Military Research Needs in Biomedical Informatics - … · unique military needs. Reference 2 provides details about the meeting, including the agenda, copies of the presentations,

Recognizing the recent advances in biology, medi-cine, information systems and computer technologiesand their potential synergism and relevance to theU.S. Army Medical Research and Materiel Command(USAMRMC) mission,1 the USAMRMC Telemedicineand Advanced Technology Research Centera

(TATRC) convened a 21/2-day Biomedical InformaticsRoadmap Meeting in spring 2001.2 The goal of themeeting was to produce a roadmap or strategic planto help align the Army biomedical informatics sci-

ence and technology (S&T) portfolio and investmentstrategy with new developments and emerging tech-nologies in this rapidly growing field. This reviewpaper identifies research priorities that can form thebasis for making new strategic research investmentsin biomedical informatics by the military in generaland by the USAMRMC in particular. Availability ofthese military research initiatives to the civilianhealthcare community can provide input for publicpolicy, foster collaboration, and avoid duplicity ofresearch efforts.

The Roadmap Meeting brought together approxi-mately 90 attendees, including military materiel andcombat developers, end users, members of theresearch community, and representatives of othergovernment agencies who are engaged in biomedicalinformatics research. Speakers and participants wereselected to provide a multidisciplinary group ofattendees, with as broad a representation as possiblefrom the government, industry, and academia, so thatend users could lead technology developers to the

509Journal of the American Medical Informatics Association Volume 9 Number 5 Sep / Oct 2002

Affiliations of the authors: Telemedicine and AdvancedTechnology Research Center, Fort Detrick, MD (JR, GRG);Stanford Medical Informatics, Stanford, California (LF); YaleUniversity School of Medicine, New Haven, Connecticut (RS).

This work was supported in part by the U.S. Army MedicalResearch and Materiel Command, Combat Casualty Care andMilitary Operational Medicine Research Area Directorates.

The views, opinions, and/or findings contained in this article arethose of the authors and should not be construed as an officialDepartment of Defense position, policy, or decision.

Correspondence and reprints: Jaques Reifman, PhD, USAM-RMC/TATRC, MCMR-AT 504 Scott Street, Fort Detrick, MD21702-5012; e-mail: <[email protected]>.

Received for publication: 10/31/01; accepted for publication:5/9/02.

White Paper ■

Military Research Needs inBiomedical Informatics

A b s t r a c t The 2001 U.S. Army Medical Research and Materiel Command (USAMRMC)Biomedical Informatics Roadmap Meeting was devoted to developing a strategic plan in four focusareas: Hospital and Clinical Informatics, E-Health, Combat Health Informatics, and Bioinformaticsand Biomedical Computation. The driving force of this Roadmap Meeting was the recent acceler-ated pace of change in biomedical informatics in which emerging technologies have the potential toaffect significantly the Army research portfolio and investment strategy in these focus areas. Themeeting was structured so that the first two days were devoted to presentations from experts in thefield, including representatives from the three services, other government agencies, academia, andthe private sector, and the morning of the last day was devoted to capturing specific biomedicalinformatics research needs in the four focus areas. This white paper summarizes the key findingsand recommendations and should be a powerful tool for the crafting of future requests for propos-als to help align USAMRMC new strategic research investments with new developments andemerging technologies.

■ J Am Med Inform Assoc. 2002;9:509–519. DOI 10.1197/jamia.M1044.

JAQUES REIFMAN, PHD, GARY R. GILBERT, PHD, LAWRENCE FAGAN, MD, PHD,RICHARD SATAVA, MD

aThe USAMRMC is the lead U.S. Army Command for medicalR&D and TATRC is the Command’s advanced research branch,responsible for leading-edge research in a number of fields.

unique military needs. Reference 2 provides detailsabout the meeting, including the agenda, copies ofthe presentations, biographies of the presenters, andtranscribed records.

