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6
Information Systems
OVERVIEW
The single most troublesome problem encountered in attempts to conduct
epidemiologic studies of illnesses among Persian Gulf War (POW) veterans has
been the inability to retrieve information on medical care events such as
hospitalizations, outpatient visits, and diagnoses and treatments from
Department of Defense (DoD) and Department of Veterans Affairs (DVA)
medical records in a uniform and systematic manner. Lack of uniform and
retrievable medical information concerning reserve, National Guard, active, and
separated forces has greatly inhibited systematic analysis of the health effects of
mobilization. DoD and DVA have different and only partially automated
inpatient hospital record systems. Neither DoD nor DVA has automated
outpatient record keeping, although the committee has recently learned that a
database with outpatient records will be available in the near future from DVA.
Current systems are fragmented, disorganized, incomplete, and therefore poorly
suited to support epidemiologic and health outcomes studies.
As an interim measure to obtain information about exposures, health, and
medical care among POW veterans, DoD and DVA established four
independent programs: the DVA Persian Gulf Health Registry (PGHR), DoD
Comprehensive Clinical Evaluation Program (CCEP), DoD Troop Exposure
Assessment Model (TEAM), and DoD Registry of Unit Locations (RUL).
The committee finds that the PGHR and CCEP are useful for clinical
evaluation of the health problems of POW veterans but cannot be utilized for
128
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INFORAt4 TION SYSTEMS
129
research because they include only self-selected individuals who volunteer to
participate in these programs. TEAM and RUL also will have limited utility for
epidemiologic studies since they provide information at the unit level rather than
at the individual level.
Whereas no system of medical record keeping can or should be designed to
provide the information needed to address every unanticipated issue regarding
the health consequences of either military service in general or a specific
military conflict, health information systems can be established to facilitate
epidemiologic studies of such service. The committee has identified several
changes in health information systems for military personnel that will enhance
the capability of the military to evaluate the health consequences of future
deployments and service. These include creation of a uniform medical record
(UMR), including data from civilian providers; full implementation of the
Defense Medical Epidemiological Database (DMED) system; and completion of
the Army's Patient Accounting and Reporting Real-Time Tracking System
(PARRTS), including expansion to the other branches of service.
Medical care and health surveillance (for persons who may need medical
attention now) and epidemiologic evaluation of potential threats to the health of
service personnel (for research to prevent future problems) will be greatly
strengthened by the development of a system that provides access to the entire
medical history of each member of the armed services and facilitates linkage to
other sources of data. Such a system would provide substantial benefits to the
service member and veteran, to future service persons whose health will be
better protected, and to DoD or any agency that needs healthy personnel.
As far back as World War I, and perhaps antiquity, every war has left a
proportion of service personnel and veterans with serious medical complaints
that are not explainable on the basis of known health hazards or identified
physical illnesses. This pattern is so consistent, and the health problems are so
important, that databases and health information systems should be designed
and implemented now to deal with and mitigate similar problems that are likely
to arise in future conflicts.
This chapter addresses the committee's charge to "assess the effectiveness
of actions taken by the Secretary of Veterans Affairs and the Secretary of
Defense to collect and maintain information that is potentially useful for
assessing the health consequences of . . . military service" and to "make
recommendations on means of improving the collection and maintenance of
such information" (see Appendixes A, B). The chapter focuses on two
categories of health and exposure information systems: (1) those established in
response to health concerns related to service in the POW and (2) those
developed to improve the future capability to evaluate military-service-related
health issues.
Several systems exist for collecting health and exposure information. Some
are relevant to clinical evaluations, others are relevant to research, and some are
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
relevant to both. Not all of these information systems are appropriate for use in
research activities, nor do they have to be. Some of these systems, such as
inpatient hospitalization data, were available at the time of the PGW; others,
such as the PGHR, were established shortly thereafter; still others, such as
PARRTS, have been developed or extended since the PGW. Some of these
systems will be useful for collecting data that strengthen future military health
preparedness to address research questions.
CRITERIA FOR A RESEARCH-ORIENTED HEALTH
INFORMATION SYSTEM
Information systems should include data items that are selected to meet a
clearly articulated purpose. A clear statement of objectives for an information
system is essential to selecting appropriate and necessary data items for
inclusion; determining the level of detail required; and assessing data
completeness, accuracy, and utility.
