GOAL
To outline the process by which medical information – particularly as it pertains to combat casualty care – is transmitted along the continuum of care. The Theater Medical Information Program (TMIP) suite of programs will be utilized for clinical documentation at all levels of care.
BACKGROUND
Information entered electronically into TMIP is visible throughout the continuum of care in the Theater Medical Data Store (TMDS), CONUS AHLTA via The CDR, BHIE (DOD-VA-THEATER SHARE) and in the VA system. TMDS is accessible from any .mil computer at the following link: https://tmds.tmip.osd.mil/
- TC2 (Theater Medical Information Program Composite Health Care System Cache) is the inpatient documentation system approved for use in CENTCOM AOR. It should be used at all Role 3 facilities. AHLTA-T (Armed Forces Health Longitudinal Technology Application – Theater) is the outpatient documentation system approved for use in the CENTCOM AOR. Information that should be recorded electronically in TC2 includes, but is not limited to:
- Detailed admission note (not to be done in lieu of completing the Trauma form/Resuscitation Record)
- Operative note(s)
- Radiology dictation(s)
- Physician note(s)
- Detailed discharge summary
- Nursing notes
- Pharmacy entries
- Laboratory results
- AHLTA-T should be used at all levels of facilities to document outpatient care. AHLTA-T may be used to initiate the longitudinal electronic medical record at Level II facilities. At a minimum, the following information shall be entered:
- Detailed exam and care notes, (not to be done in lieu of completing the Trauma form/Resuscitation Record)
- Radiology dictation(s)
- Pharmacy entries
- Laboratory tests and Results
- Note: Additional electronic documentation is highly encouraged, including but not limited to nursing documentation, pharmacy entries, and laboratory results.
- Information at Level I, II, and III facilities is to be uploaded to TMDS as an attachment as soon as possible after discharge and ideally prior to arrival at the next echelon of care. Information entered into TMDS allows medical providers at higher echelons of care to review the patients’ record prior to arrival, and allows down range providers feedback on care provided in the combat theater. In some cases, downrange providers may enter patient notes directly into TMDS if TC2 and AHLTA-T are not available and upon approval of CENTCOM Surgeon.
- Essentris is the in-patient medical record for Inpatient care at Level IV and most Level V facilities.
- BHIE (Bidirectional Health Information Exchange) is a data exchange which communicates with Clinical Data Repository (CDR), allowing Essentris data to be viewed from distant locations. Electronic records entered into CHCS/Essentris (inpatient pharmacy data, allergies, laboratory results including surgical pathology, cytology, microbiology, chemistry and hematology, radiology reports, problem lists, encounters, procedures, and clinical notes) are automatically transferred to the CDR at the time of discharge from Level IV and V. Landstuhl BHIE records can be accessed under the “Other Health History: BHIE Share LRMC” tab in TMDS and Other Health History Tab in Patient summary. Level IV and V data records can be accessed under the “Health History/VA/Theater History” tab in AHLTA (Non-deployed version only).
- If the TMIP system is not available or operational, use one of the remaining two modules, if available. For example, if TC2 is not available to document an inpatient encounter, use AHLTA-T or TMDS.
- If no electronic means exist for transmitting medical information, then it is incumbent upon the physician responsible for that patient to ensure that detailed paper records are provided to the next echelon of care to facilitate an orderly hand-off to the next set of providers.
- Optimally, all Level I and Level II facilities have electronic scanning capability to permit Resuscitation Records and other hard copy documents to be converted to digital format to be uploaded to TMDS.