reed, Western, and
  Atlantic
• eye.consult_at_us.army.mil
• On-call ophthalmologists based in Germany and
  Eastern US
• id.consult_at_us.army.mil (Infectous Diseases)
• 3 Call Teams BAMC, Walter Reed, and Western
• nephrololgy.consult_at_us.army.mil
• Managed by various Army, Navy, and Air Force
  call teams

12
AKO Teleconsultation Summary

• Program Summary
• 10 specialties with contact groups
  xxx.consult_at_us.army.mil
• 1,886 teleconsultations (April 2004 to July 2006
  29 months)
• 47 known evacuations prevented
• 3 evacuations prevented in August
• 42 known evacuations facilitated following
  consultants recommendation
• 5 evacuations facilitated in August
• 648 different referring health care
  professionals
• 250 teleconsultations on non - US patients
• Average Reply Time 5 hr 9 min

13
Tele-Dermatology

• 17,805 consultations since inception of program
• 18 reporting facilities
• 188 Army consults or 62 of total
• 92 Air Force consults or 30 of total
• 23 Navy consults or 7 of total
• 825.4K funded as clinical deficiency on FY06
  resource summary

Feb 02 May 05 12,428 consults answered
14
NARMC Tele-Neurosurgery Optimize Specialty Care

• PA screening optimizes neurosurgeon
• Conservative care improves clinical outcomes
• Recapture related RAD/PT/surgery fees/lab
• PA/Nurse Manager provide
• case management
•  

15
Tele-Behavioral Health (WRAMC) Clinical
Business Process

• Referral Management and Promotion
• MTF managed care staff and Health Net support
  referrals
• Market initiative to beneficiaries at each
  referring site
• Establish referral process/rules to exceed access
  standards
• Review civilian hospital behavioral health
  admissions daily
• Psychiatrist Scheduling
• New patients/follow-up/walk-ins/ER patients/MEBs
• Therapist screening (triage) to prioritize
  patients
• Immediate aftercare for early release of
  inpatients
• Patient Follow-Up Care
• Psychiatrist follow-up VTC visits are based on
  treatment plan
• Psychiatric NP provides VTC med mgmt clinic for
  stable patients
• Therapists take over care for long-term stable
  patients

16
DoD Telemedicine Summary

• Multiple Disparate Systems
• High and Low Bandwidth telemedicine systems
• Live Interactive and Store and Forward System
• Lack of centralized portal for both military and
  network providers
• Shortage/maldistribution of specialists

17
Scope of MHS Operations

• Average Weekly Statistics, 2005
• Direct Care Visits  590,222
• Direct Care Admissions 5,486
• Direct Care Dental Visits 99,000
• Direct Care Births 1,070
• Direct Care and Purchased Care Visits 1,885,555
• Direct Care and Purchased Care Admissions 20,667
• Direct Care and Purchased Care Dental
  Visits 104,000
• Direct Care and Purchased Care Births 2,228

18
AHLTA Deployment Statistics

• As of 25 Aug 2006
• Full use by 130 out of 138 MTFs
• 56,618 out of 63,000 users trained
• 27.3 million visits captured since Jan 2004
• Contains records for 8.4 million beneficiaries
• Documents 96,800 patient visits per day
  electronically (per 21-25 Aug 2006 survey)
• Contains 544,000 theater patient encounters
• 32,000 encounters sent from Theater to Garrison
  in July 2006

19
Telemedicine Gap of AHLTA

• The gap of EHR
• Autoregistration of virtual patients
• Workflow Ability to route consults outside
  network or facility
• Ability to order consults with images
• Workload capture/split
• Professional v. Acquisition

20
Integration effort

• Telehealth Portal
• Others
• Tricare On Line
• DFI
• Document Engine (workflow)
• EWRAM

21
TRICARE ON-LINE (TOL)

• Portal for MHS Clinicians and Beneficiaries
• Single Sign On (SSO) to MHS Applications under
  development
• Linked to DEERs for eligibility checking
• Primary Means To Support Consumer Empowerment
• Can make appointments
• Pharmacy refill under development
• Health Content for Patient Reference
• Health Assessments
• Deployment related links
• Non-availability statements
• Personal Health Manager (journal and tracker) and
  Personal Health Record (demographics, allergies,
  medication and appointment profiles) under
  development
• Home Page being re-designed

22
TRICARE Online (TOL) Schema
External Support Contractors
Beneficiaries
Service Portals
Providers/ Staff
Single Sign-On
Single Sign on to MHS Systems (in progress)
Portal to Portal Single Sign-On Services to TOL
Current TOL Applications and Services
AHLTA/Clinical Data Repository
External Systems
Patient Safety Reporting (PSR)
Health Content
Defense Enrollment and Eligibility Reporting
System (DEERS)
Defense Medical Human Resources System
internet (DMHRSi)
Health Assessment
Non Availability Statements (NAS)
Appointing
Centralized Credentials Quality Assurance
System (CCQAS)
Deployment Related Links
Secure Provider Access CHCS (SPAC)
Deployment Related Medical Records Online
(DRMROL)
Others
CHCS
104 Military Treatment
Facilities
Composite Health Care System - CHCS
23
TRICARE OnlineCurrent Capabilities

