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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System
WORKSHOP SUMMARY
David Butler, Jessica Buono, Frederick Erdtmann, and Proctor Reid, Editors
NATIONAL ACADEMY OF ENGINEERING AND INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Science, the National Academy of Engineering, and the Institute of Medicine.
Support for this project was provided by the U.S. Army (Award No. W81XWH-07-P-0979). Any opinions, findings, or conclusions expressed in this publication are those of the workshop participants and do not necessarily reflect the view of the organization that provided support for the project.
International Standard Book Number-13: 978-0-309-12758-5
International Standard Book Number-10: 0-309-12758-0
Copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (888) 624-8373 or (202) 334-3313 (in the Washington metropolitan area); online at http://www.nap.edu.
For more information about the National Academy of Engineering, visit the NAE home page at www.nae.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu.
Copyright 2009 by the National Academies. All rights reserved.
Printed in the United States of America
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
THE NATIONAL ACADEMIES
Advisers to the nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
WORKSHOP STEERING COMMITTEE ON SYSTEMS ENGINEERING HEALTH CARE: TOOLS AND TECHNOLOGIES TO MAXIMIZE THE EFFECTIVENESS OF MEDICAL MISSION SUPPORT TO DOD
NORMAN R. AUGUSTINE (NAE) co-chair,
Lockheed Martin Corporation (retired), Bethesda, Maryland
JEROME H. GROSSMAN (IOM) co-chair,
Harvard University/Kennedy School Health Care Delivery Project, Cambridge, Massachusetts (until April 2008)
DENIS CORTESE (IOM) co-chair,
Mayo Clinic, Rochester, Minnesota (from April 2008)
SETH BONDER (NAE),
The Bonder Group, Ann Arbor, Michigan
PATRICIA F. BRENNAN (IOM),
College of Engineering, University of Wisconsin-Madison
THOMAS F. BUDINGER (NAE),
University of California, Berkeley, and E.O. Lawrence Berkeley National Laboratory, Berkeley, California
BARRETT S. CALDWELL,
Purdue University, West Lafayette, Indiana
MICHAEL P. DINNEEN,
Military Health System, Washington, D.C.
PAUL M. HORN (NAE),
New York University, New York City
MICHAEL S. JAFFEE, COL (s),
Defense and Veterans Brain Injury Center, U.S. Air Force, Washington, D.C.
WILLIAM P. NASH, CAPT,
U.S. Navy (ret), USMC/USN Liaison to the Defense Center of Excellence for Psychological Health and TBI, Burke, Virginia
ALEXANDER K. OMMAYA,
Department of Veterans Affairs, Washington, D.C.
DAVID T. ORMAN, COL (ret),
U.S. Army MEDCOM, Fort Sam Houston, Texas
RONALD POROPATICH, COL,
Medical Corps, U.S. Army, Fort Detrick, Maryland
WILLIAM B. ROUSE (NAE),
Georgia Institute of Technology, Atlanta, Georgia
NINA A. SAYER,
Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
Project Staff
PROCTOR P. REID, director,
Program Office, National Academy of Engineering
FREDERICK (RICK) ERDTMANN, director,
Board on Military and Veterans Health, Institute of Medicine
DAVID BUTLER, senior program officer,
Board on Military and Veterans Health, Institute of Medicine
JESSICA BUONO, research associate,
Program Office, National Academy of Engineering
CAROL R. ARENBERG, managing editor,
National Academy of Engineering
PENELOPE J. GIBBS, senior program associate,
Program Office, National Academy of Engineering
PRISCILLA ARRIAGA, Anderson & Commonweal Intern,
Program Office, National Academy of Engineering
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
This workshop summary is dedicated to the memory of Jerome H. Grossman, M.D., a long-time member, friend, and leader in the National Academies and the primary motivator and intellectual compass for this workshop.
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
Preface
This workshop was the outcome of a sequence of events made possible by Dr. Jerry Grossman, who co-chaired a study in 2005 by the National Academy of Engineering (NAE) and Institute of Medicine (IOM) that culminated in the publication of Building a Better Delivery System: A New Engineering/Health Care Partnership. That report makes a strong case for taking advantage of the best of both disciplines—health care and operational systems engineering (a combination of science and mathematics to describe, analyze, plan, design, and integrate systems with complex interactions among people, processes, materials, equipment, and facilities)—to improve the efficiency and quality of health care delivery, as well as health care outcomes.