The first day of the meeting was devoted to presen-tations from members of the three services and repre-sentatives from other government agencies whodescribed ongoing projects and identified informaticsneeds. The second day consisted of presentations oncurrent and future research directions by representa-tives from the scientific, academic, and private sectorcommunities. The morning of the third day wasdevoted to capturing specific biomedical informaticsS&T research needs from four breakout sessions:

■ Hospital and Clinical Informatics

■ E-Health

■ Combat Health Informatics

■ Bioinformatics and Biomedical Computation

Within these four focus areas, participants identifiedseveral important areas of research needs, assignedthem to three timelines—near-term (<2 years), mid-term (2–5 years), and long-term (>5 years)—andranked them into top-, high- and medium-prioritylevels. Priority rankings reflect the potential impactof the research need and the degree to which a spe-cific research is a prerequisite to other key researchneeds. Consequently, top-priority research ideasshould offer the highest payoff. The priorities wereset by the authors based on their knowledge of cur-rent Army programs and interests and from an initiallist generated by the work group members at themeeting. An attempt was also made to recognizeresearch needs for which related projects are cur-rently sponsored through core USAMRMC funds,special interest Congressional appropriations man-aged by TATRC, and other Department of Defense(DOD) sponsored programs.

It is recognized that many of the biomedical infor-matics goals, barriers, and research needs identifiedhere—in particular, the ones at the higher echelons ofmilitary care3 corresponding to health care at generalhospitals—are germane to the civilian setting andhave already been reported elsewhere. In fact, duringthe past few years, several U.S. national level com-mittees have attempted to define the barriers to thewidespread use of computers and networking tech-nology to improve health care delivery. Of particularnote is a set of documents from the President’sInformation Technology Advisory Committee

(PITAC). The PITAC Panel on Transforming HealthCare presented a set of findings and recommenda-tions to foster the impact of computational methodson biomedicine,4 and the Panel on Digital Librariesdiscussed issues involved in the development of dig-ital repositories of information.5 Although the PITACrecommendations are designed primarily for the typ-ical medical care setting in the U.S., they are evenmore critical in the military setting, where medics,with limited medical training, may be helpingpatients using a limited set of treatment modalities inan unfamiliar environment.6 Additional notablereports describing social and technical issues—including topics ranging from the use of the internetas a technology for integrating information across thehealthcare environment to the widespread access tomedical data while maintaining privacy and securityof the data and strategies for building the nationalhealth information infrastructure—were producedby the National Research Council7,8 and the U.S.Department of Health and Human Services.9

The military needs and requirements in biomedicalinformatics exceed the ones in the civilian setting.The military health system supports a continuum ofcare starting at the point of injury in the battlefield(echelon I)—where resources are scarce and the“working” environment is dynamic and unknown inadvance—all the way to Continental United States(CONUS)-based military and civilian hospitals (eche-lon V), resulting in additional requirements andsystem functionalities unequaled in the civilian envi-ronment. For example, the capability to performremote life-sign detection of trauma casualtiesthrough nearly undetectable wireless networks,10

which would help reduce morbidity and mortality ofwounded soldiers in the battlefield, may have no par-allel in the civilian setting. Furthermore, the combatmedic (who is the “doctor” in the battlefield) has lim-ited medical training, carries limited resources, andworks in an unknown, often hostile, environment.Hence, additional medical informatics technologiesaddressing specific requirements and possessingunique functionalities are clearly needed for the mil-itary field environment and for linkage to upper ech-elons of care. Throughout the manuscript we high-light the similarities and differences between civilianand military biomedical informatics challenges anddistinguish the unique military requirements fromthose already identified in the civilian literature.

This white paper summarizes the findings of the fourbreakout sessions, which were subsequently supple-mented with contributions from key participants of

REIFMAN ET AL., Military Research Needs in Biomedical Informatics510

each of the four focus areas, analyses of the meetingpresentation materials and transcribed records, andliterature review performed by the first author. Eachof the following four Sections, Hospital and ClinicalInformatics, E-Health, Combat Health Informatics,and Bioinformatics and Biomedical Computation,consists of a summary statement and lists of identi-fied qualitative performance goals, technology barri-ers, and research needs. These are followed by aSummary Section.

Hospital and Clinical Informatics

The Hospital and Clinical Informatics Group exam-ined opportunities that enhance the design, facilitatethe use, and expedite the deployment of computer sys-tems to optimize inpatient and ambulatory medicalcare. In addition, the group also addressed technolo-gies that could potentially improve the access to clini-cal data and medical knowledge by both patients andproviders. Technologies spanning the range of issuesfrom data capture to data integration and representa-tion to decision support tools and to patient andprovider access to data and knowledge were covered.

