Comprehensive Health and Medical Surveillance

1. Program Director, Population Medicine DEPLOYMENT HEALTH SUPPORT DIRECTORATE Comprehensive Health / Medical Surveillance COL John W. Gardner, MC, USA

2. SURVEILLANCE DEFINITION Systematic collection of relevant, valid data, with timely analysis and interpretation, providing dissemination & feedback to those who need it and can act on it.

3. MEDICAL SURVEILLANCE DODD 6490.2: “The regular or repeated collection, analysis, and dissemination of uniform health information for monitoring the health of a population, and intervening in a timely manner when necessary.” KEYWORDS: systematic, timely, analysis, relevant data, population, dissemination, feedback, public health action, metrics

4. WHY SURVEILLANCE? Surveillance programs provide feedback that leads to prompt ACTION to address a health problem Surveillance data add to UNDERSTANDING of the epidemiologic behavior of disease and injury Surveillance provides data for evaluation of the quality and EFFECTIVENESS of Health Protection measures Surveillance provides data (outcome metrics) for quality EVALUATION of the Health Care System

5. COMPREHENSIVE SURVEILLANCE Multiple Objectives ? Multiple Approaches: Longitudinal Individual Health Monitoring Epidemic Outbreak Detection and Response Deployment Health and Health Hazards Environmental & Occupational Health Hazards Preventable Disease & Injury Control Healthcare System Evaluation & Planning

6. COMPREHENSIVE SURVEILLANCE Comprehensive Surveillance must integrate information for all of these objectives Integration requires common metrics & data standards The longitudinal health database provides the primary data resource for most surveillance objectives The longitudinal health database contains all medical encounters and other relevant information for each individual (AD: MEPS ? Separation ? Death) Surveillance objectives are achieved through specific population analyses of these longitudinal data

7. Service Member Life Cycle

8. Longitudinal Individual Health Monitoring Behavior, Health, and Risk Factor monitoring Recruit Health and Attrition MEPS, AMSARA, several study groups on attrition Recruit Assessment Program (RAP) Annual Health Risk Appraisal (HEAR, PHA, AHCS) Annual Flight Physical Exam Annual Pap Test , Screening, Counseling, etc. (DD2766)

9. Longitudinal Individual Health Monitoring Individual Medical Readiness for Deployment PIMR (AF), MODS/MEDPROS (Army), PHNS (Navy/MC) Annual SRC processing (include Vision & Hearing) Immunization tracking systems (AFCITA, SAMS, MEDPROS) Annual Dental Exam MEB/PEB tracking (PIMR) Physical Profile & Physical Readiness Test tracking No consolidated medical readiness measure (as we have with Dental Class I-IV system)

10. Proposed IMR Metrics: PURPOSE Ensure Military Members Are Medically Ready to Deploy Provide commanders and medical personnel with real time status of individual medical readiness (IMR) requirements for members 6 DoD Categories: Periodic health assessment Deployment prohibiting conditions Dental classification Current Immunizations Readiness labs (HIV, Blood Type, DNA, etc) Individual Medical Equipment – (Glasses, Gas Mask Inserts, etc) NOTE: Each indicator is defined by Service specific requirements

13. Longitudinal Individual Health Monitoring Longitudinal Health Events (DMSS) Death (DoD-MMR) Disability & Separation Hospitalization (SIDR ? CDR) Outpatient (SADR ? CDR) Surgery (CHCS ? CDR) Laboratory data (CHCS ? CDR) Pharmacy, Medications, Problem List, Allergies (CDR, DD2766) Unexplained Illness (CCEP, PDH CPG) Millennium Cohort Study

14. This graphic illustrates the burden that injuries impose on the Army, even though the data are limited to Active duty Army only. All data are rounded for presentation purposes. Totals to the left of the figure represent CY99 year totals; The numbers inside the figure represent relative incidence of the event (So for every death of a soldier due to an injury in CY99, there were 20 discharges due to injury disability, 35 hospitalizations, 5500 outpatient visits and an untold number of injuries for which soldiers did not seek health care.) Data sources: Deaths, admissions, outpatient visits: Defense Medical Surveillance System, USACHPPM Disabilities: Total Army Injury Health Outcomes Database, USARIEM “Injury deaths” include deaths coded as accidents (143), suicides (48), and homicides (9). Excludes illness (42), Terrorist activity (1), and determination pending (1). Hospital admissions and outpatient visit totals are for AD for any condition classified by ICD-9 code as “Musculoskeletal disorder” or “Injury and Poisoning”This graphic illustrates the burden that injuries impose on the Army, even though the data are limited to Active duty Army only. All data are rounded for presentation purposes. Totals to the left of the figure represent CY99 year totals; The numbers inside the figure represent relative incidence of the event (So for every death of a soldier due to an injury in CY99, there were 20 discharges due to injury disability, 35 hospitalizations, 5500 outpatient visits and an untold number of injuries for which soldiers did not seek health care.) Data sources: Deaths, admissions, outpatient visits: Defense Medical Surveillance System, USACHPPM Disabilities: Total Army Injury Health Outcomes Database, USARIEM “Injury deaths” include deaths coded as accidents (143), suicides (48), and homicides (9). Excludes illness (42), Terrorist activity (1), and determination pending (1). Hospital admissions and outpatient visit totals are for AD for any condition classified by ICD-9 code as “Musculoskeletal disorder” or “Injury and Poisoning”

