F1. SUMMARY
FOSIS must support all defense healthcare tasks:
• Consultation and treatment on infirmaries with and without dentist clinic, ships, and field hospitals
• Aviation and diver medical consultations
• Patient logistics in peace, crisis, and war
• Material logistics and maintenance in peace, crisis, and war
• Personnel management
• Quality Management and Administration
FOSIS will comprise the following modules to be implemented in the shown sequence:
1. Consultation
Treatment
2. Patient logistics
3. Personnel planning
4. Procurement
Inventory management
Material maintenance
Inspection
5. Development
As the modules are defined here they support all healthcare tasks in the defense with at least the following benefits:
• Benefit description
The value of the benefits has been pessimistically estimated to at least €4 million per year through:
• Better utilization of resources
• Healthier personnel
• Improved quality of offered healthcare services
We estimate that the full value of benefits can be earned over a 3-year implementation period.
First year cost based on experience with the full implementation of a COTS-based solution across all defense barracks is estimated to be €3 million.
If the defense decides to base the solution on the integrated defense COTS application that is not prepared for a FOSIS solution, the first year costs and the annual operation costs will be considerably higher.
Annual operation costs are estimated at €1 million per year.
The suggested FOSIS solution with requirements to integration, technology, and organization fulfills all Critical Success Factors from the PQA that initiated this IRS.
The estimates do not take into account adaptation to international defense standards except for the WHO terminology standards and the already established NATO standards. These standards must be adhered to in FOSIS as they become available.
The future COTS vendor for FOSIS must guarantee compliance of functions, data, and reporting terminology and classification concerned with national and international healthcare standards at delivery and by delivery of adequate adaptation and new versions in the future.
F2. THE FOSIS TASK
Replace all current systems and improve the services provided by DHS.
The primary wish is to get implemented an electronic health journal that follows all personnel wherever they are in peace, crisis, and war.
The health journal must function irrespective of geographical placement.
F2.1 Introduction
DHS (Defense Healthcare Service) requires new Information Systems.
F2.2 The DHS Situation and Initial Conditions
DHS employs 999 persons distributed as doctors, dentists, nurses, assistant nurses, and administrative personnel.
F2.2.1 DHS Tasks
Primary DHS tasks comprise:
• Prevention and treatment of military personnel health problems. In peace time, the military personnel is conducted to the civil health-care system for treatment.
• Military healthcare training of an important number of doctors and healthcare personnel that can be called upon under crisis, catastrophes, and war.
• Support of civil institutions concerned with helicopter-based surveillance and sea rescue tasks including development of special equipment to this end.
F2.2.2 DHS Current IT-Based Systems
F2.3 The IRS Method Used
The method used to prepare this requirements specification is IRS.
F2.3.1 IRS
IRS comprises the following activities:
• Establishment of study scenario
• Definition of sections (virtual organization that encompasses all DHS tasks)
• Selection of participants (Facilitator, Workgroup, Reference Group, Section interview participants, etc.)
• IRS Introduction to participants
• Interviews with section participants
• Documentation of task-based sectional information requirements
• Review and approval of section IRS reports
• Management level interviews and IRS management report writing, review, and approval
• Consolidation workshop with IRS Workgroup and IRS Reference group to write this report
• IRS result sign off by sponsor
The IRS has been done on three organizational levels of DHS:
1. Sections with managers from:
• Infirmaries with and without dental clinic
• Air force stations (aviation medicine)
• Fleet stations (diver medicine)
• Ship and sea rescue service
• Field hospital
2. Departmental managers:
• Doctors
• Veterinary doctors
• Dentists
• Planning
3. Executive Manager:
• The doctor general
The IRS-process with selection of qualified and competent participants in interviews is coordinated in a cross-organizational DHS IRS Reference group. Resulting documentation and method support is delivered by an external facilitator and an experienced DHS project manager in an IRS Workgroup supported by the DHS IRS Reference group.
F2.3.2 Interviews
Each interview has the following participants:
• Interviewers (project manager and facilitator)
• A person from the IRS reference group
• Selected persons from section or management level
The interview participants have the responsibility for the quality of the report content.
We have established five sectional reports with the following content:
• Tasks, products, and objective
• Why the tasks are performed in the context of DHS
• Information used
• Information not available that could improve section performance
• Information exchange with others
• Possible improvements of current systems and procedures
• Improvements of current systems and procedures from integration of systems
• Potential benefits from improved systems, procedures, and integration
• Suggested solutions (not required)
We have established three departmental reports:
• Department responsibility and tasks
• Who are the primary clients?