Goals

The Hospital and Clinical Informatics Work Groupidentified five key areas for improvement in thedesign and implementation of computer systems tosupport medical care. The areas identified are acommon infrastructure for both the peacetime mis-sion (which is identical to the customary civilianhealthcare) and the war-fighting mission:

■ Improved speed and completeness of datacapture

■ Improved integration of data sources and com-puting services

■ Improved coverage and utility of decision-sup-port systems

■ Improved access by patients and providers tomedical data (patient records) and knowledge(medical literature)

■ Facilitation of interaction between patients,providers, and information resources to opti-mize patient care outcomes

Technology Barriers

Many of these key goals share common technologicalbarriers. (Because of the technological nature of this

report, we chose not to address other types of barri-ers, such as organizational and behavioral, in this sec-tion as well as the sections that follow). In particular,the mapping of medical terminologies and standardsoffer significant barriers that cut across many appli-cation areas and inhibit the faster development anddeployment of medical computer-based tools.Overall, the technological barriers span the wholerange of health care delivery from difficulties inacquiring data to the ability to summarize the datastored in longitudinal health records. Some of themajor technical barriers to overcome include:

■ Data capture techniques are too slow, awkward,or error-prone

■ Need improved data integration technologies

■ Need improved medical terminology mapping11

1. From system to system to allow for dataexchange

2. From information system to decision-supportsystems

3. From clinical terminology to lay terminology

■ Data capture are not always integrated intopatient care process

■ Medical guideline description standards are notsufficient to encode all guidelines

■ Better tools and methods are needed to expeditethe guideline-encoding process and integrateencoded guidelines within institutional envi-ronments12

■ Decision-support systems are not easilyadjustable for different medical contexts

■ Information retrieval systems do not supportthe precise retrieval of answers to biomedicalquestions13

■ For patient data to be useful, it often needs to besummarized and put in the appropriate context

■ Need improved mechanisms for sharing infor-mation between patients and providers

■ Need to model and understand the medical careprocess and provider needs in support of suc-cessful installation of computer-based tools

Research Needs

Significant improvements in hospital and clinicalinformatics for inpatient and ambulatory medicalcare require near-, mid- and long-term research


strategies that address the identified technology bar-riers. The identified research needs can be structuredinto the following four technology areas: data cap-ture, data integration and representation, improveddecision support tools, and patient/provider accessto data/knowledge. These four areas represent thenatural progression of patient information flow inhospital and clinical settings—starting with the cap-ture of a patient’s records and ending with the accessto structured data, clinical analysis, and medicalknowledge by patients and providers.

Table 1 identifies the near-term (<2 years), mid-term(2-5 years), and long-term (>5 years) research needsunder each one of the four technology areas. Each pro-posed research is also ranked according to top-, high-and medium-priority levels based on their potentialimpact in improving medical and clinical informaticsand the degree to which a specific research is a step-ping-stone to other key research needs. The prioritieswere set by the authors based on their knowledge of

current Army programs and interests and on an initiallist generated by the work group members. Relatedprojects currently being funded through core MRMCresearch dollars, special interest Congressional appro-priations managed by TATRC, and other DOD-spon-sored programs are also identified.

E-Health

The facts that 55% of adult Americans with Internetaccess (52 million people as of November 2000) willgo online in search of health-related information andthat about 50% of those have said that such informa-tion has influenced a decision about treatment,14 pro-vides considerable challenges and opportunities forE-Health technologies to improve health care. Amongothers, the challenges stem from the vast amount ofavailable information whose quality has not beenassessed.15 This is a mammoth challenge. To date,there are over 60,000 websites on breast cancer aloneand over 40,000 sites on diabetes. On the other hand,


Table 1 ■

Major Research Needs for Hospital and Clinical Informatics

Data IntegrationData Capture & Representation Decision Support Tools Data/Knowledge Access

Analysis of current voice- Standardization of existing Develop and standardize Develop tools for the NEAR-TERMactivated transcription clinical terminologies to medical guideline summarization and < 2 yearstools and pen-based note- support data integration description language ‡ interpretation of clinicaltaking tools + tasks ‡ data *

Investigate how the clinical Provide integrated approach Develop and deploy tools Explore methods toenvironment affects note- to visualize complex clinical for encoding medical facilitate online capture techniques + data to facilitate physician guidelines into software ‡ provider/patient

analysis * $ communication +

Investigate multi-modality Develop methods for trans- Investigate how to adjust Develop mechanisms to MID-TERMuser input (pen + speech + lating between different guidelines for use in translate terminology from 2–5 yearskeyboard) ‡ database schemata ‡ diverse clinical clinical to lay concepts *

environment *

Investigate recovering Improve precision of Develop easy-to-usestructured information information retrieval technology for patientfrom transcribed clinical techniques from the review of medicalnotes ‡ Web + records +