15. Epidemic Outbreak Detection and Response Real-time Health visit monitoring (syndromic surveillance) ESSENCE, LEADERS, MDSS BDI Medical Surveillance - Albuquerque test-bed Reportable Medical Events - RMES, NDRS, AFRESS SIR, CCIR, SITREP status reports Outbreak Investigation (EPICON) Acute Respiratory Disease surveillance Febrile Respiratory Illness surveillance program Recruit Training Center ARD surveillance Public Health Laboratory Directory (AFIP/GEIS)

16. Key DoD Initiatives for Defense Against Bioterrorism Surveillance Laboratory-based Syndromic Education Training courses Books and manuals Simulation exercises Response Product availability Laboratory improvement Response teams Research Diagnostics Prophylactic and therapeutic drugs and vaccines Protective equipment

17. US Geographic Locations of ESSENCE Coverage

18. Outpatient ICD-9-CM Diagnoses Are Clustered into Broad Syndrome Groups Respiratory (cough, pneumonia, URI) Gastrointestinal (vomiting, diarrhea) Neurologic (meningitis, botulism-like) Dermatologic – hemorrhagic Dermatologic – vesicular (smallpox-like) Fever/Malaise/Sepsis Coma/Sudden Death

20. Diagnostic Groups Plotted Using GIS Mapping

21. Example of Detected Outbreaks

26. What Can These Systems Do? Provide early detection of outbreaks Earlier than most existing systems Provide epidemiologic tools to assist the outbreak investigation Provide information for leaders and risk communicators Decrease workload for labor intensive active systems Prompt more accurate diagnostic testing

27. What Can’t These Systems Do? Detect every outbreak early Few cases Short, explosive incubation period Decrease morbidity/mortality every time Best for diseases with longer incubation periods where effective interventions exist Tell you the causative agent Lots of nonspecific information will not give you specific information Investigate the outbreak for you Public health professionals remain the important link

28. Deployment Health and Health Hazards Environmental Baseline Survey, Industrial Hazard Assessment, and Medical Threat Assessment (DESP, AFMIC) MedThreat Brief & Pre-Deployment Health Assessment (DD2795) Occupational & Environmental Health Surveillance (DOEHRS) Operational/Environmental Risk Assessment and Management Deployment Unit Rosters & Unit/Personnel Locations (DIMHRS) Healthcare documentation during deployment (GEMS, SAMS, TMIP) DNBI & TriService Reportable Medical Event reporting (Joint Staff) Post-Deployment Health Assessment (DD2796) After Action Reports and Lessons Learned Post-Deployment Health Clinical Practice Guidelines / CCEP

29. Military Health SystemInformation Management/Information Technology Program Integrating the Health Record

30. The TMIP Solution The blue areas represent the TMIP software code which integrates the supporting pieces of software into the seamless product we will deploy. Health Care, Medical Logistics, Patient Movement, and medical C2 will be included in the final product, which will use a DII/COE compliant architecture and hardware package, and read/write from/to the new Personal Information Carrier (PIC). The Interim Theater Data Base (ITDB) produced will create an infosphere which the unified commander will utilize to plan for medical requirements in his/her theater of operation.The blue areas represent the TMIP software code which integrates the supporting pieces of software into the seamless product we will deploy. Health Care, Medical Logistics, Patient Movement, and medical C2 will be included in the final product, which will use a DII/COE compliant architecture and hardware package, and read/write from/to the new Personal Information Carrier (PIC). The Interim Theater Data Base (ITDB) produced will create an infosphere which the unified commander will utilize to plan for medical requirements in his/her theater of operation.

32. Watch Board - Annex Q Reporting

34. MDSS - Standard Reports

35. Environmental & Occupational Health Hazards Industrial Hygiene Health Hazard Assessments (HHIM, DOEHRS) Environmental Health, Water, Food, and Vector Monitoring Occupational Health Medical Surveillance Exams Hearing Conservation & disability tracking (DOEHRS) Workers Compensation Evaluation & Management Programs International Travel Clinics Worker Immunization Programs (Influenza, TB, Varicella) Pregnant Soldier Occupational Exposure Screening Respiratory, Radiological, and Vision Protection Programs Ergonomics and Physical Fitness programs Aviation Medical Programs