There is widespread agreement that the overall quality of health care delivered in the United States is not commensurate with the nation’s high health care expenditures or its global leadership in advanced biomedical technologies, and reform of the nation’s health care system is a high priority of government officials, caregivers, and patients. The premise of the NAE/IOM report is that there are lessons to be learned from the experiences of industries that have used operational systems engineering tools to make higher quality, less expensive products more efficiently. Dr. Grossman mounted a personal campaign to apply these ideas to move our health care system to a higher plane. Among those most interested in pursuing this approach are leaders in the U.S. Department of Defense (DOD) and Department of Veterans Affairs, who are
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
committed to finding ways of improving the quality of care for military personnel, veterans, and their families.
Intrigued by the possibilities, DOD decided to sponsor a series of workshops to explore the potential of applying operational systems engineering principles and tools to military health care, beginning with the diagnosis and care of patients with traumatic brain injury (TBI), one of the most prevalent and challenging injuries suffered by warriors in Iraq and Afghanistan. TBI presents an extremely complex medical problem with a wide range of severity levels and presenting symptoms. TBI patients require coordinated, often prolonged care by people in many different specialties and organizations. In short, operational systems engineering tools have the potential to improve the care of these wounded warriors.
Workshops sponsored by the National Academies are intended to identify avenues for further exploration rather than to provide consensus findings or recommendations. The workshop summarized in this volume, “Harnessing Operational Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System,” is a fitting memorial to Dr. Grossman who died suddenly during the planning stages of the workshop. We believe he would have celebrated this undertaking, not because it was held in honor of his memory, but because it demonstrates the potential for improvement in which he so passionately believed.
It is our hope that readers will be encouraged to explore the potential of applying systems engineering tools to improve health care delivery in their own areas of medicine.
Norman R. Augustine, Co-chair
Denis Cortese, Co-chair
Workshop Steering Committee on Systems Engineering Health Care: Tools and Technologies to Maximize the Effectiveness of Medical Mission Support to DOD
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
Acknowledgments
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council (NRC) Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
William B. Elliott, Quality and Operations Support, Kaiser Permanente
Elena Nightingale, Scholar-in-Residence, Institute of Medicine
Alexander K. Ommaya, Office of Research and Development, Department of Veterans Affairs
Ronald L. Rardin, Center for Innovation in Healthcare Logistics, Department of Industrial Engineering, University of Arkansas
Vinod K. Sahney, Blue Cross Blue Shield of Massachusetts
Judith L. Swain, Singapore Institute of Clinical Sciences, Agency for Science, Technology and Research, National University of Singapore, and University of California, San Diego
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Chris G. Whipple, ENVIRON. Appointed by the NRC, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors and the institution.
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
Contents
Summary
1
1
Introduction
11
Health Care Quality and Cost Challenges Facing the Military Health System,
13
The Operational Systems Engineering Imperative for the Military Health System,
14
Goals of the Workshop,
16
The Challenge of Traumatic Brain Injury Care,
17
Organization of the Workshop Summary,
18
References,
19
2
Medical Aspects of Traumatic Brain Injury
by Robert Labutta
21
Definition and Categorization of Traumatic Brain Injury,
21
Traumatic Brain Injury in the Military Environment,
23
Diagnosis and Treatment,
25
References,
28
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
3
Traumatic Brain Injury and the Military Health System
by Michael S. Jaffee
31
The Magnitude of the Challenge,
31
Components of an Effective Care Delivery System,
36
Research Questions and Initiatives,
39
References,
45
4
Examples of Operational Systems Engineering Applications Relevant to Traumatic Brain Injury Care
by William P. Pierskalla
49
Example 1: Dynamic Influence Diagrams for Medical Decision Making,
51
Example 2: Screening Blood for the Human Immunodeficiency Virus Antibody,
55
Example 3: Policy Decision Modeling of the Costs and Results of Medical School Education,
60
Example 4: The Healthcare Complex Model,
64
Example 5: A Mixed-Integer Programming Model to Locate Traumatic Brain Injury Treatment Units in the VA,
66
Conclusion,
67
References,
67
5
Case Study: Vanderbilt’s Journey Toward System-Supported Practice
by William W. Stead
69
References,
79
6
Suggestions for Analysis Plans by Working Groups
81
Working Group A: Developing New TBI Knowledge,
84
Working Group B: Detection and Screening of TBI Conditions,
91
Working Group C: Coordination and Communication for TBI Care,
96
Working Group D: Measuring and Forecasting the Demand for TBI Care,
102
Working Group E: Capacity, Organization, and Resource Allocation for a TBI Care System,
107
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
Summary,
115
References,
119
Appendixes
A Biographical Information
123
B Issues Raised by Stakeholders about the Military Care of Patients with Traumatic Brain Injury
135
C Operational Systems Engineering ApplicationsBased on Issues Raised by TBI Stakeholders
141
D National Academy of Engineering/Institute of Medicine Preliminary Information-Gathering Meeting: TBI Care System Mapping
147
E Workshop Agenda
153
F Workshop Attendees
159
G Working Groups
167
H Definitions and Examples of Operational Systems Engineering Tools and Concepts
169
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
Acronyms/Abbreviations
ACR American College of Rheumatology
AFEB Armed Forces Epidemiological Board
AFTH Air Force Theater Hospital
AHLTA Armed Forces Health Longitudinal Technology Application (formerly CHCS II), a DOD enterprise-wide electronic health record system A –T suffix specifies the in-theater component.