Design of high reliability Integrate clinical guidelines Customize decision- Design computer systems LONG-TERMmulti-modal input device with patient electronic support tools for patient that support patient/ >5 yearsfor clinical notes + medical records to allow use + provider review of the

automated use of decision- medical literature, includingAdvanced natural language support systems ‡ metanalysis of evidenced-processing to extract based studies, as an aide tostructured information joint decision-making +from clinical notes +

‡ = Top Priority * = High Priority + = Medium Priority $ = Currently Funded Project

the rapid adoption of Internet-enabled and otherinformation technologies provides significant oppor-tunities to improve the quality of care delivered, driveeconomic efficiencies and reduce costs, facilitate thelinkage of fragmented systems, and give consumersbetter access to information that can help them betterunderstand and address their own health care needs.

The E-Health Group addressed a wide range ofissues spanning from the lack of standards to tech-nology gaps and from increased availability of onlineinformation to improved education opportunities forboth patients and providers. These issues are relevantto both military and civilian requirements.

Goals

The broad goals of E-Health are to make informationsystems, both hardware and software, more support-ive of provider and patient information needs toenhance satisfaction, quality, affordability, and porta-bility of health care delivered while reducing errors,delivery time, and inconvenience. To achieve thesegoals the following needs have been identified:

■ Development and adoption of standards

■ Improved man-machine (device) interfaces

■ Identification of technology gaps to bridge vari-ous health services support systems

■ Improved interface among various applicationsand databases

■ Improved information access by patients andproviders to enhance decision-making

■ Improved education of patients and providersabout existing information technologies

Technology Barriers

Technology barriers that inhibit wider acceptance andfaster deployment of E-Health from both the patientand the provider perspective have been identified.These include interoperability barriers among differ-ent applications and between new and legacy systems,such as the lack of mechanisms to lay new applicationsover legacy databases; man-machine interface barrierscharacterized by the lack of suitable user interfacesthat provide expeditious and comprehensive view ofthe complete patient health condition; and perform-ance indicator barriers reflected in the lack of quanti-tative measures to assess the quality of health caredelivered by new information technologies. Morespecifically, the technology barriers include:

■ Need to interface and/or integrate new applica-tions with legacy systems

■ Lack of standards for a core set of quality caremeasures

■ Need to migrate from proprietary applicationsto standards-based, open source, generalizable,published applications and architectures toensure interoperability

■ Need user-friendlier interfaces that provide cus-tomizable, quicker, and easier access to desiredinformation

■ Lack of uniform evaluation criteria and auto-mated methods to assess the quality of the everincreasing amount of online health care infor-mation15

Research Needs

Research that is needed to overcome the identifiedtechnical barriers falls into two categories: infrastruc-ture and applications. Infrastructure research isneeded to provide enabling technologies to overcomeinteroperability issues, reliability concerns, and tech-nology gaps and to provide the foundation for thenext-generation of E-Health systems. Applicationsresearch will support the development and deploy-ment of new systems that will improve the safety(e.g., reduce errors), effectiveness, timeliness, andefficiency of health care delivered and that willrelieve patients and providers from the painstakingtasks of fusing, sorting, searching, and extractinginformation from exponentially increasing health-related data sources. Table 2 identifies the near-term,mid-term, and long-term research needs in E-Healthin these two categories. The research needs are sup-portive of both the military specific health care sys-tems (known as the TRICARE system16) as well aspublic systems at large.

Combat Health Informatics

The Combat Health Informatics Group examinedopportunities to improve the quality of combat med-ical care through the use of information and com-puter-based technologies. In particular, the focus wason technologies that address environmental stres-sors—a leading cause of non-battle illness17—andbattlefield trauma—as the overwhelming majority ofAmerican combat deaths since World War II haveoccurred on the battlefield.18,19 Technology barriers


were identified that involve the entire process start-ing at the collection of physiologic data at the sensorsto the transmission of information to the medic andhospitals behind the front line of the battlefield(upper echelons), including a central data repositorysystem, and to the development of mathematicalmodels for decision support. Accordingly, the workgroup recommendations include technologies rang-ing from sensing devices to communication systemsand from data warehousing to system modeling.