If information systems for DoD and DVA are to support the delivery of
high-quality medical care during mobilization and the evaluation of health
consequences associated with the conflict, information should be collected for
each individual or for well-defined subpopulations and should include at least
the following:
1. a list of all individuals participating in activities related to the conflict, to
establish the population at risk;
2. complete and accurate information pertaining to the experiences,
exposures, and environment of the individuals comprising the population at risk;
3. health experiences prior to mobilization, during mobilization, and after
the conflict; and
4. complete and accurate data on personal risk factors for adverse health
outcomes and prior health history.
Health information systems should be complete, accurate, cost-effective,
and readily usable for practical applications. Therefore, each data item should
clearly support the stated objectives of the information system, provide useful
insight into health concerns within acceptable time frames, and facilitate
decision making for prevention and health care programs. Continual evaluation
is essential.
It is not possible to design and implement an information system that can
anticipate every question of current or future concern, but systems can be
developed to maximize the opportunity to detect trends, define areas of concern,
direct corrective actions, and identify needs for supplementary data collection.
Here we discuss systems developed specifically to address PGW issues and
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INFORAl4 TION SYSTEMS
131
systems being developed to meet future needs for improved military health
information systems.
Appendix G includes a partial listing of existing databases that could
provide information for a Medical Health Surveillance System (MHSS) for the
armed forces and others that may be useful sources of supplementary
information. The large number of existing databases are acm~n~sterea
independently and are rarely linked to each other, which highlights the problems
of fragmentation and disorganization.
PERSIAN GULF WAR HEALTH INFORMATION
SYSTEMS
Several information systems have been developed in response to concerns
about the health consequences of the PGW. Those designed to obtain health
information include DVA's PGHR and DoD's CCEP. Other systems are
designed to obtain exposure information, including TEAM and RUL.
The PGHR includes active duty, retired, reserve, and National Guard
veterans of the PGW who are self-referred to obtain a medical examination and
appropriate follow-up and to provide registry information. Recently, the
committee has learned that provisions are being made to include spouses and
offspring of PG veterans in this database. The PGHR contains identifying and
demographic information, history of tobacco use, exposure to selected
potentially hazardous substances and experiences, diagnosed diseases and
conditions, and self-reported symptoms (DVA, 1995b). The CCEP includes
self-referred individuals who are experiencing illnesses that may be related to
their service in the PGW and are currently on active duty. Eligible family
members are also examined. This program was designed to evaluate and treat
the health problems of these individuals. Therefore, data contained in this
system include demographic and identifying information, medical history data,
self-reported symptoms, physical examination data, laboratory test results,
diagnostic data, reported workdays lost, and family member data (DoD, 1996;
IOM, 1996~.
Other information systems were designed to gather or use exposure data.
TEAM was presented to the committee as including National Oceanic and
Atmospheric Administration (NOAA) models for the entire period of the oil
well fires, troop unit locations and movement data, satellite imagery to
determine the daily geographic extent of oil fire plumes, U.S. Army Center for
Health Promotion and Preventive Medicine (IJSACHPPM) air pollution data,
and other relevant exposure and toxicologic information when and if it becomes
available. Recently, the committee learned that data on some individuals who
had received the botulinum toxoid or the anthrax vaccine have been included in
the database. If TEAM is to be useful for research, it must contain accurate
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
environmental measurements, plausible computer estimates for the time periods
of greatest concern, and the ability to link these data systems to each other.
One component of TEAM is RUL, which is an example of a geographical
information system (GIS). RUL establishes the latitude and longitude of each
military unit at the company level from January 15, 1991, to the date that unit
left the Gulf region. TEAM therefore excludes some troops involved in
Operation Desert Shield who left the Gulf prior to January 15, 1991. Locations
will be recorded for the unit rather than the individual soldier. For example, a
time series of geographic locations of troop units might be useful to distinguish
between units that were in the vicinity of Kuwait oil well fires and units that
were in the area but not downwind from the plume. These data could be a
useful resource for general exposure information for units of POW troops, but
they are likely to be subject to misclassification of exposures at the individual
level, particularly for individuals with assignments out of their units for
particular segments of time.
Some investigators hope to use the RUL database to assess other exposures,
such as proximity to depleted uranium (DU) weapons during tank battles. Such
a population might have greater potential exposure to DU than other troop units.
