programme cortisone: programme blueprint document version 5.0

20161025-CORTISONE_Programme_Blueprint_Int_V5 05.0

Programme CORTISONE > Blueprint Design & Delivery > Blueprint (LTD) > V5.0

Programme CORTISONE Programme Blueprint Document 25 Oct 2016 Version 5.0

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i 20161025-CORTISONE_Programme_Blueprint_Int_V5 05.0

Programme Name CORTISONE SRO Director Medical Policy & Operational Capability within the Defence Health

Change Programme Programme Manager SG DMed IS CORTISONE Programme Manager Author P Richardson, SG DMed IS CORTISONE Design SO2

Date 24/07/2013 Version 0.01 Status Initial draft for internal review 06/09/2013 0.02 Revised to include future state 13/09/2013 0.03 Desk circulation 30/09/2013 0.04 Revised to incorporate

stakeholder feedback 11/12/2013 0.05 AD level circulation 30/01/2014 0.06 For DMISSG endorsement 06/03/2014 0.07 Hd MedOpCap Review 11/03/2014 0.08 1* Circulation 27/03/2014 0.09 2* Approval 05/06/2014 0.10 Revised to incorporate

stakeholder feedback 20/06/2014 1.0 Final Version 31/10/2014 1.01 1st Review 25/11/2014 1.01.1 Showing tracked changes 27/11/2014 1.02 Desk Circulation 31/12/2014 2.0 Added comments from

Extraordinary Programme Board 11 Dec 12

24/04/2015 2.01 Desk Circulation 24/07/2015 3.0 Published version **/12/2015 3.02 Minor Amendment 01/03/2016 4.0 Published Major Version 07/10/2016 4.1 Minor Amendment 25/10/2016 5.0 Published Major Version

Annexes A DMS Current State B Gap Analysis C Glossary of Terms Reference Documents A Government ICT Strategy 2011 B Defence Information Strategy 2015 C DMS Sub-Strategy - Part 1 D DMS Information Strategy v1.9, Part - Strategy E Department of Health NHS Information Strategy – ‘The Power of Information’ F Allied Joint Medical Doctrine: AJP 4.10 Allied Joint Medical Support Doctrine, Edition A G Allied Joint Medical Doctrine: AJP 4.10 Allied Joint Medical Support Doctrine, Edition B H 20141201-CORTISONE_Tranche_Structure_v1.0.doc I Government Service Design Manual

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BLUEPRINT Purpose: The purpose of this Blueprint is to provide a model of the capability that must be in place to realise the Vision of Programme CORTISONE, which is: ‘A sustainable, integrated, cohesive and enduring information capability that will fully and effectively support the delivery of evidence-based medical and dental health and healthcare outputs, in order to achieve the Aim1 of the Defence Medical Services (DMS).’ It provides the focus for delivering the changes to the DMS’ health and healthcare information capability, as required by the DMS sub-Strategy and articulated in the DMS Information sub-Strategy2, which will meet the continuing and emerging needs of both the organisation and wider Defence. SCOPE 1. The CORTISONE programme addresses the support requirement for information generated by the DMS in producing their mandated outputs, across all contexts and capabilities of care. This includes the clinical, administrative, business management and force generation domains. 2. The Surgeon General’s remit does not cover the provision of veterinary services medical information. The programme specifically excludes addressing the information support service requirements of Defence’s Military Working Animals capability. The one exception to this is the archiving and management of veterinary radiographs which will fall within the scope of this programme. Also excluded are information services in support of medical training administration. ORGANISATION OF THE DMS – CURRENT STATE 3. A description of the DMS’ current structure and the primary business pillars that are likely to be directly impacted by the CORTISONE programme is provided at Annex A CURRENT DMS INFORMATION SYSTEMS 4. The Surgeon General and the DMS fully recognise the importance of information in fulfilling their remit to promote, protect and restore the health of the Defence Population At Risk (PAR), both in the Firm Base and on deployed operations. There is now widespread recognition that DMS must move to take its service provision to the next level and provide coherent information services spanning all medical capabilities, inclusive of single-Service elements, in order to maximise operational effectiveness. Collaborative development between the DMS and service providers will be necessary in order to achieve this goal. 5. The majority of the DMS’ information capability in the Firm Base, Permanent Joint Operating Bases (PJOBs) and Overseas Bases (OVBs) is delivered via the Defence-wide Defence Information Infrastructure (DII), although delivery over legacy infrastructures remains the only option in a very small number of locations. The major clinical information systems currently in service are:

a. DMICP – this is the core primary health and dental care information support tool, providing an iEHR capability for Defence. The acronym is now commonly regarded as referencing the iEHR software product/service rather than the originally-planned wider programme. DMICP is in daily use to underpin clinical care at all medical and dental centres

1 The Aim of the Defence Medical Services is to promote, protect and restore the health of the Defence population in order to maximise fitness for role. 2 http://cui2-uk.diif.r.mil.uk/r/573/Quality and Assurance/Strategy/2030619-DMS_Info_Strat_v1_9-U.doc.


in the Firm Base, PJOBs and OVBs. The key enabler of the system is a centralised database for the iEHR, which replaced the myriad standalone electronic and paper-based records systems previously in existence. This allows DMS personnel to access accurate, up-to-date patient records at all clinical locations where required. DMICP also provides access to a wide range of reference material and receives nightly updates from the Joint Personnel Administration (JPA) system, which is the definitive military personnel record repository for Defence. It also interfaces with the NHS Spine to facilitate ‘Electronic Referral Service’ functionality for referrals to SHC. DMICP also provided a data warehouse and Management Information System (MIS) tool (COGNOS) with query tools to allow corporate reporting. This functionality is utilised by Defence Statistics (Health), sS HQs, PJHQ and others to facilitate high level reports in support of activities including medical intelligence, medical operational planning, resource management, clinical outputs etc. b. DMICP Deployed – the deployable version of the application is modified in design to enable its operation in locations where there is no guarantee of connectivity to back-end data repositories. This includes deployments, exercises, OVBs, PJOBs, Afloat, and temporary medical facilities. DMICP Deployed operates by using a local server (laptop or tower), which synchronises with the master database when connectivity is available. Client access is achieved via ruggedized laptops. Synchronisation can occur online (gold standard) or via removable media. c. DMICP will be sustained temporarily by Project INTERMOLAR from Apr 16 until, at the latest, 2019, whilst a longer term replacement can be identified under CORTISONE. However, as the current supplier of DMICP won the competition for the INTERMOLAR contract, the risk of dislocation during migration has disappeared and reduces the challenge of completing DMICP FOC under one contract while services are sustained under the new. d. Radiology & Teleradiology systems – this capability facilitates the administration of patient and examination data through the Radiology Information System (RIS), and the viewing and subsequent archiving of Digital Images and COmmunication in Medicine (DICOM)-compliant images to the Picture Archiving Communications System (PACS). Both of these systems interface with other radiology equipment within the UK Medical Facilities. A deployed PACS was procured as a UOR and interfaced with the core Centre for Defence Radiology (CDR) PACS/RIS, which enables the transmission of image files. The current support contracts and infrastructure are nearing end-of –life and these issues are currently being addressed by the Teleradiology Project. RFA Argus is also equipped with a standalone PACS, although it currently has no means by which to transmit image files off-ship. e. Laboratory Information Management System (LIMS) – LIMS provides pathology support in a number of DMS locations. All instances of the system are standalone in nature, including the RFA Argus installation. LIMS was procured as a UOR and was brought into core as part of the Operational Deployed Medical Capability (ODMC) 2 project. f. Joint Theatre Trauma Register (JTTR) – the JTTR captures complex details of all fatalities and trauma injuries sustained in the operational environment. Its primary role is to provide continuous near real-time quality improvement of major trauma care and patient outcomes in support of current operations. Its secondary roles are to support research and development, with both Defence Statistics (Health) and Medical Directorate Staff analysing and exploiting the datasets. g. Central Health Records Library (CHRL) systems – CHRL is the main repository for the archiving of both physical and electronic medical records. CHRL receives records from many sources and in many formats, which are then converted to image format (where possible) for storage/retrieval electronically. The systems in use at CHRL are not readily