Goals

The goal of Combat Health Informatics for the nextfive years and beyond is to improve the quality ofmedical care of the soldier in the battlefield throughthe use of information and computer-based tools.This near-term focus is critical, since time is of theessence in combat casualties, and systems to improvefar-forward medical care will improve both battle-field and civilian healthcare.20,21 More specifically, thegoals include:

■ Reducing the size and improving the reliabilityof physiologic sensor data and biosensor net-works to effectively manage vast amounts ofinformation in a timely fashion

■ Identifying life-savings medical interventionsand key physiologic parameters predictive ofclinical outcome of trauma casualties

■ Constructing trauma databases for knowledgeextraction

■ Developing decision-support systems to aidcombat medics in emergency triage, includingpatient monitoring, diagnostics, treatment, andprognostics

■ Developing computational tools to expedite andimprove clinical training for medics, nurses, anddoctors22,23

Technology Barriers

Opportunities to improve the combat medical healthcare are inhibited by several key research-related bar-riers. The most significant barriers fall within theareas of physiologic information and communicationsystems. The lack of understanding of which physio-logic parameters are most useful in predictingtrauma casualty outcome precludes the developmentof downstream decision-support tools, while the lackof compatible communications systems that movedata seamlessly from the combat field through thevarious echelons inhibits information exchange and


Table 2 ■

Major Research Needs for E-Health

Infrastructure Applications

Develop technical and Investigate existing Establish performance Develop evaluation NEAR-TERMsocial approaches to data technology gaps * indicators of health care criteria for qualification of < 2 yearssecurity/confidentiality quality * medical Web sites * $

Investigate user-interface Develop modular, scalable Identify applications and Develop information MID-TERMdesign issues on mobile and extensible software tools that make individuals repository/database to 2–5 yearsplatforms + and hardware better users of health care facilitate exchange of DOD

architectures + systems + R&D capabilities ‡

Define interoperability Establish goals for Develop tools to empowerstandards for next- improvement in care individuals to managegeneration systems ‡ processes and outcomes + their own health care +

Analysis of wireless Develop evaluation Identify health metrics Develop personal Web LONG-TERMcommunication standards processes for quality that could be passively Page supporting individual >5 yearsand reliability issues + assurance of hardware and and unobtrusively health integrated with dis-

software systems + monitored by sensors + tributed, multi-site elec-tronic medical records +

Develop health sensorsintegrated into the homeenvironment +


precludes effective delivery of a continuum of care.The identification of these parameters and theirimplementation will improve the entire spectrum ofhealthcare, from far-forward battlefield to rear eche-lons to CONUS-based military and civilian hospitals.These research areas are applicable for battlefield(prehospital care), triage (emergency departmentevaluation), intensive care units, and operating the-aters. Of interest, the technologies developed for thebattlefield are exactly the ones that are lacking in sup-porting civilian disaster response and homelanddefense. The technical barriers to overcome include:

■ Lack of sensor information redundancy resultsin missing or corrupted data

■ Lack of understanding of the salient informativephysiologic data needed to develop decision-support systems and more effective trainingtools

■ Need for database architecture that accommo-dates disparate data types from diverse sources

■ Divergent information needs and difficulty ofmoving data through various echelons or fromone civilian hospital to another

■ Inadequate hardware and software compatibil-ity for logistics and communications at all levels

■ Need universal yet secure communicationsystems

Research Needs

Significant improvements in battlefield medical careand disaster response require near-, mid-, and long-term research strategies that address the technologybarriers. The identified research needs can be struc-tured into the following four fundamental technologyareas: sensing devices, communications and control(such as a central “command center” to coordinatedisaster response), data warehousing, and modelingand simulation (to predict ongoing consequences ofdisaster response). These technologies represent a nat-ural progression of information that starts at thesensor level and moves through the echelons throughvarious communications systems until it reaches adata repository or command center where analysesare performed and medical emergency decision-sup-port systems and training tools are deployed.