• Who are the primary vendors?
• The results and the result quality (client needs satisfied) of the departments activity
• Expected and required quality of the departments products
• Need of improved information
• Potential improvement of decision foundation
• Expected benefits from improvements
We have established one executive level report (doctor general):
• The business objectives of DHS
• Need of improved information
• Potential improvement of the foundation for decision making
• Expected benefits from improvements
F2.3.3 Consolidation of the Interview Reports
The conclusions in the interview reports are coordinated in a workshop with the IRS Workgroup and the IRS Reference group that could have lost participants or have had participants added.
The interviews have shown a series of information elements used in the work of the interviewed:
• Some information elements describe actions (consultation, diagnosis, usage of material, experience element, etc.)
• Some information elements describe the DHS structure (organization, infirmary, material, patient, personnel, etc.)
In the Consolidation Workshop the participants decide on the functionality that is required in the future information system. The point of departure is the actions of DHS and these actions’ requirements for procedures and information in order to be performed efficiently. It is thus decided what functionality the system elements must offer to the users thereof.
This report is the result of the IRS interviews and the IRS Consolidation Workshop.
F2.4 Other Source Material
The following supplementary source material has been used:
• Pertinent civil and military healthcare legislation and conditions
• Electronic healthcare record architecture
• Civil healthcare classification system
• The ministry of defense IT-strategy
F3. FUNCTIONAL AREA INFORMATION NEEDS
FOSIS IRS has been conducted within the following organization structure:
Sections refer to a military command unit, but for their rules of health-care conduct they refer to DHS.
All managers have received all section reports before their IRS management level interview.
The doctor general had access to all sectional and departmental reports before the direction level interview.
F3.1 The Doctor General
F3.1.1 The Business Objectives of DHS
F3.1.2 Need of Improved Information
F3.1.3 Potential Improvement of the Foundation for Decision Making
F3.1.4 Expected Benefits from Improvements
By a more systematic follow-up on diagnosis and related treatments for the single patient, the doctor general would get a better foundation for inspections, perform better inspections, and get an improved foundation for continuous performance improvement.
Objective measurements of product quality can be used for improved quality management.
Education of healthcare personnel can be adapted to the epidemiological development pattern in the military, which will improve the performance of the education and the personnel in support of better infirmary performance.
Ongoing updated information about personnel education needs and wishes can improve the planning and performance of the healthcare personnel training and the healthcare personnel carrier opportunities.
If DHS gets the resource management responsibility for healthcare personnel, this management results in higher DHS performance.
The DHS product and performance can be made more visible by registration of time used in defense and civil research, which can contribute to a more realistic budget for DHS based on the real defense benefits from the DHS organization.
F3.2 Medical Doctors
The medical doctors have the responsibility for the defense healthcare quality.
F3.2.1 Products
The medical doctors establish qualitative and quantitative requirements to the healthcare condition in Army, Navy, and Air Force.
The structure of infirmary duty is adapted to the ongoing structural changes in the defense, where ordinary military personnel and personnel such as pilots and divers with special healthcare requirements are the primary clients (patients).
F3.2.2 Objective
The medical doctors must within their resource budget and the DHS conditions in general manage the medical treatment of the defense personnel in order to ensure the physical and psychological health of the personnel that best possible satisfies the defense requirements for functionally capable personnel.
F3.2.3 The Results and the Result Quality (Client Needs Satisfied) of the Departments Activity
The medical doctors give advice to the doctor general concerning:
• Defense healthcare needs
• Defense healthcare human resource requirements
The medical doctors coordinate the contact with civil national and international organizations.
Other responsibilities comprise:
• Personnel
• Inspection
• Infirmary capacity planning
• Education, skill, and competence planning
F3.2.4 Suggested Procedure Improvements and Their Benefits
• Improved skill and competence information for improved education planning and better education performance
• Improved information about military exercises placement and timing will make it possible to ensure a better service in these situations
• The patient health journal must always be accessible under the medical contact with the personnel, which will require an IT-supported patient journal system
• Only WHO-coding of diagnosis should be used for homogenous registration in the infirmaries and field hospitals
• FOSIS must be integrated with similar NATO-based systems for improved international cooperation under international crisis and war conditions with, for example, UN or NATO involvement
• Improved personnel information exchange between defense and civil doctors can provide much better healthcare to the concerned personnel
F3.3 Veterinary Doctors
F3.4 Dentists
F3.5 Planning
F3.6 Infirmaries
F3.7 Aviation medicine
F3.8 Diver Medicine
F3.9 Field Hospital (FHOSP)
An international FHOSP has been used as a model for this section. The relationships among departments inside the FHOSP and the relations with direct partners (the logistics battalion), other sanitary units (1.-3. og 5. echelon), other FHOSP, NATO-partners, DHS, and civil hospitals has been studied.