accessible to the wider DMS or Defence. A current work steam to stabilise the CHRL infrastructure, and thereby mitigate the risk of systemic failure is partially complete. h. EPINATO – the NATO health surveillance system mandated for use on NATO operations (described in AMedP 4.1, currently awaiting promulgation by the NATO Standardization Agency (NSA)). It was developed from the UK paper-based J95 health surveillance system. On a weekly basis, medical facilities complete a spread sheet (or paper-based return where ICT support is not available) which is e-mailed to HQ , where returns are consolidated before onward transmission to the chain of command and PJHQ. NATO has recently released EPINATO 2 and the UK has decided to introduce EPINATO 2 for contingency operations. i. Defence Statistics (Health) systems – DS (Health), formerly DASA (Health), provides a number of in-house developed software applications in support of DMS activities and statistical requirements, for example:

(1) Defence Patient Tracking System (DPTS) – the DPTS contains clinical data related to patients who are the subject of a strategic Aeromedical Evacuation NOTification of CASualty (NOTICAS) signal, and all those who enter a secondary care physical rehabilitation pathway. The primary role of the system is incident-based tracking of patients through their individual care pathways to a clinically-appropriate secondary care facility. This serves to provide assurance to the DMS that the subject patients are being suitably progressed along their pathways. Its secondary role is to provide a single point of truth for patient care pathways and to provide an information source for enquiries relating to service patient numbers, types of injuries etc; (2) Automated Significant Event Reporting (ASER) System – developed to enable the capture, processing and tracking of patient safety events; (3) Dashboards – DS (Health) produces a number of bespoke statistical ‘Dashboards’ in varying formats, which are designed in conjunction with the customer eg Defence Primary Health Care (DPHC). The base data is extracted from DMICP and various other datasets within Defence and amalgamated to present the required information in an accessible format.

j. Defence Science and Technology Laboratory (Dstl) systems – Dstl provides a number of in-house developed software applications in support of DMS operational planning and statistical requirements.

6. In addition to the systems above, there are many spread sheet, database, MOSS-based and manual solutions being used across the DMS that have been developed by different units, in isolation, to meet specific local needs. Much of the functionality provided by these unsupported applications and administrative systems is duplicated across the organisation in different formats. CORTISONE will seek to harmonise the core requirements for inclusion within its service offering.


FUTURE STATE OVERVIEW 7. The primary objective of the CORTISONE programme is to introduce coherence across the breadth of the DMS information and to enable seamless interoperability with the information systems of partner and other supporting organisations, principally the NHS structures of the home nations. This in turn enables the DMS to achieve their clinical outputs in a fully-informed, efficient and effective manner, and to maximise the return on investment in clinical research programmes and projects. 8. Coherence and interoperability across information systems:

a. Provides timely access to accurate, up-to-date patient information in support of clinical activities and diagnoses; b. Underpins clinical best practice through provision of integrated health and reference information at the point of delivery of care; c. Ensures that data can be captured once, at source, and used for their primary and secondary purposes across the organisation, regardless of host system configuration or location; d. Enables integration of deployed services into the DMS’ information mainstream.

STRATEGIC COMPLIANCE 9. CORTISONE will adhere to government and Defence strategic direction in designing and implementing its information services. Figure 1 illustrates the ‘golden thread’ that links the programme to overarching departmental strategy, and thus supports Defence outputs:

Figure 1 – Strategic ‘Golden Thread’


10. In 2011 the Cabinet Office published the Government ICT Strategy3. From this has developed the Government Service Design Manual4 which provides clear and unambiguous direction on the standards to be adopted and approach to be taken when considering the implementation of ICT solutions going forward. The key elements are:

a. The mandated reuse of proven common application solutions; b. A move towards ‘cloud’ computing; c. A move away from sourcing via large systems integrators in favour of small to medium enterprises (SMEs); d. Adoption of open standards to promote interoperability; e. A presumption against projects with a through-life estimated cost of £100m or higher.

11. This represents a step-change in the specifying and sourcing of public-sector information and communication technology and provides a solid foundation on which to build next-generation DMS information support services. The approach has been contextualised for Defence with the publication of the Defence ICT Strategy 20135 and updated in the Defence Information Strategy 20166. CORTISONE will fully align with both the government and MOD strategies. Additionally, Defence has created the Defence Information Reference Model (DIRM), the purpose of which is to promote information and ICT re-use, coherence, interoperability and open standards across the department. Reference to and full use of the DIRM will also be made in specifying and designing service offerings. 12. In line with Cabinet Office and MOD Chief Digital & Information Officer (CDIO) direction, CORTISONE will, wherever possible, adopt a service-orientated approach to acquisition. All service component solutions will be tightly integrated with the clinical and business capabilities and processes that they are ultimately designed to support. CORTISONE PRINCIPLES Introduction 13. The Vision of Programme CORTISONE is to provide a sustainable, integrated, cohesive and enduring information capability that will fully and effectively support the delivery of evidence-based medical and dental health and healthcare outputs, in order to achieve the Aim7 of the Defence Medical Services (DMS). Aim 14. The principles of Programme CORTISONE underpin the programme approach to delivering the vision. The Principles 15. The high level Programme CORTISONE Principles are:

3 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/85968/uk-government-government-ict-strategy_0.pdf 4 https://www.gov.uk/service-manual 5 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/255880/Defence_ICT_Strategy_2013_Final.pdf 6 https://www.gov.uk/government/publications/defence-information-strategy/defence-information-strategy 7 The Aim of the Defence Medical Services is to promote, protect and restore the health of the Defence population in order to maximise fitness for role.


a. to design user centric Medical Information Services that are focussed on quality, safety and better patient outcomes;

b. to ensure integrated, cohesive and scalable Medical Information Services are available in all DMS environments (fixed and deployed);

c. to facilitate the DMS to focus on Digital Transformation not Technology to enable the DMS to deliver its vision;

d. to provide a Single Point of Access for all healthcare information relating to each individual patient;

e. to enable Healthcare Information Exploitation (HIX) at all levels; f. to deliver an evergreen, enduring and sustainable Medical Information Services architecture and solutions; g. to enable interoperability between DMS Medical Information Services; h. to enable interfaces for efficient and effective information exchange; i. to deliver Services not just Software and j. to choose Commercial Off the Shelf (COTS) services first with Open Standards wherever possible. User Centric Medical Information Services 16. The term user includes patients, healthcare professionals and all personnel who may use the Medical Information Services (Med IS) provided by CORTISONE. These services should focus on ensuring the right information is available to the right people in the right format at the right time. Better information enables better patient outcomes which will benefit both the individual patients and Defence. The programme must have effective and continuous communication with the users to ensure it delivers what the users need not what the programme thinks they need. Integrated, cohesive and scalable Medical Information Services are available in all DMS environments 17. Appropriate Med IS must be available in all environments where the DMS is delivering healthcare from the firm base through fixed bases around the world to all types of deployments. Med IS should be scalable and capable of functioning offline with subsequent synchronisation, to meet the variable capability requirements at different locations. They should also be integrated and cohesive to avoid duplication of effort and wasting valuable clinical time. There should be a single source of the truth for each information item. Facilitate the DMS to focus on Digital Transformation not Technology to enable the DMS to deliver its vision 18. Digital Transformation is about transforming business activities, processes and competencies to fully leverage the changes and opportunities of digital technologies in a strategic and prioritised way. This enables organisations to be more agile, people-orientated, innovative, connected, aligned and efficient. CORTISONE will enable the delivery of technology that facilitates this transformation. Single Point of Access