Investigating possible disease clusters is another potential use of this database-
for example, studying diseases or symptoms among units closest to damaged
Iraqi chemical weapons depots.
Unit location data will be linked to models of oil well fire location, oil fire
plume location, and air pollution data collected by the Army beginning in May
1991. Plans include the development of individual exposure information
matrices. Risk values for putative carcinogenic and noncarcinogenic exposures
will be determined from sampled as well as modeled grid data. Risk
information is to be provided to individual veterans, but this step should be
carefully planned and should include explanations of the limitations of
interpolating unit data to individuals.
Unit-level data are "ecologic" in nature because each person in a given unit
will be assigned the average or aggregate exposure for the entire unit. With
ecologic data, information about the joint distribution of exposure and health
outcome at the individual level is unknown. This can give rise to the "ecologic
fallacy," in which the true exposure-response relationship at the individual level
is biased by the grouping of data and possibly by uncontrolled confounding at
the individual level. This bias could result in either overestimating or
underestimating the risk being considered.
Other limitations affect one-time ecologic summaries of environmental
conditions such as oil fire plumes. Exposures that have varying intensity or are
characterized by a "pulsing" or short duration of exposure may be inadequately
measured. Late placement of health professionals to document these changing
conditions in-theater has probably led to mismeasurement of exposures; this
may be especially serious for troops or units with the highest levels of exposure.
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133
Inadequate data will severely limit the ability of analyses to establish a
connection between a service-related exposure and health outcomes or to
demonstrate a dose-response relationship. Merely confirming the presence of a
potential hazard in the combat environment does not indicate whether the
exposure itself caused the adverse effect or whether there was a level of
exposure below which no adverse effect occurred. These questions must be
assessed accurately to respond to service members' questions and to evaluate
the effectiveness of current preventive medicine practice and of protective
equipment and programs.
HEALTH INFORMATION SYSTEMS FOR THE
FUTURE
New information systems are being planned and developed to improve
military readiness to respond to future health concerns of military service and
deployments. These include the UMR, DMED, and Army PARRTS.
The committee has identified several changes in systems and practices for
collection of information on the health and service-related exposures of military
personnel that will increase the ability of the military services to pursue
epidemiologic investigations and health outcomes studies. These changes will
increase the capacity of the services to evaluate the efficacy of mobilization-
supporting health services, including prevention programs; Remobilization,
mobilization, and demobilization services; and routine military medical care.
The most important of the proposed changes is the creation of a uniform,
continuous, and retrievable medical record. The UMR system should include a
minimal data set for all service personnel, encompassing personal and
demographic descriptions; health- and service-related exposures; illnesses,
injuries, and medical conditions that occur during military service; hazardous
and potentially hazardous exposures, job assignments, and locations throughout
military service; and periods on temporary duty assignment for training and
during deployment for military action, particularly to overseas locations. It also
should include information about medical contacts that occur after military
discharge through the DVA or other government medical providers and,
wherever possible, private providers.
This information should be collected according to standardized procedures
and maintained in a computer-accessible format. The primary value of a
uniform and centralized record system used by all military services will be an
improvement in the health protection and treatment of individuals. Another
important benefit will be the support of epidemiologic investigations. A UMR
would facilitate selection of appropriate comparison groups as well as linkage to
civilian data sources, such as cancer registries, mortality files, and birth defects
registries for health outcomes assessment. A UMR also could facilitate follow-
up and follow-back by linkage with such electronic data sources as the Health
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
Care Financing Administration, the National Death Index, and other data files.
These sources are utilized for vital status follow-up in longitudinal studies.
Although attractive scientifically, follow-up methods, linkages, and information
collected require careful attention to infonned consent and privacy protection.
A UMR would solve certain problems in the current medical information
systems as well. Most current medical information is in the traditional paper
format. Electronic data are limited primarily to hospital inpatient discharge
summaries, utilizing international diagnostic codes for predominant medical
conditions and the more common medical procedures. Information from
mobilization stations and mobile field medical facilities is most likely to be
incomplete and to be separated from other military medical records. A single
computerized record that follows each individual throughout all facilities would
solve many of these problems. Furthermore, such a UMR system would
eliminate the need to establish conflict-specific registries for current and future
deployments.