Table 3 identifies the needed research under each oneof these four technology areas. The identifiedresearch needs have elements that support legacy

systems as well as new Army initiatives of theObjective Force strategy,24 such as the Land Warriorsystem25 and the Objective Force Warrior system,26

that can reach a field-testing maturity level within thenext five years. These future combat systems includemedical informatics technology components, such asan array of biosensors embedded in the soldier’s uni-form and integrated with database management sys-tems and decision support systems to provide assis-tance in casualty prevention and casualty manage-ment,10,21 in an effort to improve force survivabilityand sustainability across the entire spectrum of mili-tary operations. Developments in these future battle-field healthcare systems could concomitantly beapplied to civilian disaster response.

Bioinformataics and Biomedical Computation

The recent developments in the Human GenomeProject27 create both challenges and opportunities forthe Army to extract knowledge from large amounts ofgene and protein data that lead to the discovery ofnew drugs, diagnostics, and detection of chemicaltoxic and biological threats and diseases. The chal-lenges stem from the need to ensure that researchersfrom bioscience and computer science, who generally“speak different languages” and have limited cross-disciplinary skills, work together in an effectivemanner. On the other hand, the mapping of new genesequences and the discovery of protein 3D structuresoffer significant opportunities for the development ofnovel bioinformatics tools and algorithms that couldexpedite and reduce the cost of detecting and diagnos-ing biological threats, toxic exposure, and diseases.The Bioinformatics and Biomedical ComputationGroup focused primarily on software technologiesthat address challenges in bioscience and biomedicalresearch and that provide infrastructure that supportsthe other three domains—Hospital and ClinicalInformatics, E-health, and Combat Health Informatics.

Goals

The goal of Bioinformatics and BiomedicalComputation is to speed the progress of bioscienceand biomedical research through the power of com-puting to manage and analyze data that will supportrapid scientific progress. It has been recognized,28

however, that this goal cannot be achieved withoutcross-disciplinary collaboration involving researchersfrom both information science and technology andbioscience and biomedical research areas. In particu-lar, the goals include:


■ Fostering interdisciplinary research involvingthe collaboration of bioscentists and computerscientists

■ Creating better algorithms and tools to analyzegenomic and proteomic data

■ Investigating the use of distributed databasesconsisting of heterogeneous types of data toidentify, prepare for, and respond to emergingbiological threats or diseases

■ Identifying specific applications of high-per-forming computing and communications (HPCC)that would enhance Army medical research29

■ Encouraging the development of applicationsthat would benefit from the large bandwidth ofthe Next-Generation Internet

Technology Barriers

A number of technology barriers inhibit the fasterdevelopment of bioinformatics and biomedical com-

putation, precluding the invention of more insightfultools that would improve understanding and extrac-tion of knowledge from the immense and fast grow-ing genomic and structural genomic databases. Somebarriers are related to the lack of basic understandingof how genes—and the proteins they instruct thebody to make—work. A better understanding ofthese phenomena would lead to a more expedientdevelopment of analytical tools and would helpimprove the accuracy of simulation models andknowledge extraction algorithms. Other barriersrelate to the lack of standards and methods associ-ated with data acquisition, representation, archival,and retrieval. The noted technology barriers include:

■ Lack of standards for data characterization andstorage in databases

■ Need to store massive amounts of data, which arebeing generated at exponentially increasing rates

■ Lack of flexible methods for indexing informationand for purging/adding obsolete/new information


Table 3 ■

Major Research Needs for Combat Health Informatics

Sensing Devices Communication Data Warehousing Modeling

Develop sensor Investigate field use of Consolidate all post Develop flexible (not NEAR-TERMvalidation algorithms * digital photography for Vietnam combat casualty “hardwired”), portable < 2 years

assessing temporal changes data in a single database * and realistic simulatorsof battlefield casualties + and training tools ‡

Develop interactive combat Construct civilian pre-medic/medical support hospital (emergencyunit communications transport) physiologicalsystems for reach back _ trauma database ‡ $

Develop a wearable Develop portable “dash- Develop computer systems Identify physiologic MID-TERMbiosensor network to board” communications capable of integrating, parameters predictive of 2–5 yearsmonitor physiologic state architecture to facilitate storing and retrieving clinical outcome of traumaand injuries of soldiers ‡ $ overall information complete patient’s records casualties to develop

exchange _ coming from sources predictive models andConduct research on ranging from the battlefield decision support systems ‡sensors and systems for Develop data communica- to the hospital +psychological assessment tion systems to transmitand interventions to continuous and intermit-reduce stress * $ tent soldier physiologic

status data throughvarious echelons _

Develop non-invasive Develop database manage- Develop computer-based LONG-TERMscanning hand-held sensor ment systems that support medic aids for triage of > 5 yearsdevice and portable “plug- ad-hoc query of streaming unforeseen injuryand-play” monitor for and historical time-series conditions *injury assessment * $ data * $


