Seong K. Mun

Patient-Centered Medical Home: An Emerging Primary Care Model and the Military Health System

The patient-centered medical home (PCMH) is a primary care model that aims to provide quality care that is coordinated, comprehensive, and cost-effective. PCMH is hinged upon building a strong patient-provider relationship and using a team-based approach to care to increase continuity and access. It is anticipated that PCMH can curb the growth of health care costs through better preventative medicine and lower utilization of services. The Navy, Air Force, and Army are implementing versions of PCMH, which includes the use of technologies for improved documentation, better disease management, improved communication between the care teams and patients, and increased access to care. This article examines PCMH in the Military Health System by providing examples of the transition from each of the branches. The authors argue that the military must overcome unique challenges to implement and sustain PCMH that civilian providers may not face because of the deployment of patients and staff, the militarys mission of readiness, and the use of both on-base and off-base care by beneficiaries. Our objective is to lay out these considerations and to provide ways that they have been or can be addressed within the transition from traditional primary care to PCMH.

Perspectives on Clinical Informatics: Integrating Large-Scale Clinical, Genomic, and Health Information for Clinical Care

The advances in electronic medical records (EMRs) and bioinformatics (BI) represent two significant trends in healthcare. The widespread adoption of EMR systems and the completion of the Human Genome Project developed the technologies for data acquisition, analysis, and visualization in two different domains. The massive amount of data from both clinical and biology domains is expected to provide personalized, preventive, and predictive healthcare services in the near future. The integrated use of EMR and BI data needs to consider four key informatics areas: data modeling, analytics, standardization, and privacy. Bioclinical data warehouses integrating heterogeneous patient-related clinical or omics data should be considered. The representative standardization effort by the Clinical Bioinformatics Ontology (CBO) aims to provide uniquely identified concepts to include molecular pathology terminologies. Since individual genome data are easily used to predict current and future health status, different safeguards to ensure confidentiality should be considered. In this paper, we focused on the informatics aspects of integrating the EMR community and BI community by identifying opportunities, challenges, and approaches to provide the best possible care service for our patients and the population.

Imaging components for a robotic casualty evaluation system

Combat medics have a vital role in the protection of wounded soldiers in the battlespace. However, their duties expose them to great risks. Furthermore, these medics are a limited resource and must be carefully tasked in order to provide maximum benefit to their units. For these reasons, we are applying the American GNC Corporations (AGNC) Coremicro® Robotic System for autonomous evaluation of battlefield casualties. These robots are intended to navigate to a casualty, determine his/her overall health status, and perform limited diagnostic imaging in order to assess the presence of injuries that would prevent or complicate extraction. In this paper, we describe development work on some of the key components of the proposed robotic system, namely the overall concept of operations (ConOps) and initial testing of infrared and ultrasound imaging cameras. When fully deployed, this system will act as a medical force multiplier, enabling improved care of wounded soldiers and protecting the health and safety of military medical personnel.

The executive summary of the National Forum on the Future of Defense Health Information Systems.

The Department of Defense (DoD) has been engaged in the development and deployment of the longitudinal health record (LHR). It has achieved remarkable technological success by handling vast amounts of patient data coming from clinical sites around the globe. Interoperability between DoD and VA has improved and this information sharing capability is expected to continue to expand as the defense health information system becomes an integral part of the national network. On the other hand, significant challenges remain in terms of user acceptance, ability to incorporate innovations, software acquisition methodology, and overall systems architecture.

Background and mathematical analysis of diffusion MRI methods

The addition of a pair of magnetic field gradient pulses had initially enabled the measurement of spin motion to nuclear magnetic resonance (NMR) experiments. In the adaptation of diffusion weighted (DW)‐NMR techniques to magnetic resonance imaging (MRI), the taxonomy of mathematical models is divided in two categories: model matching and spectral methods. In this review, the methods are summarized starting from early DW NMR models followed up with their adaptation to DW MRI. Finally, a newly introduced Fourier analysis based unifying theory, so‐called Complete Fourier Direct MRI, is included to explain the mechanisms of existing methods.