In the construction of the UMR and related databases and their application
to military health issues, care must be taken to safeguard the privacy and
confidentiality of military personnel and their family members encompassed by
these systems.
The committee has identified three aspects of current policies and practices
that must be modified to support the completion and implementation of
integration of medical record systems and their coordination with civilian
medical records. The first is the policy of assigning separate responsibility to
each military service for the medical records of active personnel and separate
responsibility to DVA for the medical records of veterans in its facilities.
Second, medical records established and maintained by the reserves and
National Guard are kept separate from each of the above and are not routinely
linked. As a result of these practices, the content of the medical record differs
among medical services. Third, data recorded by the reserves, National Guard,
DVA, and DoD are not linked to data from civilian physicians and facilities.
Therefore, one cannot obtain a comprehensive profile of the health of service
personnel discharged from active duty.
The committee concludes that the branches of the military service, the
reserve and National Guard organizations, and the DVA must work together in
the development of standardized and uniformly applied practices regarding the
collection, recording, and maintenance of service health records. Medical care
of the individual, the efficiency and effectiveness of the medical care system,
health surveillance, and epidemiologic evaluation of potential threats to the
health of service personnel will be greatly strengthened by the development of a
system that provides access to the entire medical history of each member of the
armed services.
The committee is mindful of the need for meticulous attention to many
difficulties that will arise in the last step of this proposed data system the
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INFORMi4 TION SYSTEMS
135
linkage to civilian sources. Those difficulties will include concerns about
privacy and confidentiality, costs imposed on the provider of the information
(individually small perhaps, but large in the aggregate), barriers to integrating
information from civilian sources that is not provided in a UMR format, the
need for very rapid response regarding individual medical problems, and the
sheer size of the proposed system. We believe that these problems can be
solved, but solutions will take time. Delay in integrating data from the civilian
sector must not be allowed to retard progress in integrating data from all
segments of the military.
The committee is encouraged that efforts are being made toward unifying
medical records among the service branches, and computerizing parts of this
record in a uniform way is being discussed. It is understandable that each
service will have aspects of the medical record that are specific to its mission;
however, uniform collection of core data items is important.
The complexity of medical information systems and the problems
encountered in obtaining such data are exacerbated when investigations focus
upon reproductive outcomes. Therefore, problems related to health studies in
this area highlight issues critical for developing a military medical information
system.
Discharge summaries, records of infant births, and records of congenital
malformations recognized at the time of a newborn's discharge from the
hospital are collected in a standardized manner throughout DoD medical
treatment facilities worldwide. However, only limited data are available from
insurance records such as CHAMPUS (Civilian Health and Medical Program of
the Uniformed Services a civilian community-managed care plan for DoD
beneficiaries) or from TRICARE (regionalized tri-service health care system).
These data may be useful for studying the effects of service on late-gestational
pregnancy losses, prematurity, birth weight, and major malformations
identifiable within the first days of life. Data are less likely to be available for
infertility, pregnancy loss prior to the third trimester, delayed growth and
development of offspring, or any condition dealt with by civilian health care
providers. The committee has been told that service members on active duty
often choose to obtain reproductive care from civilian sources, thus highlighting
the need for linkage of this important area of military medical research with
civilian medical records.
Although a uniform medical record would substantially strengthen the
ability of the military services to evaluate the health of service personnel and the
efficacy of military health programs and doctrine, it cannot provide all of the
information that might be needed to respond to unanticipated health problems
arising after a deployment. Several supplementary databases are described
below.
The committee has heard presentations on the DMED system under
development by the three services and the DVA. This system will contain
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
standardized data elements from each service's epidemiologic database,
including demographic data (sex, race, ethnicity, date of birth, marital status,
education), personnel data (personal identification number, rank, duty station,
unit identification code, unit zip code, DoD occupation group, length of service,
dates of active service), and medical events (hospitalization dates, disposition,
up to eight diagnoses and eight procedures, cause of injury, sick days per
episode, medical treatment facility, autopsy). Future expansion of DMED may
include deployment data, medical readiness data (vaccinations, examination
status), temporary duty stations, reserve and National Guard data, and outpatient
data.