36. Occupational & Environmental Health Surveillance

37. Preventable Disease & Injury Control Service Safety Programs Aviation mishap prevention Ground mishap prevention Operational Risk Management Occupational & Training Injury Prevention Programs Heat/Cold Injury Prevention Suicide, STD, Risk Reduction Programs (Drug & Alcohol) Blood Bank monitoring (DBSS) Family Violence (Family Advocacy, Social/Community Services) Cancer Registry (ACTUR) Birth Defects Registry (NHRC) Defense & Veterans Head Injury Program (DVHIP)

38. Healthcare System Evaluation & Planning Medical Errors (JCAHO focus) Nosocomial Infections (CIS) Medical Outcomes (CHCS, ADM, CHCS II, ORYX) Preventive Services (HEDIS) Population Health (PHOTO) & PCM Panel health status Clinical Practice Guideline implementation/evaluation Outcomes-based Quality metrics We need outcomes-based health care decision-making, rather than workload-based processes This requires surveillance of health and medical outcomes

39. Force Health Protection SURVEILLANCE SUPPORTS COMMANDER Guidance for policy, programs, and implementation Environmental and process Monitoring water, food, hazards, conduct of operations, etc. Health Outcomes deaths, hospitalizations, emergency treatment, etc. Analysis and Recommendations feedback into revised guidance circular process for continuous quality improvement

40. Medical Surveillance System Model

42. Sir, this is the Health Surveillance PRIORITIZATION MATRIX. This describes the entire field of possible targets of Health Surveillance, not only across the three perspectives discussed, but also across the time continuum and across the 5 major populations served by the MHS. The value of this Matrix is that it has an inherent prioritization and allows us to focus our surveillance efforts on target areas that we determine to be of the greatest interest.Sir, this is the Health Surveillance PRIORITIZATION MATRIX. This describes the entire field of possible targets of Health Surveillance, not only across the three perspectives discussed, but also across the time continuum and across the 5 major populations served by the MHS. The value of this Matrix is that it has an inherent prioritization and allows us to focus our surveillance efforts on target areas that we determine to be of the greatest interest.

43. This slide portrays an initial quick assessment of existing systems that are already monitoring the specified elements. RMES is the Reportable Medical Events System which is a component of DMSS. DOEHRS is the DoD Occupational and Environmental Health Reporting System, for which the Hearing Conservation module is already in use. Green, Yellow, and Red shading is applied to indicate the status of the systems in each indicator cell. In addition to assessing the ability of the systems to effectively monitor the specific health surveillance elements, we will also integrate and report on the results provided by the systems themselves.This slide portrays an initial quick assessment of existing systems that are already monitoring the specified elements. RMES is the Reportable Medical Events System which is a component of DMSS. DOEHRS is the DoD Occupational and Environmental Health Reporting System, for which the Hearing Conservation module is already in use. Green, Yellow, and Red shading is applied to indicate the status of the systems in each indicator cell. In addition to assessing the ability of the systems to effectively monitor the specific health surveillance elements, we will also integrate and report on the results provided by the systems themselves.

44. In this final organizational diagram, the DHSO includes Data Integration, Analysis and Reporting, and the DOD MHS Fusion Center elements. In this concept, each service would retain an operational “Response Center”, but the Fusion functions would be at the DoD or EA level.In this final organizational diagram, the DHSO includes Data Integration, Analysis and Reporting, and the DOD MHS Fusion Center elements. In this concept, each service would retain an operational “Response Center”, but the Fusion functions would be at the DoD or EA level.

45. This is the “straw-man” organizational structure which you asked me for at our first IPR. As shown, the DHSO would operate under your Executive Agency. A Board of Governors, consisting of representatives from all services, would function as an Integrated Concept Team. Much of the of the organization under the Deputy for Onsite Operations is the current activity of the DMSS, and that is what we are thinking here. What is added is the “Fusion Center” concept, which picks up the critical coordination pieces.This is the “straw-man” organizational structure which you asked me for at our first IPR. As shown, the DHSO would operate under your Executive Agency. A Board of Governors, consisting of representatives from all services, would function as an Integrated Concept Team. Much of the of the organization under the Deputy for Onsite Operations is the current activity of the DMSS, and that is what we are thinking here. What is added is the “Fusion Center” concept, which picks up the critical coordination pieces.

46. This is the “straw-man” organizational structure which you asked me for at our first IPR. As shown, the DHSO would operate under your Executive Agency. A Board of Governors, consisting of representatives from all services, would function as an Integrated Concept Team. Much of the of the organization under the Deputy for Onsite Operations is the current activity of the DMSS, and that is what we are thinking here. What is added is the “Fusion Center” concept, which picks up the critical coordination pieces.This is the “straw-man” organizational structure which you asked me for at our first IPR. As shown, the DHSO would operate under your Executive Agency. A Board of Governors, consisting of representatives from all services, would function as an Integrated Concept Team. Much of the of the organization under the Deputy for Onsite Operations is the current activity of the DMSS, and that is what we are thinking here. What is added is the “Fusion Center” concept, which picks up the critical coordination pieces.