Interactive Feature Space Explorer© for multi-modal magnetic resonance imaging

Wider information content of multi-modal biomedical imaging is advantageous for detection, diagnosis and prognosis of various pathologies. However, the necessity to evaluate a large number images might hinder these advantages and reduce the efficiency. Herein, a new computer aided approach based on the utilization of feature space (FS) with reduced reliance on multiple image evaluations is proposed for research and routine clinical use. The method introduces the physician experience into the discovery process of FS biomarkers for addressing biological complexity, e.g., disease heterogeneity. This, in turn, elucidates relevant biophysical information which would not be available when automated algorithms are utilized. Accordingly, the prototype platform was designed and built for interactively investigating the features and their corresponding anatomic loci in order to identify pathologic FS regions. While the platform might be potentially beneficial in decision support generally and specifically for evaluating outlier cases, it is also potentially suitable for accurate ground truth determination in FS for algorithm development. Initial assessments conducted on two different pathologies from two different institutions provided valuable biophysical perspective. Investigations of the prostate magnetic resonance imaging data resulted in locating a potential aggressiveness biomarker in prostate cancer. Preliminary findings on renal cell carcinoma imaging data demonstrated potential for characterization of disease subtypes in the FS.

Defense Health Information System as a case study for national health IT

The National Forum on the Future of Defense Health Information Systems (National Forum) held in Washington, DC in March 2008 provided a unique opportunity to conduct a case study of developing a large complex health information system. The concept of the health information system has evolved from the days to electronic hospital information system (HIS) to longitudinal health record (LHR) which refers to a complete information system that adequately captures what occurs to service persons from “cradle to grave”, including but not limited to the clinical record. As originally imagined after the first Gulf War, the LHR is supposed to serve many functions in occupational health, medical logistics, health planning, and medical surveillance as well as clinical care. The LHR has become central to both DoD and VA health systems. As LHR emerges, the interoperable national health information system is becoming critical for the future. DoD and VA collaboration has accelerated in the last two years as exemplified by current efforts to exchange information between AHLTA (DoD Health IT system) and VistA (VA health IT system). With almost 70% of defense and veteran healthcare happening outside of the DoD/VA system, the LHR must accept information from the private sector not only Government sources. Given their size and position, DoD and VA have the potential to lead the nation in supporting standards for national health information network (NHIN). With that in mind, the VA and DoD are coordinating their efforts with the Office of the National Coordinator Health Information Technology (ONCHIT) that is leading the nations interoperability and information exchange effort. Knowledge discovery and management is vital to bringing benefits of data repository to the clinicians and researchers. The growth of clinical data, image files, physiologic data, and omic data among others has produced an information explosion in healthcare and forced successful organizations to become knowledge-driven enterprises. Moreover, the recent IOM Roundtable on “Data for the Public Good” discussed the current challenges of aggregating large sets of data while taking the position that exploiting large databases would significantly accelerate science. Although DoD and VA have numerous databases and two of the largest growing clinical data tissue repositories in the world, they lack a common healthcare data model to link the databases together and sponsor no significant effort to create an infrastructure to make this data available for research. The MHS currently also lacks a strategy for managing its growing amount of data. Recently, MHS has worked with TATRC and IBM to develop a roadmap for developing a strategy but much more work remains. There are increasing needs for efficient software engineering and ability to integrate innovations in IT development process. Many participants expressed dissatisfaction with the current performance of AHLTA. Slow and awkward to use, AHLTA delays clinical work at a time when maximizing physician throughput really matters. The IT development occurred in a closed environment, insulated from evolving new ideas and best practices outside the DoD. As a result, while the previous efforts developed and implemented software for health care applications, global advances in information technology render it obsolete by the time it becomes available for use. With these problems and consequences in mind, participants in the National Forum consistently called for more open process of software engineering, program management and knowledge sharing to allow lessons learned to flow freely among government, academic and industrial partners in the software development process. As the health IT and personal health records (PHR) have become important national agenda, the experiences gained from the development and deployment of health IT systems in DoD and VA should provide important lessons for the national community.