Many important research investigations could be undertaken with such
information. The fully developed system will, however, have other research
capabilities. First, it can be used as an index to persons who have specific
features, for example, all those who may have had military occupational
exposure to some solvent or all those who have developed some specific form of
cancer. Such persons can then be studied in greater depth from the original
health records, personal interviews, or other information sources. Second, a
complete listing can be used as a "sampling frame" for detailed study of a
random sample of persons with specific characteristics, such as a sample of all
those who served in the POW. This may be critical when the intensity of
analysis precludes study of all persons who have specific features (e.g., the
697,000 who served in the POW).
The committee believes that mechanisms should be established to collect
more extensive data during periods of deployment and combat. A presentation
and demonstration to the committee of the Army's PARRTS indicated that
significant efforts have been made to collect in-theater hospitalization data.
Inclusion of information from other services and casualties and addition of
information on ambulatory care will strengthen the ability of this system to
provide real-time data on medical conditions in-theater. PARRTS demonstrates
that the Army has initiated real-time electronic submission of data describing
health conditions that may compromise the success of a mission and events that
may reflect a breakdown in the prevention of illness. These data will have to be
linked to individual health information in other databases or in the UMR to be
of value beyond the reporting of aggregate combat field hospitalizations. A
central group of civilian experts, military specialists, and major operational
commanders should review and evaluate the program periodically as one means
to advance its mission.
The current surveillance of reportable illnesses and the publication of the
Medical Surveillance Monthly Report by the Army provide timely data for the
entire Army, not just the deployed forces. Similarly, it is important that real-
time data collection be monitored to document the numbers of key adverse
health effects and the characteristics of the population from which they derive.
Medical profiles should be updated periodically to reflect current experiences.
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For each military operation, prior or concurrent identification of plausible
infectious threats or environmental hazards to health will assist in determining
what additional data should be collected for specific in-theater exposures.
Additional information needed will depend on geographic area, endemic
diseases, nature of the conflict, expected duration and intensity of exposures,
and perhaps other factors specific to the conflict. Forward planning for a range
of future conflicts will be required, along with ongoing revision during
mobilization and deployment, during the conflict itself, and during the postwar
period.
Establishment by the Army of the Theater Area Medical Laboratory
(TAML) for the purposes of identifying and evaluating medical problems and
conducting studies during deployments will improve the capability to
investigate potential health problems and disease outbreaks while troops are still
in the field. However, the success of this concept in the future will depend on
the commander's support and commitment to utilize the unit early in
deployment. The expertise in epidemiology and the clinical and laboratory
diagnostic capabilities offered by TAML could provide immediate and useful
guidance and capability to collect information in the field when problems or
unusual exposures are identified.
In combat situations, military success is, of course, all important. Our
recommendations in no way suggest or endorse compromising the military
mission for the purpose of improving health data collection. Questions about
possible acute or delayed health effects of military service must not interfere
with operational activities in any way that could degrade effectiveness in
successfully fulfilling the primary military mission. Rather, there should be
prior and concurrent review and planning by experts who understand both the
military imperatives and the health consequences of service to establish the
appropriate mechanisms to collect these data. Two examples from the POW
where improvements in data maintenance would have been valuable are the
preservation of predeployment immunization records and a more full,
informative, and nonthreatening health assessment at the time of demobilization.
CONCLUSIONS
The purposes of medical records and research records differ, but there is
great benefit in collecting as much information as possible in a structured
format. This structure will reduce data errors, be compatible with computerized
clinical data systems, and be available for research studies. A medical record
system for patient care should be constructed with major input from physicians,
nurses, and administrators and should be oriented largely toward the care of the
individual patient. There is a need for a detailed record of personal, family, and
medical history; symptoms at the time the patient is first seen and later; physical
findings and how they change; results of each laboratory test and radiological
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HEALTH CONSEQUENCES OF THE PERSIAN GULF WAR
procedure; detailed records of findings at surgery and from pathology
examination; reasons for and results of specialist referrals; daily or even hourly
nurses' notes; and condition at discharge, with copies of any instructions
provided to the patient regarding activity level, drugs, return visits, etc.
Considerable information must be in free-form text, but much can be collected
in a structured format.