19. The user must be able to access all healthcare information (that they are entitled to see (Role Based Access Control)) from a Single Point of Access. This does not mean all healthcare information must be held in a single database. CORTISONE will deliver a federation of services rather than a ‘one size fits all’ system. Healthcare Information Exploitation (HIX) 20. The DMS must be able to exploit all the healthcare data in records by transforming it into useful information. This information must be trusted to avoid duplication of effort. Services to enable HIX are required at all levels from the individual patient/clinician/practice to Defence. The information generated by HIX services will be used to inform individual healthcare planning, practice management, medical governance, HQ level reporting, medical intelligence, health surveillance, medical research, wider data analysis and to monitor adherence to regulations. Evergreen, Enduring and Sustainable Medical Information Services Architecture 21. CORTISONE will deliver a Med IS architecture that enables the Med IS to keep pace with rapidly changing technology and medical/Defence policies. This will enable the procurement of Med IS via shorter, more flexible and configurable contracts which can ‘plug and play’ services into the architecture without disrupting other services. Interoperability 22. CORTISONE will deliver interoperability between Med IS to ensure that the component parts of the Med IS architecture can operate successfully together and avoid duplication of effort. This will enable information to be recorded once but used many times which will optimise clinical time. This will deliver benefits to Defence and individual patients. Interfaces 23. CORTISONE will enable interfaces for efficient and effective information exchange. In particular the DMS needs to securely exchange healthcare information with the current and future NHS (including all devolved administrations) systems and services to support recruitment, healthcare delivery to Regular Service Personnel, Reserves and Veterans and to benefit from national initiatives such as cancer screening, GP2GP and Summary Care Record. The Med IS also need to interface with MOD HR services and NATO services provided by the MEDICS project. Programme CORTISONE services should also have the potential to receive feeds from international and private health organisations. Services not just Software 24. Software needs to be delivered as part of service packages which fully address capability integration considerations such as training, compliance with Defence as a Platform (DaaP)/MODNET strategy and implementation and have appropriate Through Life Management Plans. COTS first with Open Standards wherever possible 25. CORTISONE will employ a COTS (Commercial Off The Shelf) first approach to simplify procurement and reduce the costs/time of implementing upgrade as standard releases can be applied without need for additional customisation. Any specific DMS capability requirements will be met by configuration and business process change in the first instance. Any bespoke functionality deemed essential will be incorporated into sub-components that will interface with the chosen COTS package. This approach ensures that the core health record remains separate from


(though related to) Defence-specific information and can therefore be readily transferred to/from NHS or other provider systems as and when required, with the military element remaining within the DMS information domain. 26. CORTISONE services should be based on Open Standards wherever possible in line with the government’s commitment to the wider use of open standards across government8 FUTURE MODEL 27. Future information support services for the DMS must be innovative, agile, efficient and effective. In line with strategic direction, every effort will be made to avoid acquisition of highly-bespoke information services that are expensive to develop and maintain, and are a barrier to rapid adoption of technological developments. 28. AJP 4.10, Editions B9 set out the medical doctrine applicable to fixed and deployed operations. 29. The CORTISONE model will seek to deliver information services that provide full support across all of these capabilities, allied with a comprehensive Firm Base provision that, combined, will underpin patient-focused DMS activities and outputs end to end (E-2-E). CORE COMPONENT – THE iEHR 30. The core business of the DMS is delivering military medical operational capability, the major component of which is PHC as part of E2E healthcare provision. It therefore follows that the future information support service must be designed around the iEHR. The iEHR is defined as a digital collection of patient health information compiled at one or more clinical encounters in any care delivery setting. It will be constructed using commercial off-the-shelf (COTS) software products specifically designed to support primary health care service delivery, including support for dental, rehabilitation, occupational and mental health. 31. Any military functionality deemed essential will be incorporated into sub-components that will interface with the chosen COTS package. This approach ensures that the core health record remains separate from (though related to) Defence-specific information and can therefore be readily transferred to/from NHS or other provider systems as and when required, with the military element remaining within the DMS information domain. It also simplifies procurement and reduces the cost of implementing upgrades to COTS products, as the manufacturers’ standard maintenance releases can be applied without a need for additional customisation. 32. The existing iEHR and separate anonymised MIS databases will be exported from DMICP and used to populate the new medical information services, with the military elements extracted to populate the relevant sub-component(s). The concept of a centralised data warehouse for the PHC record – as developed under the DMICP initiative – remains a valid and essential part of the overall service architecture and will endure for the foreseeable future. A key work stream when evaluating suitable COTS products will be analysis of the underlying database structure to ensure that open standards can be applied and used for data interrogation and exchange, and to guard against proprietary lock-in. Where practicable and possible, established commercial frameworks – within Defence; NHS England; or wider UK Government – will be utilised to acquire CORTISONE capability.

8 Open Standards Principles 9 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457142/20150824-AJP_4_10_med_spt_uk.pdf


33. The current DMICP solution has 2 variants: Firm Base and Deployed including Afloat. The new iEHR solution will consist of a single service provision that has full utility across all contexts and environments that the DMS is required to provide health, healthcare, medical and dental support. It will present a common interface through which sub-systems can easily and securely interoperate, linked via a unique patient identifier. SUB-COMPONENTS 34. The following sub-components will interface with the iEHR to provide an information capability that spans the DMS. Each will be capable of modular deployment and incremental introduction to service. Similarly, each will be designed to be upgradeable discretely from other service components, so that advances in technology can be taken advantage of with minimal risk to the integrity of the wider system. 35. Figure 2 below provides a graphical representation of how component information services will, where appropriate, interact with and update the core iEHR:

Figure 2 – CORTISONE Vision

36. All sub-components/information services will be designed to be device and platform-independent where possible. This will enable access to DMS information services across a range of End User Devices (EUDs) and promote the spiral acquisition of value-adding emerging technology as and when it becomes available. 37. A fuller listing of sub-components, loosely arranged into functional groupings to aid clarity, is shown below:

a. PRIMARY HEALTHCARE SUPPORT

(1) Fitness for Duty – a capability for recording PULHHEEMS (or any future classification system) to enable decisions to be made regarding suitability for postings and roles, and generation of Joint Medical Employment Standard (JMES) codes. This functionality exists within recruiting support software applications.


