What health care can learn from the military

While the typical physician is now accepting of the IT changes that are intruding into their work environment, he often does not understand the reasons or the strategic underpinnings for the push for the digitalization of healthcare. Being a typical modern consumer, he understands smartphones, online shopping and email, but doesn’t understand concepts such as clinical data repositories, data warehouses, decision support and business intelligence.  Analogies can help, but carts, horses, sticks and carrots are a bit tired.

Being an amateur historian, I realized that the modern military is rife with models that can be used to make the point.  These analogies are not meant to be comprehensive of the broad strategic goals of health information technology, but they do help the rank and file physician understand why there is such a push to integrate information technology into the healthcare world.

Carpet bombing

One example highlights the broad “high level” view in more ways than one. In World War II, the US Air Force generally relied on eyeballs on target to bomb surface targets.  Objectives previously were targeted with squadrons of bombers, risking the lives of the pilots and also creating all sorts of collateral damage.  It was terror in the air and on the ground.  Then in Vietnam, the Air Force began utilizing “smart bombs,” or precision guided munitions. The contrast was illustrated by the Air Force’s campaign against the Thanh Hoa bridge in Vietnam.  It was the target of 800 unsuccessful sorties with unguided munitions, but was finally successfully dispatched by a single flight of 12 planes with microchip enhanced bombs.

If you think about how we practice medicine now, we are essentially carpet bombing our patients. This sort of approximated, empiric “targeting” occurs when we treat pneumonias with broad spectrum antibiotics, tumors with chemotherapy, and asthma with steroids and leukotriene inhibitors. These treatments are quite effective, most of the time. Relative to the alternatives, they are also safe, most of the time.  However, physicians frequently encounter the “collateral damage” of well-intended treatment such as C. difficile, allergic reactions and drug interactions which are certainly not intended, but occur because we clinicians are constantly barraged by so much data that there is no possible way to avoid all such incidents.

So how do we “smart-bomb” illness and injury? The modern bomber flying at 30,000 feet hitting a small target miles away on the ground does not do this in isolation. It relies on huge amounts of data that is processed by multiple entities from satellites in space to targeting resources on the ground and complex systems within the plane and munitions themselves.  We in medicine also rely on large amounts of data that we are required to apply at the point of care. Unfortunately, more often than not, this data is difficult to access (ie. locked as text on paper) and even more difficult to aggregate so that it can be usable and the time and point of care. We need to collect this data, put it together, and use it in real time to affect our clinical decisions. Examples of this are using allergy and medication interaction information to reduce the risks of medication.

However, such information is just the low hanging fruit because medication information is easy to store as discrete data. The vast majority of medical knowledge is locked as unusable data. We need to codify this bulk of clinical data so that is usable by digital systems and patterns can be dredged, enabling our therapies to be more nuanced and accurate.

Integrated systems

There are anecdotes describing how Navy destroyers saved the day at the Omaha beach landing on D-Day. The planned landing Omaha Beach on D-Day was a failure. The infantry that had landed on the beach were in chaos and impotently pinned by German firepower in protected positions.  However, despite not being part of the plan, these smaller ships were able to move in close to shore and noticed that a lone Sherman tank was pounding in vain against a German gun battery encased in concrete. They were able to provide tactical fire support using their larger 5 inch guns and neutralized the battery.

Noticing this, the tank went on to “target” other batteries and the destroyers apparently were happy to use this information.  Despite not having direct communications, resourceful soldiers and sailors cobbled together a makeshift communication system.  It didn’t occur to the US military that facilitating tactical communications between the branches (in this case, the Navy and Army) would amplify their effectiveness. Today, the military has embraced the concept of combined arms and integrated systems.  Well known example are the AWACS and Aegis combat systems that coordinates various military assets.  Such coordination allows military command and control to see data from multiple sources, allowing them to direct their forces efficiently and in a time sensitive manner.

