Rapid advances in technology during the past two decades have combined with Defense Department and Veterans Affairs efforts to modernize health care delivery to a point where both are now leading civilian health care in many areas.
Electronic health records (EHRs) are now the standard for active duty, National Guard, and Reserve service members, as well as the nation’s rapidly expanding veterans community. Telehealth and telemedicine programs are expanding beyond increasing convenience for veterans and active-duty dependents in remote locales to offering new – and sometimes more accepted – treatments. Pharmacy automation is increasing efficiencies and patient safety while reducing costs.
In short, virtually every aspect of health care for the nation’s warfighters – past and present – is being affected by new and evolving technologies. As with any such change, of course, there are glitches, incompatibilities, cultural resistance and a continuing need for new training. But unlike many other areas, where military technology development, adaptation and acquisition often lag one or more generations behind the commercial world, military health care has become a global leader in innovation.
“Where the DoD is unique is that we take care of patients in some very austere and rugged locales, unlike any other health provider organizations. We have 9.6 million beneficiaries and capture 148,000 outpatients a day, many of those in no- or low-communications areas, so our product line must support all of those different situations,” according to Capt. Michael Weiner (USN), deputy program manager and chief medical officer for the Defense Health Information Management System (DHIMS).
“Military health underwent a small transformation in 2008 when TMIP-J [Theater Medical Information Program-Joint] merged with CITPO [Clinical Information Technology Program Office] to baseline those code sets and capabilities so they were wholly aligned, ensuring the theater product and garrison product spoke to one another. I think everyone will agree that has been a successful merger with a positive outcome, with all work anyone now does related to everything from the point of injury in the battlespace to care as a veteran.”
The overall goal is to deliver better health care by utilizing modern technologies, he added.
“This is a uniquely transformational time in health care history. For the future, it is aligned with the nation’s vision of full interoperability of EHRs across the country. Health and Human Services recently issued a ‘meaningful use’ criteria for civilian doctors and hospitals. DoD and VA have been practicing meaningful use for two decades or more, not only in hospitals but on the battlefield,” Weiner explained.
“The nation has a 17 percent adoption EHR rate now, while DoD and VA have been 100 percent for decades. The nation will catch up and, as it goes from paper to digital – which is a truly radical change – the vision is to make sure data are standardized, fully interoperable and shared, not just as now done between DoD and VA, which share more non-billable health care data than any other two organizations in the nation, but with our civilian partners.”
A similar transformation is occurring within the DoD and VA pharmacy systems, although each has instituted its own system and the two are not compatible. In both cases, however, they have gone from handwritten prescriptions and manual pill-counting to a fully electronic system linking doctors, health care facilities, and pharmacies – including computerized systems to verify, count, and fill orders.
“In the last two decades, we moved from typewriters to TMPS [Tri-Service Microcomputer Pharmacy System] to CHCS [Composite Health Care Systems], the data entry system that ties in all military pharmacies,” noted Col. Everett McAllister, deputy chief of the DoD Pharmaceutical Operations Directorate. “So instead of having a system specific to pharmacies, every clinic, lab and physician now has access to the patient’s profile, which is a leap forward in patient safety.
“The next step – PDTS [Pharmacy Data Transaction Service], introduced into all our systems in mid-2001 – gave us visibility on patients throughout the system. If I’m at Nellis AFB in Nevada, for example, and have a patient in Florida, we have access to what medications that patient is on and they can have a prescription filled anywhere and screen for drug interactions – at our pharmacies, at retail and even by mail. And for order fulfillment, we now have pharmacy automation using barcode technology – digital imagery that reduces the potential for filling the wrong drug, so the right drug goes into the machine and then to the correct patient. All of which really enhances patient safety.”
Efforts also are now under way to provide interoperability to the DoD and VA systems.
“We’re working with the VA, trying to bring their pharmacies into our network, so if we have patients being seen at a VA facility, their prescriptions can be sent electronically through PDTS. We’re just now working an MOU [memorandum of understanding], but are not far from making that happen,” he said. “The VA still has to finish some software applications at their end. But we already have CHDR [Clinical Data Repository/Health Data Repository], developed in 2006 to combine the VA [HDR] and DoD [CDR] systems and allow us to share information electronically.”
According to the VA, the exchange of computable data begins with a DoD or VA health care facility or provider “activating” or flagging the patient’s EHR. That enables the data from each repository to flow through the CHDR interface and become a permanent part of the patient’s medical record in both systems. Termed a significant departure from “viewable” data, CHDR is considered an important step forward in achieving cross-agency interoperability.
Another upgrade to the system is telepharmacy, which allows pharmacies to leverage staffing, especially in remote areas and overseas. Led by a Navy pilot program in Florida, the goal is to enable a patient to access a pharmacy even if there is no local pharmacist available.
“The patient still goes to a local pharmacy with a hard-copy prescription, where the order is placed into the system and checked remotely. If the patient does not have a physical prescription, one is generated through CHDR,” McAllister explained. “The patient simply gives the pharmacy his name, doctor’s name, and ID card so they can pull up his profile and activate the prescription. The pharmacist on the other end – such as a central hub – will have a physical image of the medication and the fulfillment record.”
Versions of these same technologies also will be applied to in-patient care in military hospitals and clinics.
“Using barcode technology bedside, we will be able to identify the patient and make sure they receive the correct medications while an in-patient,” he continued. “The automation system for filling may be a bit different, with a pharmacist placing the filled prescription into a Pyxis MedStation and that drawer will release the medication to the patient’s nurse. So instead of having all medications on the ward, the nurse will go into the system through CHDR to release the prescription.”
The Air Force, for which McAllister previously served as chief pharmacist, already has standardized prescription fulfillment equipment throughout its health care facilities and the Army and Navy are working to do the same, he said. All such hardware and software will be compatible with CHDR, which is deployed throughout the Military Health System (MHS).
The next step is to take the DoD and VA e-prescription capability and make it standard in civilian operations – from physician to pharmacy.
“That is something Congress is trying to incentivize the civilian medical profession to move toward, using Medicare as the primary driver,” McAllister said, “so we are not far from making that happen.”
As to what else may be in the future for pharmacy automation, he said one possibility is using radio frequency identification (RFID) chips to track large inventories – but the primary focus, at least in the near-term, is on expanding e-prescription capability throughout all levels of American healthcare.