(2) Dental Imaging – a distinction is made between medical and dental digital imaging. Dental practitioners capture and interpret radiographs in the primary healthcare environment as an integral part of most routine consultations. Dental records, including ante mortem radiographs, are frequently used in forensic human identification as odontology is an internationally accepted primary identification criteria. (3) Near Real-Time Disease Surveillance (NRTDS) – a warning and reporting, tracking and intervention capability for outbreaks of disease by time/place/person. To be enabled via close coupling with the core EHR, NATO and Allies.

b. SECONDARY HEALTHCARE SUPPORT

(1) Digital Imaging – a vital part of Deployed Medical Care (DMC) provision on operational deployments is an ability to capture and interpret radiograph, CT and other images to aid rapid and often life-saving diagnosis. CORTISONE will provide an asynchronous means by which images can be transmitted to consultants in the Firm Base for interpretation and for reports to be returned; as there is no guarantee that a radiologist will be available in-Theatre. A fully portable solution for the capture, recording and transmission of patient monitoring data will host the service at the DMC MTF. (2) Laboratory Information Management – functionality that is required to track and control pathology requests and analyses, which can be related to the subject’s iEHR.

c. PAN-HEALTHCARE SUPPORT

(1) Telemedicine – a synchronous service that will also incorporate a video-conferencing capability that supports the provision of remote consultations, and additionally enables tele-consultations to be conducted. This also allows assurance of junior doctors by appropriate senior doctors. (2) Health Surveillance - a capability that enables the extraction of data from the iEHR, allowing clinicians and other authorised users in medical headquarters to access and analyse anonymised data sets. The requirement covers both diseases and health conditions. (3) Pharmacy and Medicines Management – a solution for controlling and auditing the supply of drugs and medicines, it will also provide clinical decision support functionality at the point of delivery. A key component in delivering increased patient safety. (4) Clinical Research Repository – much of the valuable research undertaken by DMS staffs is currently unavailable electronically to the wider Defence medical community. CORTISONE will provide a means by which this material can be stored, indexed and retrieved across the organisation for contextual use. (5) Medical Equipment – enabling the capture at source of data generated through the use of specialised medical equipment, and subsequent integration with the iEHR. This capability has a close correlation with planned telemedicine functionality and will be developed to complement and enhance the telemedicine service. (6) Blood Supply Management – close control and accounting for blood products is mandatory and of paramount importance on deployed operations. CORTISONE will provide a deployable solution that can integrate with DHC MTFs and exchange


information with the iEHR. (7) Quality Improvement – a capability to capture near real-time clinical outcome data, matched to detailed injury/illness mechanisms and diagnoses, physiology and interventions in order to monitor and assure clinical performance at the individual patient and institutional level. This capability is linked to the telemedicine function to provide reach forward direction and reach back advice to enhance performance in the deployed medical treatment facility.

d. ADMINISTRATIVE AND BUSINESS SUPPORT

(1) Patient Tracking – an ability to track, in near-real time, the location of patients both geographically and through their respective care pathways. This functionality will ensure that patients complete their care programmes in a timely and effective manner, and mitigates the risk of DMS staffs losing sight of individuals. There are a number of mature, in-house produced systems within Defence that currently provide elements of this functionality (JTTR; DPTS; WISMIS etc) and there exists an opportunity to identify ‘best of breed’ for further development and integration. (2) Patient Administration – for use on deployment and in the Firm Base (primarily at DMRC, Headley Court and/or the planned DNRC, Stanford Hall). The system will make use of the PHC Master Patient Index (MPI) to maintain accuracy and avoid duplication of data. There are many COTS packages on the open market that provide this functionality; key to product choice will be scalability and flexibility regarding modules that can be added to the base system. (3) Bed Management and Record Keeping – this is an important extension of the patient administration capability that enables control and monitoring of bed allocation. Records of bed occupancy are necessary in the investigation of disease outbreaks and cross-infection. Acquisition of a suitable solution will replace the current manually-intensive methods, which are prone to transcribing errors and do not provide an audit trail of bed usage. (4) Health Records Management – a large and complex area that has suffered from an element of neglect in the past. The DMS are in the process of developing a new policy for the management of health records and the CORTISONE solution will directly support its implementation. The CHRL medical records archive contains valuable information that cannot be readily exploited at present, thus leaving a gap in regard to epidemiological capability. The future solution will ensure that metadata is clearly defined and rigidly applied as an integral part of the archiving process, and that there is tighter integration with the wider DMS information domain. This will include a link to the individual’s iEHR. (5) Medical Data Interrogation – an essential capability that will enable cross-platform interrogation of all electronic data repositories. It will be designed so that suitably authorised system users can create and produce reports and reporting formats independently of the service provider. (6) Corporate Support – in order to allow clinical staffs to discharge their responsibilities in a manner that is compliant with all legal and statutory requirements, with minimum encroachment on their primary duties, a suite of information services in support of corporate administration and governance activities will be designed. This will enable the analysis by HQ staffs of data captured during routine clinical activities,


whilst reducing the administrative burden on patient-facing personnel. Correctly specified services will promote continuous improvement activities and provide reliable and consistent performance evidence against Key Performance Indicators (KPIs).

e. DMS INFORMATION DOMAINS

(1) The CORTISONE suite of services will provide support, either directly or indirectly, for the following domains of information, which the DMS routinely augment or require access to in the production of their clinical and business outputs:

Domain Elements

Archived information

Defence Health Records.

Business Intelligence

Decision Support; Continuous Improvement.

Business Support KPIs; Compliance; Governance; Infrastructure; Asset Management.

Clinical Administrative information Appointments Scheduling; Bed Management; Hygiene; Staff Rotas.

Clinical Information PHC; SHC; Intermediary; Dental; Occupational; Mental; Rehabilitation.

Clinical Research Outcome Information; Performance Information; Force Protection Information; Reports and Papers (outputs).

Deployability information

Fitness for Duty; Fitness for Deployment.

Epidemiological information

Analytical datasets.

Logistical information AEROMED & MEDEVAC; Blood Stocks; Pharmacy Supplies and Restock; Medical Equipment Movements & Serviceability States.

Personnel information DMS Service Personnel (Reserves tba); DMS Civilian Personnel; PAR (Reserves tba).

Quality Improvement Registries for Major Trauma and Medical Illness; Performance data (KPIs; actions taken following significant events; clinical case conference minutes; post mortem analyses; public enquiry outcomes)

Strategy & Policy outputs

Strategic Planning; Medical Policy.

Table 1 – Information Domains

(2) Figure 3 below provides a graphical representation of how these domains integrate with the overarching CORTISONE model:


Figure 3 – Information Service Structure

f. INTERFACES

(1) Central to the CORTISONE approach is an understanding that information should be entered only once, at source, and then be made available for contextual use across the DMS information domain and sphere of operations. This links in with the CTO’s and DBS Data Management Services’ drive to identify producers and consumers of data, in order to ensure that there is ‘…only one authoritative source for each type of master data.’10 Once established, authoritative data sources (ADS) must be made available in open and common formats for exploitation ie data will be shared unless there is a valid reason for not doing so. ADS custodians will also be responsible for managing their data in such a way as to maintain quality and accuracy over time. (2) The shift from stovepiped bearers to layered services in the Defence as a Platform concept will deliver the cloud hosting and gateways services needed for CORTISONE service elements to co-operatively interact, regardless of physical location. Future hosting capabilities including containerisation and automated tooling is being established under Project EMPORIUM and it is intended that CORTISONE will exploit these. (3) Much of the base information required by the DMS is created and held within other ADS domains, both internal to and outside of Defence. Robust and secure interfaces will be established with each as necessary. Interoperability will be underpinned by a clearly-defined technical specification for interface requirements, as mandated by the Government Service Design Manual11 and Defence ICT strategies, which will be strictly adhered to during service and solution design.

(4) The CORTISONE suite of services will interface with:

10 https://www.gov.uk/government/publications/defence-information-strategy/defence-information-strategy, page 17 11 https://www.gov.uk/service-manual


(a) Defence civilian and military Personnel Administration systems and/or successor services – JPA currently provides the definitive military personnel record within Defence; HRMS is its civilian equivalent. Both provide key personal identifiable data; (b) Defence logistics systems – to exchange information for AEROMED and MEDEVAC operational requirements; tracking of medical equipment locations and maintenance states; blood stock management; medical inventory management and stock control; pharmacy and medicines management; (c) NHS spine (and/or successor services) – to commission secondary care and to enable the exchange of the Defence iEHR with NHS service providers when required; access to E-referrals and other NHS services, both existing and planned. This interface will also enable interaction with NHS trust systems where there is a military presence; (d) Medical equipment supplier systems (including Medical & General Supplies (M&GS) Delivery Team) – to enable an integrated approach to procurement, maintenance and monitoring; (e) NATO, allies and other health service providers (including 3rd Sector organisations12) – for the exchange of health records (where authorised13); medical planning, management and support information; epidemiological data; (f) Wider UK Government departments – for the exchange of statistical and other information as required.