Likewise, our healthcare environment is currently a victim of information isolation.  It is quite common to have patient information from separate sources inaccessible to the providers who are actively taking care of a patient.  A patient can be hospitalized with much of his data locked in a doctor’s office or vice versa.  Obstructions to information flow can even occur in the same physical plant.  It is quite common for doctors, nurses, and other ancillary providers to record and document information in different ways and on separate parts of the chart or even separate physical charts.  Because of this, it is even common for the patient to go through their inpatient clinical course without doctors even looking at any nursing documentation.  The eventual goal is a single common electronic patient document.  The patient information then is simultaneously available to all providers as a single merged source of truth, allowing a coordinated approach to the care of the patient rather than multiple strategies that are blinded to other practitioners.

Force multipliers

The US military uses Special Forces teams (typically 12 men) to train a larger size (100-200) of indigenous fighters to engage in guerrilla warfare.  Thus, the Special Force unit has multiplied their effective size.  The GPS technology we now take for granted in our cars allowed the US led coalition forces to outmaneuver the Iraqi forces in the first Gulf War, allowing the Allied forces to choose when and where they wanted to fight, again, making a fighting force more potent than their pure numbers.  These tactics and technology were force multipliers, amplifying the strength of a single unit or soldier.

We often hear about the silos of data and information in health care.  However, we also have silos of knowledge.  It took 15 years for 50% of patients to receive beta-blockers after myocardial infarction and 25 years to reach 90%.  The studies and knowledge that beta-blockers improved outcomes was readily available, but the academics failed to reach the trenches of real world medicine.  If this clinical knowledge had been presented at the appropriate times, compliance would have reached 90+% much sooner.  Reading about evidence based recommendations and filing them away is one thing.

Trying to remember and implement them during the chaos of the real world medicine is more difficult.  Decision support allows such recommendations and reminders to be delivered at the point of care, where we wage the real fight. Discovering evidence based practices is not enough.  We must use technology enhanced decision support to amplify and accelerate evidence based academic findings when and where the clinician needs them, not locked up in a journal.

Our healthcare environment and national economic circumstances dictate that we take care of patients better with fewer resources.  Although it may seem odd to relate strategies used by an organization to exert physical power to the healing purposes of healthcare, the US military has evolved its technology and tactics to be a leaner but more potent force.  Healthcare can learn from their evolution to be leaner and more potent as well.

John Lee is an emergency physician.

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  • Emily Feiner

    As a VA employee I can attest to the benefits of the Electronic Health record but it is still dependent upon the user. A provider must be able to spend the time to wade through lots of data to find the information he or she needs. I often have the experience that a patient is seen by someone who does not read the treatment notes, the patient may provide an inaccurate history which the provider never verifies by looking through the chart. This leads to needless delays in the course of treatment as the wrong interventions are used because the data is not accessed.