• Online appointing
• Automatically checks eligibility for care
• Information on MHS Services and Benefits
• 18 million pages of Health Content
• Online drug interaction checking
• Non-Availability Statement (NAS) processing
• Secure Access to Composite Health Care System
  (CHCS)
• Access to Deployment Related Records Online
  (DRMROL)

24
Document,Files,Imaging (DFI)

• Provides ability to capture, identify, and
  present DFI to the clinical user within the
  context of clinical workflow.
• Current MHS environment presents numerous
  instances in which in hard copy and digital
  clinical encounter documentation originating from
  outside sources needs to be incorporated into
  AHLTA
• This project is essential for ensuring that the
  healthcare professional has a complete and
  comprehensive record for use while delivering
  quality patient care.

25
Document, Files, Imaging (DFI), continued
26
Document Engine/AHLTA Integration System
Architecture
Legends
AHLTA Client WS
Available
Document Engine Server
To Be Implemented
Core Module
Port 443
Port 443
Oracle HTTP Server
Document Capture Applet
AHLTA DE Module
ICD Enc. Mapper
OC4J (J2EE) Container
Integration B2B
System Print Services
DE Application
Document Capture Driver
CDR Enc. Mapper
DE Web Services
HL7 Engine
Port 443
JDBC
Medical Records Printers
HL7 Messages ADT, SCH
Generic Interface
HL7 Messages ADT, SCH
Transcribed docs
AHLTA DE Web Services
XML Proxy
Pulmonary Function System
LCS Server
LGSFEP 2 Server
ICD
Listener Port (e.g. 1521)
CHCS
Transcription System
Listener Port (e.g. 1521)
CWSFEP
Encounter Mapper
27
Document Engine (DE)

• DE module provides a universal, standard
  interface for incorporating clinical documents
  into patient records. Comprehensive information
  capture is provided from the following
• Clinical text Health Level Seven (HL7) messages,
• Print jobs from other Windows applications, and
• Print jobs via serial port data from legacy
  hardware devices.
• Project to integrate GOTS Document Engine (DE)
  into AHLTA to provide interface to import
  documents from external vendors, other
  print-capable Windows software, and legacy
  hardware.
• Allows users to manage unsigned documents through
  a delegation, review, and signing workflow.

28
Enterprise Wide Referral and Authorization Module
(EWRAM)

• Background
• Per HIPAA Law, covered Entities are Required to
  use Standard Transactions (X12 278) for all
  Electronic Referral Authorization Requests
• If MHS Sends / Receives Electronic Referral
  Request, (X12 278) Required
• Faxing Not Considered Electronic
• Long History of Development of CONOPS through
  Flag-led WIPT and negotiations with MCSCs on what
  is required

29
Enterprise Wide Referral and Authorization Module
(EWRAM)

• HIPAA RA WIPT HIPAA OIPT Referral
  Authorization (RA) WIPT Created to Address
  Direct Care Business Process HIPAA RA
  Transactions Between MTF and MCSC
• EWRAS Enterprise Wide Referral and
  Authorization System
• NAS Non Availability Statements Permits
  TRICARE Non-enrolled Beneficiaries to Receive
  Inpatient Care in the Civilian Market (NDAA 2002
  Mental Health Care only) Europe Uses NAS
  System For Referrals
• EWRM Enterprise Wide Referral Management IPT
• EWRAP Enterprise Wide Referral and
  Authorization Process IPT
• M-EWRAS Modified-EWRAS as a CHCS II Module
• EWRAM Enterprise Wide Referral and
  Authorization Module

30
EWRAS Interfaces

• High Reliability Availability
• Local Redundancy

DEERS
REFERRING PROVIDER ENTERS REFERRAL INTO EWRAS
271
271
270
270
TOL CENTRAL SERVER (at DISA)
MCSC
Referral Request, Status Updates, Results
MTF HUB
278
Civ Net
INTERFACE ENGINE
INTERFACE ENGINE
MCP Request, Appointment
Ref. Approved to Direct Care Appointment
HL7
Specialty Provider or Transcriptionist Enters
Verifies result into EWRAS
CHCS
31
Telehealth Convergence

• Telehealth as portal into AHLTA
• Single Point of Entry
• Network providers
• MHS providers
• Deployed Environment
• Fixed Facilities
• From Specialists Home or remote location
• Seamless workflow with AHLTA
• Single view/ desktop
• Leveraging existing and ongoing functionalities
• Process over existing infrastructure

32
Telehealth Portal

• Outsourcing Specialists
• Most of our patients are seen by our network
  providers (Tricare)
• Leveraging telehealth to optimize delivery of
  healthcare
• Contract Process (Tricare Contract)
• Ensure that Telehealth is used especially when
  specialty access is not available by traditional
  means
• Second Opinion
• CDC
• Subspecialty Care
• Pediatric genetics

33
Summary

• Telehealth Portal from Walter Reed
• Require backend integration with Tricare On Line
• Gap Analysis and Convergence
• Tricare On Line
• Document, File, Images
• Document Engine
• EWRAM

34
Questions

• Hon Pak
• Pak_at_tatrc.org
• 301-619-7923