Although patient care data should be collected in as structured a format as
possible, the requirements of research studies are somewhat more stringent. A
research protocol generally requires additional structure. For example, the
investigator may need to collect the same data items for each patient in the same
way at the same time point in the medical process. Requirements for precision
of observations may also be more rigorous (e.g., special devices and techniques
to measure liver function with more precision than is needed for clinical care),
and some observations may have to be made with increased frequency. Thus,
data items of research interest tend to be more numerous, more precise, and
more patterned than those for patient care only. Importantly, most of the text in
a clinical record will be of little value to the researcher in that format, although
it may have a very important role in helping to understand a complicated
medical situation and in the completion and accurate coding of structured items.
Computerizing the entire medical record may also reduce the cost of research
that utilizes the data, since access to such information will be more efficient.
Because of the need for meticulous attention to research needs for specific
data in a sometimes unavoidably chaotic medical setting, investigators often
find that they must take the lead in screening and securing the data they require,
and the data must be available in their laboratories or offices. However, a
combined system of records for patient care and research will be increasingly
feasible, and the collection of structured data should be maximized.
The committee considers these four steps the development of a
uniform medical record, (2) the improvement of data collection on exposures
and health status of deployed service personnel, (3) the provision of
supplementary data on occupational and environmental exposures, and (4) the
inclusion of early detection medical teams during major deployments to be
important elements of an MHSS that would increase the nation's capacity to
address questions about the acute and chronic health consequences of
deployments of U.S. military service personnel.
In summary, an MHSS would establish the capacity to respond to questions
such as the following:
1. What are the baseline personal characteristics and medical status of
military service personnel? To what extent are these baseline or preexisting
characteristics correlated with the risk of future illnesses and adverse health
conditions? Is any correlation likely to be one of cause and effect?
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2. For each activity in, or in support of, combat-related military duty, what
assignments and exposures are potentially hazardous to health? How great is
the hazard?
3. What is the incidence of illnesses, injuries, and medical conditions
occurring during routine active military duty?
4. What incident illnesses, injuries, and medical conditions occur during
combat-related military duty? Does their frequency or severity change because
of specific deployment activities?
5. What hazardous exposures and assignments experienced during active
military duty can be linked to specific health outcomes, particularly military-
unique exposures or exposure conditions that are significantly different from
civilian settings?
6. What preventive measures can be taken prior to or during known
exposures to specific hazardous substances or conditions? Are important
positive synergies or adverse interactions anticipated among the multiple
prevention approaches employed (multiple vaccines, chemopreventives,
uniform repellents, area spraying, etc.~?
The development of an MHSS should focus on several issues. Data quality
should reflect attention to case and item definitions and ease of input. Data
systems should serve a shared purpose among all participating services,
agencies (the DoD, DVA, Department of Health and Human Services,
Environmental Protection Agency, etc.), and components (active, reserve, and
National Guard troops). A lead agency should be identified as the government's
proponent and authority for maintaining the MHSS.
Recent military deployments have raised questions of service-connected
adverse health effects of delayed onset. These often will be identified and
treated in DVA or civilian settings after active military demobilization. As a
result, it will be extremely important for DoD to ensure that active military
health data systems facilitate efforts to address questions that arise months or
years after personnel leave active service or that occur among their family
members. Such a proposal would require a research capability and supporting
health information system that do not exist today in either DoD or DVA.
Cooperation of agencies within the government toward this objective is essential
to establishment of an effective MHSS.
Questions about the frequency of health events also occur independently of
deployment. Therefore, national data systems maintained by government
agencies such as the Department of Health and Human Services or the Centers
for Disease Control and Prevention should be analyzed to obtain baseline or
comparison data for referent populations. Participation and oversight of experts
external to the government will increase the operational effectiveness of such
health information systems.
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Any impediment to health care access by service members decreases the
ability of health information system to recognize that health events are occurring
and to assess their service-connectedness in a timely manner. Such obstacles to
access to health care after the POW resulted in amplification of concern,
exaggerated community and political response, and well-intended but
occasionally unwise and potentially uninformative government-funded
activities, as described throughout this report.
Information systems developed immediately after the POW are limited in
scope and disconnected from each other. Systems under development to ensure
future medical readiness and to enhance epidemiologic capabilities have great
potential for producing a seamless medical record that can be linked to other
information systems, and thus meet the important military medical objectives of
prevention, providing effective and appropriate medical care, and facilitating
epidemiologic research.
Representative terms from entire chapter:
health consequences