Figure 4 – Interfaces

12 The Oxford Dictionary defines the 3rd Sector as: ‘The part of an economy or society comprising non-governmental and non-profit-making organizations or associations, including charities, voluntary and community groups, cooperatives, etc.’ 13 There is uncertainty at time of writing as to whether member-state agreement on NATO iEHR exchange can be achieved.


(5) CORTISONE services will also extend into:

(a) The Defence Statistics (DS (Health)) organisation – for the exploitation of health information to support the delivery and continuous improvement of health and healthcare services; (b) Dstl– for the exploitation of health information for Operational Analysis, to inform Operational Medical Planning.

(6) All CORTISONE services will present a standards-based interface that can be readily utilised for any future, as-yet unidentified interoperability requirement. The standards mandated for Defence and government are outlined later in this document.

g. NHS ALIGNMENT

(1) A key strategic objective of the DMS is the strengthening of relationships with the NHS. An important element in shaping the future CORTISONE landscape is therefore alignment with planned information initiatives across the NHS organisations of the UK. The Department of Health has published its information strategy14 for NHS England, and CORTISONE service design will be fully informed by the direction provided therein, together with corresponding initiatives in Scotland, Wales and Northern Ireland.

h. COMMUNICATIONS INFRASTRUCTURE

(1) The global nature of DMS deployment demands a global reach for supporting information services. CORTISONE services will therefore be designed and developed in close liaison with Defence technical authorities to ensure full compatibility with current and planned Defence communications infrastructures and connectivity, principally DII Fixed, Deployed and Maritime15, deployed Tactical Communications Systems and Beyond Line Of Sight (BLOS) capabilities. (2) Cognisant of the need for cross-Governmental and inter-departmental communication, those service elements that can be hosted in the government secure cloud will be designed so to be.

i. SERVICE ACCESS

(1) The service interface presented to the end-user will allow access to all functionality, service components and information commensurate with their role and responsibilities, in a seamless and coherent manner, via a single login. This will be achieved through utilisation of the Identity and Access Management (IdAM) service. IdAM is ’…an integrated set of policies, processes, standards and technologies that create and manage digital identities and associated access privileges for all people and other entities within an organisation and over the whole lifecycle of activity16.’

j. TECHNICAL STANDARDS

(1) Adherence to common, agreed standards is critical to future CORTISONE service interoperability across Defence and the wider stakeholder community. CDIO has mandated17 that all Defence ICT programmes must apply the following standards

14 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213689/dh_134205.pdf 15 Being replaced by New Style of IT (Base and Deployed) 16 https://www.gov.uk/government/publications/defence-information-strategy/defence-information-strategy, page 11. 17 https://www.gov.uk/government/publications/defence-information-strategy/defence-information-strategy, page 17.


hierarchy, in the order shown, when designing and implementing ICT solutions and information services:

(a) Open standards, including International Standards and the Cabinet Office ‘Open Data Standards Process’; (b) NATO standards; (c) British Standards Institute standards; (d) Other Government standards; (e) Proprietary standards; prior agreement to each application of proprietary standards must be sought from the Network Authority.

38. The CORTISONE suite of services will be designed in accordance with this direction. In particular, proprietary standards will be avoided unless there is absolutely no viable alternative. GAP ANALYSIS 39. Annex B provides a Gap Analysis, which has been cross-referenced with the strategic objectives of the DMS. Whilst not exhaustive, it aims to:

a. Highlight the major areas where an information capability shortfall has been clearly identified; b. Provide a focus for initial programme planning and project identification.

PROGRAMME STRUCTURE 40. Programme CORTISONE has been restructured to enable capability driven service delivery from three Projects to five Themes. The original project names REBRACE, ACTUARY and CHINAR will no longer be used. 41. The 5 Themes have been derived from the Project URDs that have been grouped into three delivery tranches with commensurate investment decision points:

b. Investment Approval Point 1.

(1) Theme 1 - Healthcare Information Exploitation (HIX). Theme 1 will deliver the underpinning Management Information Service (MIS) architecture for CORTISONE that will allow clinicians to view, exchange and share health and healthcare information across Defence (fixed and deployed) and, through a variety of secure interfaces, with various non-DMS healthcare providers (e.g. NHS, NATO and other allies). The information generated by the HIX will be used to inform individual healthcare planning, practice management, medical governance, HQ level reporting, medical intelligence, multiple-patient health surveillance, medical research, wider data analysis and to monitor adherence to regulations;

(2) Theme 2 - Healthcare Delivery. Theme 2 will support healthcare activities across Defence (fixed and deployed) by providing a suite of information services including (although not exclusively) medical, dental, mental and occupational healthcare, rehabilitation, radiology, practice management and medicines management. The various healthcare data elements will form an integrated Electronic


Health Record (iEHR) service. This will allow health and healthcare information to be captured, integrated, accessed and maintained across all DMS clinical environments. Additionally, it will provide the means by which the INTERMOLAR capability can be retired by Apr 19.

c. Investment Approval Point 2.

(1) Theme 3 - Deployed Healthcare Support. Theme 3 will support non-primary healthcare activities in the deployed environment. These services include (although not exclusively) support of MEDEVAC (Forward, Tactical and Strategic), telemedicine, patient administration, theatre management, deployed laboratory activities, patient tracking and the recording of clinical data (non-primary healthcare) in deployed pre-hospital/hospital care environments;

(2) Theme 4 - Archiving. Theme 4 will provide an archiving service for all Health Record types and manage access to archived patient records and historical data.

d. Investment Approval Point 3.

(1) Theme 5 - Patient Facing Services. Theme 5 will enable the patient to communicate with Healthcare Professionals and access online Healthcare Records.

Summary 42. This is a living document that will evolve and gain greater detail as the programme matures and progresses. The next version of this document will be during 2016 as the programme matures. The Blueprint is not a specification, nor does it represent any form of requirements document for the components listed within it, and is subject to change.

Annex A To CORTISONE Blueprint V5.0

Dated 25 Oct 16

A – 20161025-CORTISONE_Programme_Blueprint_Int_V5 05.0

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DMS – CURRENT STATE

1. The DMS’ current structure and primary business pillars that are likely to be directly impacted by the CORTISONE programme are described below.

Surgeon General (SG)

2. The SG is the three-star professional head of the DMS and the Defence Authority for end to end defence healthcare and medical operational capability. The SG is accountable to the Defence Board, reporting routinely through the Defence Audit Committee and the Defence People and Training Board. The SG is responsible for:

a. Defining the boundaries and processes, in consultation with Top Level Budget Holders, together with organisational structures and composition of forces, and the standards and quality needed, to provide advice on health policy, healthcare and medical operational capability;

b. Setting the overall direction on all clinical matters relating the practice of medicine within the military;

c. Setting and auditing the professional performance of all medical personnel; d. Setting clinical and medical policies and standards, and auditing compliance by military organisations across defence; e. Developing the science of military medicine to develop approaches and treatments that will best counter threats to the health and well-being of service personnel; f. Building and maintaining the medical infrastructure and cadre of people; g. Delivering a comprehensive healthcare system that provides the appropriate timely healthcare to service and other entitled personnel; h. Ensuring coherence of health plans between defence, the NHS and the devolved administrations’ Departments of Health; and i. Chairing the DMS Board, the forum for providing strategic direction and guidance to the DMS.