FHOSP is subordinated a logistics battalion. Replenishment of material and equipment and reparation and maintenance support is required through this logistics battalion.
FHOSP must be able to serve nationally and internationally, for example, as demanded from UN, NATO, OSCE, or EU partners.
FHOSP is focused on chirurgical treatment at least on high civil quality level. It receives, treats, and evacuates patients. It delivers sanitary equipment and material to sanitary units closer to the front (1.-3. echelon).
FHOSP comprises the following “departments”:
• Reception and registration
• Ambulatory
• X-ray, EKG
• Dental clinic
• Operation rooms
• Intensive/anesthetic
• Bed sections
• Isolation
• Sterilization
• Laboratory
• Evacuation/leave instruction/administration/conference
• Sanitary supply
• Kitchen/cafeteria
• Operational (logistics and communication)
• Technique and maintenance (power, plumbing, electronics)
• Personnel quarters (tents, containers)
• Rolling materiel (parking)
FHOSP is 4. echelon, while the supply of material, power, plumbing, etc. is 1. echelon relative to FHOSP functionality. This means that basically all supply of material and equipment must be delivered from national ground because 1. echelon carries as little material as possible.
For the FHOSP a manual journal system has been developed. The field journal has been replaced by a Field Medical Card (FMC) covering the journaling needs at 2. and 3. echelon. FMC complies with NATO STANAG requirements. FMC is relatively fail-safe as no written documentation is required except for y/n tick off.
The route of the wounded is:
4. Place of injury (1. echelon)
5. Departmental place of bandage (2. echelon)
6. Main place of bandage (3. echelon)
7. FHOSP (4. echelon)
8. Civil hospital or garrison infirmary (5. echelon)
Healthcare documentation comprises:
1. Echelon—Fills out FMC in English, French, and national language.
2. Echelon—Fills out FMC front page in English, French, and national language.
3. Echelon—Fills out FMC last (back) page in English, French, and national language.
4. Echelon—From 4th echelon the language is national in journals and other documents. Documents to follow the patient through NATO links are in English.
FHOSP maintains a list of all patients who have been received for treatment. The list from the last 24-hour period is sent to the operative command unit by military mail and is one of the foundations for requirement of replacement personnel, for the activation of sanitary units, and finally to be able to trace personnel.
F3.9.1 Products
FHOSP services always to be delivered at civil quality comprise:
• Chirurgical treatment (primarily)
• Observation and treatment
• Sanitary material supply
• Requisition of sanitary material
• Normal infirmary service to own personnel
• Administrative duties and communication
F3.9.2 Objective
FHOSP must treat sick and wounded with the intention to protect life and mobility. FHOSP must communicate to ensure optimal logistics of patients and of sanitary material and equipment. It is a national political requirement that FHOSP can be activated fast worldwide as part of a purely humanitarian effort.
F3.9.3 Work Processes and Procedures
The work processes and procedures for 1.-4. Echelon structure with FHOSP are:
Place of Injury
FMC is filled in with:
• Person ID
• Grade
• Unit
• Name
• Time of injury
• Type of injury
• Contamination
• Intermediate diagnosis
• Transport Instruction
FMC follows the patient to 2. and 3. echelon.
Field journals such as the FMC are different from nation to nation.
Department and Main Place of Bandage
FMC is filled in with big differences in quality based on:
• Personal qualifications FMC
• National differences in format
• National differences in attitude
F3.9.3.1 Reception on FHOSP
F3.9.3.2 Treatment on FHOSP
F3.9.3.3 Evacuation from FHOSP
F3.9.3.4 Supply Logistics
F3.9.3.5 Patient Logistics
F3.9.4 Suggested Improvements to Procedures
• Access to centrally controlled and valid patient healthcare information
• Possibility to register validated patient healthcare information decentrally with automatic central update when connected
F3.10 SHIP
F4. FOSIS SYSTEM REQUIREMENTS
By the implementation of healthcare information systems in the defense, two central tasks must be completed:
1. As IT and information systems are responsible, one must ensure that the future system can operate within the framework of the defense IT standard platforms. Even though you might be able to find and acquire suitable COTS products, these must be adapted to meet the DHS needs. This adaptation requires set up, development, and system testing, integration testing, and acceptance testing of the COTS-based solution, which is done in a phase after the purchase of the COTS product.