  • http://twitter.com/iraagatstein ira agatstein

    In a a healthcare world that has embraced Process Excellence Quality Lean Six Sigma. This is an unreadable series of culturally disjointed factoids,so anachronistic duct tape could not piece them together coherently :). {2 othera haver agreed for 4 dollars!}
    A Weak central hypothesis, no references or transparency of political view.
    Students of Military History would be flummoxed with the misplaced mixed metaphors.
    Read Sun Tzu Le Tso. Read about Oppenheimer FDR Truman Eisenhower.
    Read the Company by Littel, The Art of Intelligence by Crumpton which runs counter to some of the factoids.
    Go to the CIA museum in Washington. Watch Patton the Godfather and Every episode of ER it’s on ebay. If haven’t finished House Scrubs Grey’s anatomy -just kidding/
    The confusion here of Correlation and Causality in Root Cause Analysis is common to new systems that fail.(For this the Merovingian chided NEO)
    ∑Google™☞Six Sigma+ Healthcare∪Six Sigma+ Military &pieces♜ connect.▙▜ Spend your time better Exploring great ideasToyota GE Motorola employed in Process Excellence, Six Sigma and Quality for Health Care
    Now with Healthcare passionately embracing those synergies.What’s the concern about Dresden and wherever…
    Samuel Shem’s “House of God” even went through a exceptionally well orchestrated Lean transformation ..
    Digitalization is a double edged sword.
    No room for worrying that the cheese is moving
    Lead – Follow – or get out of the way it is.
    Landmines are present.
    #1Sysadmin an achilles heel- it’sthe fox guarding the hen house.They can CNTR-ALT-DEL,add stuff, subtract goodies ,encrypt,doodle,restrict access to your patients. Providers get a small window on the EMR.
    #2 “Law of Unintended Consequences”party-pooper to be announced at later date
    #3Liability Responsibility Discoverable Evidence Subpoenas on systems maintenance Authoring of templates,data entry,who owns the data‽, permits transmission‽log access,document retention,storage,notes signed?
    Remember kiddies even with IT
    Momma sayz: Ignorantia juris non excusa
    @ira #IRantThereforeIam
    Disclaimer: This is a random internet post. And if asked I will repeat the famous words of Sgt Schulz “I know nothing”

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    How much of those “huge amounts of data” is the bomber pilot required to manually collect in the course of bombing targets?
    Somehow systems are capable of collecting data as work is done, compile and analyze it and give the pilot and his bombs exactly what is needed when it’s needed. When health IT can do that, I am sure it will be very useful.

    “Despite not having direct communications, resourceful soldiers and sailors cobbled together a makeshift communication system”. That’s the way it should be. From the bottom up to the top driven by real needs on the ground. Would a top down wholly theoretical approach would have worked better?

    I’m not sure what training locals in guerrilla combat is illustrating, other than very bad judgement on our part, since sooner or later we seem to end up fighting those “indigent” fighters ourselves.
    As to GPS, yes it’s very nice, but even during the revolutionary war, victory usually went to those who managed to force the enemy to engage where and when it was not prepared to fight, so I don’t really understand the implications to health care IT.

    As to the US military being leaner and more potent, I’m sure that is true and I am certain this was enabled in large part by technology (not just informatics though), but somehow defense expenditures did not go down (understatement), and I wonder how this translates to health care costs.

  • http://www.facebook.com/lucy.hornstein.1 Lucy Hornstein

    >>
    This sort of approximated, empiric “targeting” occurs when we treat pneumonias with broad spectrum antibiotics, tumors with chemotherapy, and asthma with steroids and leukotriene inhibitors.

    Um, no. Even if I had every possible piece of data instantly available, intelligently sorted so I could easily access anything I wanted, none of it would tell me what organism is causing a particular patient’s pneumonia (or any other infection). Nothing but a culture will do that. Ditto chemotherapy (already targeted by cell type, tumor markers, etc). I have no idea how improved information would change asthma therapy.

    Your point about health IT and improved information accessibility modeled by the military is well taken, but I see harms to patients coming more from excessively repeated testing than actual treatments. They’re being carpet-bombed with scans and blood tests.

    • http://www.facebook.com/jsleemd John Lee

      As we get populate a patient’s record with more and more data along with fleshing out a robust data warehouse, this data can be mined for trends. For instance, if a patient has a propensity to develop antibiotic colitis with Cipro, this sort of information can be pushed to the ordering provider to prevent such reactions in the future. This is a simple example. There are already more complex examples of using large amounts of data to tailor patient care in a more effective and safe manner. Practitioners at hospital and hospital systems (like Kaiser) are already using their databases in this manner. However, to get to the point where their data is usable, they have had to develop robust data infrastructures to collect data and then deliver this data as actionable knowledge at the point of care.

  • militarymedical

    An integrated medical data system in the military? Then how come inpatient records are not readily available to outpatient providers, and vice-versa? Those are two totally different EHR systems requiring different authorizations and passwords. Sorta defeats the purpose of shared info, eh? PS. LOVE the post, ira agatstein!

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