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

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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

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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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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 man- date 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 Na- tional 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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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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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 i

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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. ii

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Preface This workshop was the outcome of a sequence of events made pos- sible 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 Deliery 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, equip- ment, 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 bio- medical 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. Depart- ment of Defense (DOD) and Department of Veterans Affairs, who are ix

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x SyStEmS ENgiNEEriNg to imProvE trAumAtiC BrAiN iNjury CArE 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 sys- tems 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 con- sensus 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 under- taking, 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 poten- tial 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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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 delibera- tive 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 xi

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xii SyStEmS ENgiNEEriNg to imProvE trAumAtiC BrAiN iNjury CArE Although the reviewers listed above have provided many construc- tive 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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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 21 by Robert Labutta Definition and Categorization of Traumatic Brain Injury, 21 Traumatic Brain Injury in the Military Environment, 23 Diagnosis and Treatment, 25 References, 28 xiii

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xi SyStEmS ENgiNEEriNg to imProvE trAumAtiC BrAiN iNjury CArE 3 Traumatic Brain Injury and the Military Health System 31 by Michael S. Jaffee 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 49 by William P. Pierskalla 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 69 by William W. Stead 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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x CoNtENtS Summary, 115 References, 119 Appendixes A Biographical Information 123 B ssues Raised by Stakeholders about the Military Care of I Patients with Traumatic Brain Injury 135 C perational Systems Engineering ApplicationsBased on O Issues Raised by TBI Stakeholders 141 D ational Academy of Engineering/Institute of Medicine N Preliminary Information-Gathering Meeting: TBI Care System Mapping 147 E Workshop Agenda 153 F Workshop Attendees 159 G Working Groups 167 H efinitions and Examples of Operational Systems D Engineering Tools and Concepts 169

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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 xii

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xiii SyStEmS ENgiNEEriNg to imProvE trAumAtiC BrAiN iNjury CArE 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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xix ACroNymS/ABBrEviAtioNS 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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