2. As a user, you must ensure the ease of use of the future system, its ability to protect confidential patient information, its ability to ensure the ethical behavior of the personnel, and its ability to meet the defense security requirements. These properties cannot be controlled solely with IT. They require better and appropriate work-flows, new personnel agreements, and training that is adapted to the improved behavior.
This consolidated IRS report not only describes the requirements to an IT COTS-based solution, but also describes the requirements of better DHS business workflows.
With FOSIS as it is outlined in this report, the defense will be able to contribute to an improvement of the public and private healthcare service.
F4.1 General FOSIS System Requirements
Confidential information.
F4.2 FOSIS Information System Modules
FOSIS must offer the following information system modules:
• Consultation
• Treatment
• Patient logistics
• Personnel planning
• Procurement
• Inventory management
• Development
• Maintenance
• Inspection
In the following chapters, the system module functionality is outlined. For each module, selected parts of the overall information model will be presented to illustrate the objects used in the module. ACTION objects are shown with bold frame, while STRUCTURE objects are shown with normal frame.
This module must ensure that the defense always knows where a patient is.
F4.3 Consultation
F4.4 Treatment
F4.4.1 Plan Treatment
F4.4.2 Perform Treatment
F4.4.3 Invoice to Civil Client or from Civil Treatment Vendor
F4.4.4 Pay Invoice
F4.4.5 Integration with Other Systems
F4.4.6 Target Users
F4.5 Patient Logistics
F4.5.1 Receive Patient
F4.5.2 Admit Patient
F4.5.3 Move Patient
F4.5.4 Exit Patient
F4.5.5 Integration with Other Systems
F4.5.6 Target Users
F4.6 Personnel Planning
F4.7 Procurement
F4.8 Inventory Management
F4.9 Development
F4.10 Maintenance
F4.11 Inspection
F5. CONCLUSION AND RECOMMENDATIONS
F5.1 Cost/Benefit Analysis
The cost and benefit analysis is based on rough cut estimated amounts because there are no statistical reports or accounts that can support an objective economic feasibility study of the introduction of FOSIS except for the few key figures shown below.
All amounts are determined on the basis of the benefits that the defense as a whole can achieve by improving the healthcare systems. Where these benefits are expressed as a public benefit of less strain on the public health-care system, these benefits are included. The immediate personal benefits that patients, other treated persons, and FSU personnel may obtain have not been included.
Some statistics have a relationship with FOSIS implementation benefits, for example:
• The current annual costs of DHS are close to €25 million.
• Soldiers discarded after acceptance to be employed by the defense cost €10,000 per person. This happens approximately 550 times per year with an annual cost of €5 million.
If one would try to estimate the real public benefits of FOSIS one could show astronomic amounts from:
• Reduced risk of cardiovascular diseases based on improved defense healthcare statistics
• The value of less F16 accidents annually
• The value of 50% less work injuries in the defense annually
The accumulated value of these benefits is so big that one can wonder why FOSIS has not been implemented a long time ago.
F5.1.1 Calculation of Benefits
Benefits |
Value €/year |
Maintenance of current systems |
40,000 |
Improved prevention of personnel health problems (also useful for civil authorities) |
150,000 |
… |
150,000 |
… |
40,000 |
… |
… |
… |
… |
Total €/year |
5,000,000 |
F5.1.2 Estimation of Costs
Investment |
€ |
Purchase of COTS for FOSIS implementation |
800,000 |
Implementation of FOSIS workflows and reports |
1,000,000 |
Implementation of FOSIS requirements in COTS |
300,000 |
Development of training material |
150,000 |
Design and development of integration with defense and civil systems |
300,000 |
IT infrastructure and IT support organization development |
400,000 |
User documentation |
150,000 |
Initial training |
150,000 |
Total |
3,250,000 |
Annual costs |
€ |
… |
… |
Total |
1,000,000 |
F5.2 Recommended Information Systems and Their Priority
6. Consultation
Treatment
7. Patient logistics
8. Personnel planning
9. Procurement
Inventory management
Material maintenance
Inspection
10. Development
F5.3 Suggested Implementation Project
F5.3.1 Important Phases and Milestones
• Legally compliant tendering material for COTS-based FOSIS solution (turnkey)
• Detailed requirements spec for FOSIS as basis for turnkey agreement
• Legally compliant solicitation
• Selection of maximum five potential vendors
• Distribution of tendering material with turnkey contract
• Evaluation of offers and choice of vendor if possible
• Preparation of infrastructure for installation of basis COTS
• COTS installation and product sign off from defense IT
• PQA in the FOSIS IRS Reference group
• Selection of implementation project manager for the FOSIS solution
• Agile FOSIS development and implementation including documentation
• Implementation of FOSIS test and training environment
• Preparation of testers and test scenarios for Simulated Accept Test (SAT)
• FOSIS IRS Reference group accept test of FOSIS
• Establish learned lessons collection and communicate them
Attachment 1 Critical Success Factors
CSFs were formulated under PQA by the IRS Reference group:
