Contemporary Issues in Medical Informatics: Good Health IT, Bad Health IT, and Common Examples of Healthcare IT Difficulties
New York Times

New York Times

March 30, 2007

 

Disuse of System Is Cited in Gaps in Soldiers’ Care

 

By IAN URBINA and RON NIXON

 

WASHINGTON, March 29 — Lapses in using a digital medical record system for tracking wounded soldiers have led to medical mistakes and delays in care, and have kept thousands of injured troops from getting benefits, according to former defense and military medical officials.

 

The Defense Department’s inability to get all hospitals to use the system has routinely forced thousands of wounded soldiers to endure long waits for treatment, the officials said, and exposed others to needless testing.

 

Several department officials said the problem may have played a role in the suicide of a soldier last year after he was taken to Fort Lewis in Washington State from Iraq. His intentions to kill himself were clearly documented in his digital medical record from overseas, but doctors at Fort Lewis did not consult the file and released him, according to department records and defense officials.

 

“The D.O.D.’s failure to share data and track patient records is truly a matter of life and death,” Senator Patty Murray, Democrat of Washington, said in a statement. “This isn’t an isolated case, but a system-wide failure.”

 

The system was designed to make seamless the transition of soldiers who were wounded in Iraq and Afghanistan as they moved to hospitals stateside. But only 13 of 70 military treatment centers in the United States use it even though it was mandated by the Pentagon more than two years ago, according to agency documents.

 

As a result, military doctors say they are less able to learn from mistakes since they cannot track the progress of wounded soldiers from one location to another. Others complain of costly and redundant testing.

 

“Patients are being unnecessarily exposed to radiation,” said Lt. Col. Gina Dorlac, medical director of the intensive care unit at a hospital in Landstuhl, Germany, where most severely wounded soldiers are taken from Iraq.

 

She said doctors from Walter Reed Army Medical Center and elsewhere regularly ordered CAT scans and M.R.I.’s even though the same tests had already been performed and the results were in the tracking system. “It’s a waste of time and money,” Colonel Dorlac said.

 

X-rays and CAT scans are generally considered safe, but doctors are wary of unnecessary tests because radiation can be harmful if it accumulates in a patient over time.

 

M.R.I.’s do not produce radiation.

 

Colonel Dorlac said that most doctors who used the system agreed that it worked well. But she said many doctors at United States military hospitals seemed reluctant to use it because doctors did not know they had access or were unwilling to learn how to use it.

 

Until he left the Defense Department in August, Tony DeNicola was responsible for ensuring that the digital system, known as the Joint Patient Tracking Application, was used throughout the military. In an interview, Mr. DeNicola said he ran into resistance: “We couldn’t get the services to use the system because they wanted to use their own. We also never got enough cooperation from the office in charge of electronic patient records.”

 

The application was developed in 2004 to allow doctors and military officials to track the medical care given to troops from the moment they arrive at field hospitals in Iraq or Afghanistan through their stay in military hospitals stateside.

 

The Internet-based system allows doctors or other personnel to enter or view clinical data and upload images from certain types of tests. Defense Department officials said the system was just one of several sources of information used in providing care for soldiers.

 

Tommy J. Morris, director of deployment health technologies and support programs, also said that the record system was being integrated into a larger defense system, which would particularly help in tracking patients moving into the Department of Veterans Affairs system.

 

Frustrations with the Pentagon’s tracking of medical data come at a time of growing concern on Capitol Hill about medical treatment and benefits for soldiers coming home wounded from Iraq and Afghanistan.

 

On Tuesday, defense officials testified before Congress that their department was improving data tracking and increasingly sharing medical information with Veterans Affairs. But Senator Murray raised concerns that the Joint Patient Tracking Application was not being used.

 

The Defense Department blocked Veterans Affairs access to the system entirely in January and as of this week only 12 of the 40 authorized V.A. officials and doctors had had their access restored, according to Defense Department records.

 

Representative Steve Buyer, Republican of Indiana, said he sought a meeting with Defense Department officials after visiting a V.A. hospital in Minneapolis where doctors lacked direct access to the patient tracking system and were still receiving faxed medical records from military hospitals.

 

He said he left that closed-door session on Wednesday after an hour and a half of discussion “not knowing the answer” to when the problems with data tracking would be resolved.

 

For wounded troops, the difficulties have complicated an already frustrating experience, according to veterans advocates and defense officials. At military hospitals that still depend on paper records, wounded soldiers endure long waits for appointments because their records cannot be found or were never transferred, advocates say. Soldiers also face delays in getting rehabilitation because defense officials do not use the system to assign specialists to centers with the biggest backlogs.

 

According to a congressional aide who attended the meeting on Wednesday, Defense Department officials said they were not familiar with the details of the Fort Lewis suicide.

 

According to other defense officials and department records, that soldier was evacuated from his unit in Mosul, Iraq, on Aug. 18, 2006, after telling doctors he had thoughts of suicide. After being evacuated to a military hospital in Germany, the soldier received psychological treatment and his condition was noted in the digital records system. On Aug. 24, he was sent to Madigan Hospital at Fort Lewis but was not admitted.

 

On Sept. 7, he killed himself. Defense records indicated that doctors at Fort Lewis did not check the soldier’s file in the digital system, where his suicidal tendencies were described, until a day after his death.

 

Sharon Ayala, spokeswoman for Madigan Hospital, said the hospital would not comment on the case because of privacy issues.

 

“Please be assured that the Army takes suicide and the risk of suicide very seriously,” Ms. Ayala said, adding that all troops returning from Iraq and requiring mental health evaluations are seen and evaluated by mental-health providers the day they arrive.

 

Soldiers may also not be receiving certain benefits, such as $430 a month for combat-related injury rehabilitation pay, because the office that provides those checks depends on data from the digital system to determine which soldiers qualify, according to Mr. DeNicola, the official who used to oversee the system.

 

Lt. Col. Mike Place, a physician at Blanchfield Army Community Hospital at Fort Campbell, Ky., said it was important for stateside doctors to use and update the digital records because doctors in Iraq and Afghanistan often access the files to check up on soldiers they cared for and to learn from the results.

 

Colonel Place said, for example, that many soldiers with blast wounds in Iraq experienced certain complications after returning to the United States, like muscle swelling that causes severe nerve damage. If battlefield doctors knew that, they could change how they treat soldiers immediately after they are wounded.

 

With the Joint Patient Tracking Application, Colonel Place said: “We don’t have to wait until the surgeon comes home to tell them. They can see the trend right away and start making changes.”

 

Steve Robinson, a veterans’ advocate, said virtually all military doctors agreed that the digital system was effective in tracking patients. But he added that he had participated in seven Congressional hearings, most recently last week, that focused on problems with how the defense and veterans departments track medical information.

 

“We don’t really have time to wait for another system to come online when we have one ready now that the D.O.D. approved,” Mr. Robinson said. “The tools are there, but we just keep having meetings about whether to use them.”

 

Defense Department officials say they need more time — and an additional $30 million in the next fiscal year — to integrate the joint patient tracking system with the department’s larger system, an effort that has already cost more than $200 million. The Joint Patient Tracking Application cost an estimated $320,000 to develop and about $2 million a year to operate, according to Defense Department documents.

 

But last September the department certified that the tracking application had adequate security and privacy protections, according to documents from the office of the deputy assistant secretary of defense for force health protection and readiness.