Dated 25 Oct 16


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Figure 5 - Headquarters Surgeon General Top-Level Organisation as at 01 May 15

Director Medical Policy and Operational Capability 3. DMedPolOpCap is the 2-star officer who provides the key health and healthcare interface within HQ SG and more broadly acts as the cross-cutting health lead within Defence and its relationships with other governmental departments. He works directly in support of SG but reports to the Chief of Defence Personnel (CDP), the designated Defence Authority for People, on health issues relating to Service personnel policies; and to DCDS (Mil Strat & Ops) on delivery of medical operational capability.

Figure 6 - DMed Pol & Op Cap Organisation as at 07 Oct 16

Head of Medical Policy and Personnel 4. Med Strat Pol delivery health policy, personnel support and DMS strategy for SG. It covers SG medical policy (including policy on healthcare records), personnel policy and administrative matters, Defence Public Health Unit (DPHU), occupational medicine advice, medicines


Dated 25 Oct 16


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optimisation, revalidation and Defence Nursing Advisor. Hd Med Strat Pol is the Defence Caldicott Guardian. 5. DPHU provides both public health advice and support, the later including the investigation and control of outbreaks and public health incidents worldwide (including force health protection as described in JDP 4.03). A key output of DMedPolOpCap’s area is medical strategy and policy, which provides the framework and direction for delivery of the DMS’ core clinical outputs. This, in turn, creates the environment in which the CORTISONE suite of services must be designed to operate. Medical Director 6. The 1* Medical Directorate is based within the 2* Director Medical Operational Capability & Policy pillar. This position uniquely requires routine engagement and acceptance of tasks directly from across SGs HLB. With the establishment of Defence Primary Health Care (DPHC), a further Command relationship with Commander DPHC and his HQ has been developed. 7. The frequency and complexity of injuries inflicted on our Service personnel places demands for skills which require intelligent investment in training and education, informed by research. The environment in which our personnel operate requires appropriate military competencies that need to be delivered by a suitably structured, resourced, and led training organisation. The need to prepare personnel for operations both militarily and clinically within a hostile and austere environment requires constant refinement and development that the Medical Directorate is central to. 8. The Medical Directorate mission is to both:

a. SUPPORT Defence with expert clinical advice in order to PROMOTE, PROTECT and RESTORE physical and mental health; and PLAN, EXECUTE and SUSTAIN operations with minimal risk and optimal clinical care. This will be achieved through:

(1) Defence Consultant Advisers; (2) Defence Advisers (General Practice, Nursing, Dental); (3) Defence Specialist Advisers.

b. INNOVATE through invention, adoption and analysis across the Defence Lines of Development in order to better PREVENT, DETECT and TREAT illness or injury on operations, IMPROVE outcomes in operational healthcare and BUILD organisational reputation. This will be achieved through the Defence Professors and the Clinical Information and Exploitation Team.’

Head of Medical Operational Capability

9. The mission of the Hd Medical Operational Capability is to direct, develop and assure medical operational capability in order to minimise disease, injury and death in all operational environments, and hence maximise fighting power. Med Op Cap is to provide timely, accurate and appropriately prioritised strategic level medical advice to Ops Dir and other relevant stakeholders. This is to enable informed strategic level decision-making with regard to medical risk, and potential mitigation options. The Defence Crisis Management Organisation is to be effectively supported with appropriate medical expertise including Medical Intelligence, as required, on an enduring


Dated 25 Oct 16


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basis. The provision of Med Op Cap is to be safe and effective, with a view to enabling the maximising of the Fighting Power of the UK Armed Forces, and should achieve Value for Money for Defence. Joint Medical Capability Development is to be informed by relevant research and scientific innovation, and should be focussed on optimising patient care, whilst minimising logistic drag. Decision making should be timely and carried out by the most appropriate person available, without them exceeding their competence. All Med Op Cap staff should feel empowered to act within this Intent, and should be encouraged to demonstrate initiative, seek originality and be implacably determined to succeed. Trust and mutual understanding should be actively fostered, and reinforced at every opportunity. Authority, responsibility and accountability should be closely aligned wherever practicable. The Main Effort is ensuring provision of timely, safe and effective Med Op Cap to operations, and lies with the Commitments team.

Figure 7 – Hd Medical Operational Capability Organisation as at 24 Jul 15

Director Delivery Healthcare and Training

10. The post of Director Healthcare Delivery & Training (HDT) was established from the amalgamation of the 2* roles of Comd JMC and Comd DPHC. The key responsibilities associated with the post include the delivery of Primary Care including: Rehabilitation; Mental Healthcare; the placement of Secondary Care personnel in NHS facilities; and responsibility for Medical Education and Training. The Directorate has the following vision:


Dated 25 Oct 16


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Excellence in Healthcare Delivery for our patients and in the development of our people

Figure 8 - Director Delivery Healthcare and Training Organisation as at 01 May 15

Head of Future Healthcare

11. Head Future Healthcare provides the primary strategic planning function for the Directorate of Healthcare Delivery & Training, including horizon scanning and planning to meet National changes in healthcare delivery. The post oversees the integration of services and outputs across the Directorate, managing the finance, business and force generation, and close integration with HQ SG functions.

Figure 9 - Future Healthcare Organisation as at 01 May 15

Commander Defence Primary Healthcare (DPHC)

11. DPHC delivers a primary and occupational healthcare service for entitled regular and reserve personnel. It employs the most effective Defence, NHS and contracted resources, to provide value healthcare, focused on return to work and fitness to deploy, rather than sickness, and secures bespoke training opportunities. Or, put simply it provides:

The best treatment for our people, the right healthcare for Defence, the most capable professionals delivering it

12. DPHC was created as a result of Defence Reform recommendations and achieved Full Operating Capability (FOC) on 1 Apr 2014. It is the largest formation within the DMS and has responsibility for providing primary health care (PHC) services to all entitled Regular and Reserve Service personnel in the UK Firm Base, Germany and Permanent Joint Operating Bases (PJOBs). In many areas this also includes the delivery of a PHC service to Service dependants.


Dated 25 Oct 16


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13. The scope of DPHC includes Medical and Dental Centres, Regional Rehabilitation Units (RRUs), Departments of Community Mental Health (DCMH), genito-urinary (GU) clinics and Regional Occupational Health (OH) Departments. The high-level organisational structure of the DPHC is illustrated below:

14. DPHC operates 9 geographic regions within the UK and manages the service delivery in approximately 230 facilities. DPHC is a principal user of DMICP in support of its clinical outputs.

Figure 10 - DPHC Organisation as at 01 May 15

Defence Healthcare Education & Training (DHET) 15. DHET was formed from a number of existing DMS business units, reaching IOC on 1 May 2013. DHET is the JMC J7 Pillar. On behalf of SG and Comd JMC the DHET owns, manages and delivers the training DLOD for all Joint healthcare education and training. The DHET also manages and delivers some education and training solutions for the single Services and civilian personnel. The Mission statement for the DHET is: ‘To commission, develop and quality manage education and training for DMS personnel, and provide effective and efficient training for DMS delivered healthcare throughout the operational patient pathway, from Force Generation to Role 4 and Recovery, in order to meet operational requirements and in accordance with internal and national policies’. 16. DHET also now incorporates the Defence Medical Library Service. DHET is expected to have a central role to play in identifying, specifying and designing the training requirements generated by CORTISONE-introduced medical information support services.


