Providing healthcare for the armed forces is like running a primary care trust without geographic boundaries. Defence Medical Services (DMS) looks after about 200,000 service personnel and 50,000 civilians - support staff and families - at hundreds of sites between the Falklands and Afghanistan. The numbers present a challenge, but it is the geographical spread and the changeable, often dangerous nature of operations which makes it a daunting task.
In the past it has been made harder by the fact that military medical records are held on non-networked computers or paper. Service personnel may even have more than one record as they move between different locations.
Now, according to defence minister Derek Twigg, "the days of paper records are numbered". At the beginning of August he spoke at the formal launch of the Defence Medical Information Capability Programme (DMICP), describing it as "a huge step change in medical care".
"Doctors, pharmacists, nurses and other health professionals will now benefit from access to one central database, providing the most up-to-date information on their patients," he said. "It will not matter if they are in Birmingham or Basra."
The programme, developed under an £80m contract awarded to LogicaCMG in April 2006, is now moving beyond the pilot phase to early implementation. It was tested early in the year at two small sites at Chicksand and Waterbeach, and in June was implemented as a "pathfinder" at the first large centre, the Colchester Medical Reception Station. The system is now being progressively rolled out to all UK Army medical facilities, before being extended to the RAF, Royal Navy, Defence Dental Services and permanent overseas bases by August 2008.
After 2008, a version of the system will be available in field hospitals, on Royal Navy ships and on the battlefield via laptops and other portable equipment under development. It will provide instant access to casualties' medical records to support diagnosis and improve treatment.
Colonel Mike Manson, assistant director of development for DMICP, says the system has two key capabilities: an enterprise solution working off a central database that makes it possible to share information across all the services; and an up to date knowledge base to support diagnosis and treatment.
The system's core function is to provide the integrated health record (IHR) to be created for every patient of the DMS. This invites comparisons to the Summary Care Record being created under the NHS National Programme for IT (NPfIT), but is more comprehensive, including details of every element of care while in the service. It includes primary, secondary, dental, rehabilitation, mental and occupational care.
Lieutenant Colonel Jonathan Cox, clinical policy adviser for DCMIP, relates the development of the IHR to the kind of problems faced by GPs in obtaining records for new patients. He says they are worse for military doctors as patients move more often, and that the DMS also had to keep in mind the question of appropriate access.
"We constructed a complicated network to ensure patient confidentiality based around the role the person who logged on is fulfilling that day," he says. "Different clinicians have different types of access, and some staff can't get it all." He adds that patients can see their own records.
The record will be accessible to NHS staff when service personnel are on leave or referred for secondary care. However, the demands of the healthcare programmes in the different countries of the UK mean that access will remain within the constraints of what can be seen on their electronic patient records.
For two years Manson has been a member of the NHS UK e-Health Committee, looking at ways in which the four countries, along with Jersey, Guernsey and the Isle of Man, can connect their health services.
"There are different approaches but it is coming together," he says. "People are beginning to identify ways it can be done which are acceptable and cost effective.
"We have also had discussions with individual countries."
The IHR incorporates the EMIS clinical information tool, which is currently used by the majority of GPs in England. It is kept on the database housed at a LogicaCMP facility in Bridgend, south Wales, with all the data mirrored at a back-up centre at another location which kicks in if the main one goes down.
Access will be provided through the Defence Information Infrastructure network, making patient information available not just to the 227 medical and 165 dental centres around the world, but to field hospitals, air bases and Royal Navy ships.
Casualty chips
The system will also allow casualties to be issued with a chip loaded with their health records as a back-up until they reach a military medical or NHS facility. It is possible to put their entire IHR onto the chip, although in battlefield situations - when the information is originally recorded on ruggedised laptops or wristband PDAs - it is most likely to be a summary of wounds and immediate treatment.
The only limitation is on images. Some can take up over 10Mb of memory and would place a great strain on battlefield communications systems that do not have a high bandwidth.
"We need to look at where we could strip things out," Manson says. "We don't yet know the capacity of the chips we'll be using, but we will go for the latest and most appropriate hardware when we roll it out in a year.
"It will be transported with the patient so we need something quite hardy."
Among the other functions of DMICP are medical practice management, and the ability to provide reports and analysis. This is a key component of the Defence Health Change Programme.
Cox says the process makes use of the Cognos 8 tool to anonymise all of the data and run management reports on a range of issues. This can work for individual medical centres, military units and on a split of operational and non-operational bases, and covers obvious areas such as injuries on duty, or less obvious subjects such as the success of a centre in persuading patients to quit smoking.
This has required a lot of work on the schemas for the data, and it is still going on, but Cox says it has already been possible to compile some simple reports.
"It enables us to answer questions more easily, which is important in dealing with ministers and Parliament," he says. "It can effectively work as a data warehouse."
He adds that DMS has an advantage over the NHS in this field in that it can use the whole patient record, not just a summary or the detail from one stage of care.
The other main functions of the system are interfaces with the MoD's Joint Personnel Administration system, making it possible to align health records with more general service records, and from 2010 with the NHS. This will mean that the NHS medical records of new recruits can be imported directly into the DMS, and records can be exported back to civilian GPs when they leave the forces.
Risk reduction
Manson says there has been no significant change in the plans since the contract was signed. He attributes this largely to the development of the programme, including a substantial risk reduction and demonstration phase to ensure the technology works at all levels. About 400 members of the DMS have had an input into the process, and the programme is now being promoted throughout the organisation so that all its staff will be aware of its capabilities once it is available to them.
Features currently outside of the programme's scope may be added in the future. Manson says that one possibility is to include body charting on the IHR, and that there could be further interfaces to systems such as those for forces' logistics; but the DMS wants to concentrate on the original scope during the roll out to minimise any risk to the programme.
While it is taking a cautious approach, the defence hierarchy is sufficiently confident to claim a success.
"The Defence Medical Services are delighted with the achievements made by the DMICP programme so far," says Lieutenant General Robert Baxter, deputy chief of defence staff (health). "The ability to access patient records anywhere, anytime is an invaluable asset, and the assurance of a single record for each patient will give medical staff greater confidence that when treating patients they are looking at a definitive record.
"The system will allow staff to work more efficiently, spend more of their time caring for patients and utilise medical resources more effectively. We will quickly see the powerful impact that DMICP will have on both DMS staff and patients, and we are looking forward with great enthusiasm to the deployment phase of the programme."