1. Essential FOSIS functionality implemented simultaneously on time.
2. Intuitive Danish language user interface.
3. FOSIS supports all healthcare services throughout.
4. FOSIS provides access to necessary and complete healthcare information.
5. FOSIS communicates with relevant systems.
6. FOSIS is aligned with the defense IT strategy and is based on relevant standards.
7. FOSIS meets all requirements for safety and traceability.
8. FOSIS enables a flexible, user-specific data handling.
9. FOSIS increases quality and efficiency in healthcare service.
Attachment 2 Object Lifecycle Matrices (CRUD)
Note: C: Create, R: Read, U: Update, D: Delete.
Consultation:
Process Object |
Plan Consultation |
Perform Consultation |
Invoice |
Pay Invoice |
DEPARTMENT |
R |
R |
||
INSTALLATION |
R |
R |
||
TREATMENT |
R |
|||
CIVIL INSTITUTION |
R |
R |
R |
R |
DIAGNOSIS |
C |
R |
||
DIAGNOSIS CODE |
R |
|||
DOC REF |
R |
RC |
||
DOCUMENT |
R |
RC |
||
SUBJECT |
R |
|||
INVOICE |
CU |
CU |
||
COMPONENT |
C |
RUC |
R |
R |
STOCK LOCATION |
R |
|||
MATERIAL |
R |
|||
MATERIAL USE |
C |
R |
||
MYNDIGHED |
R |
R |
R |
R |
CONSULTATION |
C |
RUC |
R |
R |
… |
||||
ORGANIZATION |
R |
Treatment:
Patient logistics:
Personnel planning:
Procurement:
Inventory management:
Development:
Inspection:
Attachment 3 Object Descriptions
1. Consultation
2. User guide to the object description usage
3. Object description columns user guide
4. Object descriptions for FOSIS
Attachment 4 Input-Output Tables
Here is shown the total interchange of information between sections and sections and between sections and external organizations as this was documented in the sectional reports; including the information maintained in each section.
Table over information to and from IBA sections and externals
FROM TO |
INF |
FHOSP |
SHIP |
ORG |
INF |
Exit letter |
Healthcare journal extract |
||
FHOSP |
||||
SHIP |
Approval of healthcare journal |
|||
… |
Attachment 5 Vocabulary
Acronym Concept |
Definition |
Example |
LOGBTN |
Logistics battalion |
|
COMEDS |
Committee of the Chiefs of Military Medical Services in NATO |
|
COTS |
Commercial Off The Shelf |
|
EDI |
Electronic Document Interchange |
|
FHOSP |
Field Hospital |
|
WHO |
World Health Organization |
|
WONCA |
The WONCA International Classification Committee (WICC) has produced the International Classification of Primary Care (ICPC), a clinical coding system for primary healthcare. |
World Organization of National Colleges, Academies (WONCA) of doctors |
… |
… |
… |
Attachment 6 Key Figures
1. Infirmaries
INF activity:
1993 |
1994 |
1995 |
1996 |
|
Medical |
||||
Consultations |
205.266 |
173.6361 |
200.391 |
|
Treatments |
34.074 |
32.636 |
38.772 |
|
Dental clinic |
||||
Consultations |
142.251 |
153.331 |
140.425 |
158.359 |
1993 |
1994 |
1995 |
1996 |
Treatments |
55.209 |
52.720 |
45.928 |
47.523 |
Working days |
12.152 |
11.256 |
||
External consultations |
53.417 |
53.486 |
40.191 |
39.322 |
No shows |
7.717 |
7.749 |
6.120 |
5.684 |
2. Diver medicine
3. FHOSP
4. SHIP
Attachment 7 ERD User Guide