Dated 25 Oct 16


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Figure 11 - DHET Organisation as at 01 May

Commander Defence Medical Group (DMG)

17. The DMG Mission statement is: ‘To provide highly capable Secondary Health Care (SHC) personnel for operations and to deliver the operational Role 4 pathway in order to support the physical and moral components of Fighting Power’. 18. The DMG has responsibility for managing the patient care pathway within the Role 4 Medical Group, which encompasses the Royal Centre for Defence Medicine (RCDM), Birmingham and the Defence Medical Rehabilitation Centre (DMRC) at Headley Court. This also involves implementing a robust patient tracking regime for all operational casualties. DMG has wide-ranging contact with the NHS in order to establish high-quality placements for DMS SHC personnel to maintain their readiness for operational deployment. This is coordinated within 4 further regional units at DMG South West (Derriford), DMG South East (Frimley Park), DMG North (Northallerton) and DMG South (Portsmouth).

Figure 12 - DMG Organisation as at 01 May 15


Dated 25 Oct 16


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DMS GEOGRAPHICAL FOOTPRINT 19. The DMS have a global remit to provide clinical services to the Defence PAR over a diverse range of physical environments and climates, all of which provide their own unique challenges. An overview is provided below: Firm Base - UK 20. The DMS have a nationwide footprint, which ranges from regional combined medical and dental centres sited at larger military locations to part-time medical practices serving smaller military units. The primary location for DMS headquarters and medical training functions is Defence Medical Services (Whittington), Lichfield; however, DMedPolOpCap maintains a presence in MOD Main Building, London. 21. DMS staff are also located at (not exhaustive):

a. DMG South West;

b. DMG South East;

c. DMG North;

d. DMG South;

e. The Royal Centre for Defence Medicine (RCDM) Clinical Unit within Queen Elizabeth Hospital, Birmingham (QEHB);

f. The Institute of Naval Medicine (INM);

g. The Centre for Aviation Medicine (CAM);

h. The QEHB Research Park, Birmingham;

i. A number of NHS Trusts across the country, in singleton placements;

j. The Defence Medical Rehabilitation Centre (DMRC), Headley Court, Surrey;

k. 13 Regional Rehabilitation Units (RRUs) in the UK (plus 2 in Germany);

l. The Central Health Records Library (CHRL) at Shoeburyness in Essex;

m. The Defence Animal Centre (DAC) at Melton Mowbray.

Mainland Europe 22. British Forces Germany (BFG) – full PHC and social provision, with SHC contracted from the SSAFA-GSTT Health Alliance, which sub-contracts with German Provider Hospitals. 23. NATO locations – various levels of provision. Permanent Joint Operating Bases


Dated 25 Oct 16


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24. British Indian Ocean Territory (BIOT), Diego Garcia – Limited UK PHC capability (US facilities used for emergency treatment and dental care); MEDEVAC. 25. Cyprus – PHC inc Dental and Pharmacy, GU, MH, MEDEVAC; SHC contracted from host nation suppliers. 26. Gibraltar – PHC inc Dental, Pharmacy and Physio, MEDEVAC; SHC contracted from host nation suppliers. 27. South Atlantic Islands (Falklands/Ascension) – PHC inc Dental and Pharmacy, MEDEVAC. SHC contracted from host nation suppliers. Worldwide 28. British Army Training Unit Kenya (BATUK) – PHC inc Pharmacy, MEDEVAC. 29. British Army Training Unit Suffield (BATUS), Canada – PHC inc Dental and Pharmacy, MEDEVAC. 30. Brunei – PHC inc Dental and Pharmacy, Physio, MEDEVAC. 31. Nepal – PHC inc Dental and Pharmacy, MEDEVAC. 32. Afloat – PHC inc Dental and Pharmacy, MEDEVAC. 33. Joint Counter-Terrorism Training Advisory Team (JCTTAT) – Appropriate provision. 34. Support to Exercises – Appropriate provision. DEPLOYED ENVIRONMENT 35. Medical support is a key force multiplier, with the recent return to contingent operations, the picture of where DMS personnel will deploy in the future is not clear. All that can be stated with any certainty is that they will deploy and will need agile and scalable medical information systems to support their task across all the deployed capabilities of care. The diversity of environments across which the DMS must provide world-class medical services and support presents a number of information challenges, not least of which is establishing timely and reliable communications links to back-end data repositories in-Theatre, intra-Theatre and in the Firm Base, when deployed. 36. Particular information challenges exist in the maritime environment. Ships and submarines are regularly and routinely deployed across the world, with no guarantee of SATCOM availability or bandwidth for medical information systems’ use.

Annex B To CORTISONE Blueprint V5.0

Dated 25 Oct 16 GAP ANALYSIS – INFORMATION CAPABILITY

B – 20161025-CORTISONE_Programme_Blueprint_Int_V5 05.0

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DMS STRATEGIC OBJECTIVE18 CURRENT STATUS DEFICIENCY ACTION REQUIRED

Promote: - Optimal understanding and evidence-based mitigation of risks to health.

- Promotion of healthy lifestyle.

- Support to Chain of Command (CoC) in promoting health.

Comprehensive library of Defence medical research held on UHB Trust information systems. Health information available from iEHR data repository for CoC decision support.

No ease of access to research material and resultant conclusions/recommendations for wider DMS. IEHR data needs to be interpreted by DS(Health) and is not directly accessible by CoC, which reduces agility of the DMS to react to emergent health trends.

Create cross-indexed repository for research outputs that is fully integrated with future DMS information services. Design integrated reporting services that can be directly accessed at desktop level, which incorporate iEHR and all other relevant data sources.

Protect: - Integration of resources to optimise health protection.

- Provision of specialist medical advice.

- Generating medical capability across all contexts.

Preventive medicine relies for the most part on collation of statistical information from a number of disparate data sources. MEDEVAC information support and patient tracking functionality delivered via ‘standalone’ systems. Legacy APHCS single-Service Staff Database has been adapted for use by DPHC in assuring that Firm Base PHC practices are correctly staffed. DMS uses an in-house developed MOSS solution to determine medical staff suitability to deploy. PULHHEEMS & JMES codes currently generated via DMICP.

Collation of preventive medicine statistical data is manually intensive and time-consuming. MEDEVAC and patient tracking information is duplicated on a number of restricted-access standalone systems that do not always report a consistent picture. The Staff Database is essentially a personnel tool (not core business for the DMS) that, in common with patient tracking applications other than DPTS, does not interface with Defence personnel systems, thus creating duplication and the inherent risk of mismatched data.

Create a DMS information architecture that: utilises base data from source repositories, via secure and robust interfaces; enables ease of linking and interrogation of relevant datasets to generate timely and accurate reports; makes better use of Defence corporate data repositories in support of FE@R activities.

18 Extracted from Reference Document C.




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Restore: - Excellence in the provision of healthcare.

- Engagement with DNRC project (rehabilitation).

- Integration of all PHC component parts.

In the Firm Base, both in the UK and overseas, the DMS commission SHC from the NHS and other 3rd party providers. Choose and Book functionality has been rolled out to facilitate this requirement with NHS England, although it is not currently possible to exchange the iEHR in the same way. DMICP is used at DMRC to support secondary/tertiary care activities, supplemented by manually-intensive procedures for management of other supporting functions.

Limited connectivity with NHS and other SHC providers; rudimentary cross-government connectivity; no connectivity with 3rd sector providers. DMICP is a PHC application that is being used to support secondary/tertiary care at the current DMRC. There is therefore no dedicated provision for information supporting e.g. bed management; clinic management; general patient administration, all of which is carried out manually.