ANAM Automated Neuropsychological Assessment Metric
BAS Battalion Aid Station
BLI blast lung injury
CA cellular automata model
CASEVAC casualty evacuation
CDC Centers for Disease Control and Prevention
CDP Center for Deployment Psychology
CDR Clinical Data Repository
CONUS Continental United States
CSTS Center for the Study of Traumatic Stress
DARPA Defense Advanced Research Projects Agency
DCOE Defense Center of Excellence
DHCC Deployment Health Clinical Center
DOD U.S. Department of Defense
DVBIC Defense and Veterans Brain Injury Center
DVHIP Defense and Veterans Head Injury Program
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EIA enzyme immunoassay
EOD Explosive Ordnance Disposal
EVAC evacuation
FRSS Forward Resuscitative Surgical System (USN/USMC)
FST Forward Surgical Team (USA)
GAO Government Accountability Office
GI gastrointestinal
GPS Global Positioning System
HIV human immunodeficiency virus
HMMWV/HUMVEE High-Mobility Multipurpose Wheeled Vehicle
ICD International Classification of Disease
ICU intensive care unit
IED improvised explosive device
IHI Institute for Healthcare Improvement
IOM Institute of Medicine
JTTS Joint Theater Trauma System
MC4 Medical Communications for Combat Casualty Care
MCAS Marine Corps Air Station
MDP Markov decision process
MEDEVAC medical evacuation
MHS Military Health System
MIP mixed-integer programming model
MRI magnetic resonance imaging
MRP material requirements planning
mTBI mild traumatic brain injury
MTF military treatment facility
NAE National Academy of Engineering
NHLBI National Heart Lung Blood Institute
NICoE National Intrepid Center of Excellence for Psychological Health and Traumatic Brain Injury
OEF Operation Enduring Freedom
OIF Operation Iraqi Freedom
OSD/HA Office of the Assistant Secretary of Defense for Health Affairs [also OSD(HA)]
OSE operational systems engineering
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Systems Engineering to Improve Traumatic Brain Injury Care in the Military Health System: Workshop Summary
OIPT overarching integrated product team
PDHA post-deployment health assessment
PDHRA post-deployment health reassessment
PET position emission tomography
POMDP partially observable Markov decision process
PPOC polytrauma points of contact
PRC polytrauma rehabilitation center
PSCT polytrauma support clinic team
PTSD post-traumatic stress disorder
QALY quality-adjusted life year
RMC regional medical center
RPG rocket-propelled grenade
RTD return to duty
SDT signal-detection theory
SPECT single-photon emission-computed tomography
SSTP Surgical Shock Trauma Platoon (USN/USMC)
TBI traumatic brain injury
THA total hip arthroplasty
TRAC2ES TRANSCOM Regulating and Command & Control Evacuation System
UHC University Hospital Consortium
USAMRMC U.S. Army Medical Research and Materiel Command
USTRANSCOM U.S. Transportation Command (USAF)
VA U.S. Department of Veterans Affairs
VHA Veterans Health Administration
VHIS Vietnam Head Injury Study
VISN 8 Veterans Integrated Services Network Region 8
VISTA Veterans Health Information Systems and Technology Architecture
VSA value-stream analysis
WB western blot
WRAMC Walter Reed Army Medical Center
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