Address interface and interoperability issues with partner organisations (with a particular focus on NHS component elements) and wider government to ease transmission of vital health and pandemic information. Design a modularised information service that supports the delivery of Defence rehabilitation at any geographic location, liaising closely with the DNRC project team throughout to ensure that there is no divergence during planning.

DMS INFORMATION OBJECTIVE19

Single source of information. A subset of the core iEHR database is duplicated for use on DMICP(D) systems. There are multiple sources of clinical information held on a variety of information systems e.g. the Defence Patient Tracking System. Core data, particularly personal identifiable data, are widely duplicated via direct manual input to systems.

The design of DMICP(D) necessitates duplication of information, which is not always synchronised in as timely a manner as required when the updated dataset is returned from deployment. Manual input of personal data is inefficient and can cause potential patient safety issues due to erroneous data entry.

Design a single future iEHR dataset that is accessible from all DMS locations. Ensure that all sub-component information services draw base data from their original source to eradicate duplication and thus de-risk care delivery.

19 Extracted from Reference Documents D and E.




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Deployable medical information capability in support of Medical Force Elements at Readiness (FE@R).

DMICP(D), PACS/RIS and LIMS, provides deployed medical information support capability.

WHIS was only available for use in Op HERRICK. Therefore since the end of this operation the DMS does not have a deployable Patient Administration System (PAS).

Design a scalable, deployable medical information capability that provides support for all DMS operational activities and integrates more readily with the wider DMS information architecture. The patient administrative elements of the capability should have wider utility across the DMS, and in particular for the support of Defence rehabilitation.

Connectivity with NATO and other Allies.

DMS staffs treat NATO/Allied casualties on operations but do not have ready access to their health records. Epidemiological data are exchanged with NATO.

No access to health records constitutes a patient safety risk. Epidemiological data are collated and exchanged in a manually-intensive manner using a NATO spread sheet format.

Deployable information services to be designed to facilitate ease of interfacing with those of NATO/Allies (dependent upon member-nation agreement), with NATO standards as the primary design driver.

Effective management and exploitation of health records.

Hard copy records are scanned and archived on standalone LAN at CHRL. Electronic (non-DMICP) records are stored on original or removable media. Radiographs are stored as hard copy.

Medical records are archived with minimal metadata, which severely restricts exploitation possibilities. Archived electronic systems are of obsolete design and the data they host cannot be readily accessed. The primary archive at CHRL is not accessible outside of the site.

A redesign of the record archiving function and supporting technology to ensure that controlled and auditable access to the archive can be enabled across the DMS and Defence by those with a need to do so, and the information can be readily anonymised for research and statistical exploitation purposes. Future design to include an ability to directly archive from DMS core information support systems. Archived data repository




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to be fully integrated with wider DMS information architecture.

Annex C To CORTISONE Blueprint V5.0

Dated 25 Oct 16 GLOSSARY OF TERMS

C – 20161025-CORTISONE_Programme_Blueprint_Int_V5 05.0

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ABC Annual Budgetary Cycle ADS Authoritative Data Source AEROMED Airborne Medical [services] AHE Applications Hosting Environment APHCS Army Primary Health Care Services ASER Automated Significant Event Reporting ASDT Application Services Design Team ASG Acquisition System Guidance BATUK British Army Training Unit Kenya BATUS British Army Training Unit Suffield (Canada) BFG British Forces Germany BIOT British Indian Ocean Territory (Diego Garcia) CADMIT Concept; Assessment; Demonstration; Manufacture; In-service; Termination CAM Centre for Aviation Medicine

Cap C4ISR Capability Command, Control, Communication and Computers, Intelligence, Surveillance, Reconnaissance

CDP Chief of Defence Personnel CDR Centre for Defence Radiology CHRL Central Health Records Library CDIO Chief Digital & Information Officer CMP Capability Management Plan CoC Chain of Command CONEMP Concept of Employment COTS Commercial Off-The-Shelf CT Computerised Tomography CTO Chief Technology Officer DAC Defence Animal Centre DBS Defence Business Services DCDS(Mil Strat & Ops) Deputy Chief of Defence Staff ( Military Strategy & Operations)

DCHET Defence College of Healthcare Education and Training DCMH Department of Community Mental Health DCNS Defence Core Network Service (now Grapevine, etc) DE&S Defence Equipment & Support DHET Defence Healthcare Education and Training DICOM Digital Imaging and Communications in Medicine DII Defence Information Infrastructure DIRM Defence Information Reference Model DLOD Defence Lines of Development DMC Deployed Medical Care DMedPolOpCap Defence Medical Policy and Operational Capability DMG Defence Medical Group DMICP Defence Medical Information Capability Programme DMICP(D) Defence Medical Information Capability Programme (Deployed) DMRC Defence Medical Rehabilitation Centre DMS Defence Medical Services DNRC Defence and National Rehabilitation Centre DPA 1998 Data Protection Act 1998 DPHC Defence Primary Health Care DPTA Defence Patient Tracking Application DPTS Defence Patient Tracking System




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DSF Director Special Forces DS(Health) Defence Statistics (Health) – formerly DASA (Health) DSTL Defence Science and Technology Laboratory E2E End to End ESB Enterprise Service Bus ESG European Support Group EUD End User Device FE@R Force Elements at Readiness FHP Force Health Protection FOC Full Operating Capability GSTT Guy’s & St Thomas’ NHS Foundation Trust GU Med Genito-Urinary Medicine HQ Headquarters ICT Information and Communication Technology IdAM Identity and Access Management iEHR Integrated Electronic Health Record INM Institute of Naval Medicine IOC Initial Operating Capability ISS Information Systems & Services [Directorate] JCTTAT Joint Counter-Terrorism Training Advisory Team JDP Joint Doctrine Publication JFSp Joint Force Support JMC Joint Medical Command JMES Joint Medical Employment Standards JPA Joint Personnel Administration (System) JTTR Joint Theatre Trauma Register KPI Key Performance Indicator LAN Local Area Network LIMS Laboratory Information Management System M&GS Medical and General Supplies MEDEVAC Medical Evacuation MH Mental Health MOD Ministry of Defence MOSS Microsoft Office SharePoint Server MPI Master Patient Index MSV Mission Specific Validation MTF Medical Treatment Facility N3 New National Network NATO North Atlantic Treaty Organisation NHS National Health Service NOTICAS Notification of Casualty NRTDS Near Real-Time Disease Surveillance System NSA NATO Standardization Agency ODMC Operational Deployed Medical Capability OH Occupational Health OVB Overseas Base PAR Population at Risk PAS Patient Administration System PCRS Primary Casualty Receiving Ship PHC Primary Healthcare




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PHEC Pre-Hospital Emergency Care PJHQ Permanent Joint Headquarters PJOB Permanent Joint Operating Base

PULHHEEMS Physical capacity; Upper Limbs; Locomotion; Hearing (left); Hearing (right); Eyesight (left); Eyesight (right); Mental capacity; Stability (emotional).

QEHB Queen Elizabeth Hospital Birmingham RFA Royal Fleet Auxiliary RCDM Royal Centre for Defence Medicine RIS/PACS Radiological Information System/Picture Archiving and Communication System RRU Regional Rehabilitation Unit SATCOM Satellite Communications SDSR Strategic Defence & Security Review SG Surgeon General SGIS Surgeon General’s Information Strategy SHC Secondary Healthcare SME Small to Medium Enterprise (in the context of this document) SSAFA Soldiers‘, Sailors’, and Airmen’s Families Association TBA To Be Advised UHB University Hospitals Birmingham NHS Foundation Trust UOR Urgent Operational Requirement WHIS Whole Hospital Information System WISMIS Wounded Injured Sick Management Information System