■ Need for new data acquisition, registration andstorage methods to accommodate disparatedata types from diverse sources collected at dif-ferent times

■ Inadequate data mining tools and algorithmsfor information visualization, knowledgeextraction, and intelligent ad-hoc query in anever-increasing data-rich environment

■ Inadequate security systems to protect net-worked computers and linked databases

■ Need to understand how genes and proteinwork and identify functional markers

■ Need for multiple data representation schemesto accommodate different user needs

Research Needs

Research that is needed to overcome technical barriersfalls into two broad areas: data management and dataanalysis (Figure 1). Research in data managementaddresses the four logical sequential elements (dataacquisition, data representation, data archival, anddata retrieval) of data processing from the point dataare acquired to the point they can be retrieved formining and analysis. By and large, the identifiedresearch needs in these four elements are not neces-sarily unique to the Army environment as they repre-sent basic needs that encompass applications in anyenvironment involving significant data collection.Research needs in data analysis, on the other hand,consisting of modeling and simulation, knowledgeextraction, and visualization algorithms, potentiallyhave more components that are unique to the ArmyBioinformatics and Biomedical Computation environ-ment and should, therefore, be the primary focus ofthe USAMRMC strategic investments in this area.

In bioinformatics, data analysis tools are not beinginvented at the same rate that gene and protein dataare being generated, continuously increasing the gapbetween available information and acquired knowl-edge. To make effective use of the large amounts ofdata being generated, new, more insightful datamining and analysis tools need to be developed.30

These and other research needs in data analysis aswell as in data management are identified in Table 4.

Summary

This review paper summarizes the key findings andresearch recommendations in each of the four focus

areas, Hospital and Clinical Informatics, E-Health,Combat Health Informatics, and Bioinformatics andBiomedical Computation, covered at the USAMRMCBiomedical Informatics Roadmap Meeting. In gen-eral, each area had distinct aims and recommenda-tions, although there was some overlap betweenHospital and Clinical Informatics and E-Health,because the character of the problems in these areasare quite similar. An attempt was also made to iden-tify similarities and differences between civilian andmilitary biomedical information challenges. Of inter-est, because of the recent terrorist attacks to the U.S.,many of the challenges once considered unique to themilitary may now be associated with homelanddefense and, hence, related to public health care.

Analysis of the results identified several fields ofresearch as being important across all four areas.Most notable of these “cross-cutting” issues are theneeds for: (a) developing natural language process-ing software with semantic capabilities to enhanceand expedite information retrieval and facilitate theman-machine interface; (b) investigating technolo-gies that allow for seamless integration and interop-erability of promising new systems and applicationswith legacy systems and databases; (c) establishingstandards for guideline description languages, inter-operability of next-generation systems, and dataexchange formats, including data representation,characterization, and storage; and (d) developingmethods to integrate multimodality data from dis-tributed databases.

Although these common research needs are impor-tant in and of themselves, in general, they are notunique to the Army. They are symptomatic of the


F i g u r e 1 Research needs in Bioinformatics andBiomedical Computation.

“curse of the information age,” in which many differ-ent technologies are being developed at an acceler-ated pace without a firm foundation and oftentimeslacking adequate interoperability. While the USAM-RMC should closely monitor progress in these areas,it should focus its resources in niche research areasthat address unique military needs, such as thedevelopment of:

■ Information repository/database to facilitateexchange of DOD R&D capabilities

■ Wearable biosensor network to monitor physio-logic state and injuries/illnesses

■ Data communication systems to transmit con-tinuous and intermittent soldier physiologicstatus data through various echelons

■ Military casualty database to warehousedetailed documentation of all military engage-ment casualties in the post-Vietnam era

■ Civilian pre-hospital physiologic trauma data-base to allow the identification of life-savingsinterventions and key physiologic parameterspredictive of clinical outcome

■ Flexible computer-based medic aid for triage ofunanticipated injury conditions

■ Comprehensive biological threat database thattransforms dispersed biological threat resourcesinto integrated and interconnected informationresources

■ Analysis algorithms of gene expression and pro-tein folding patterns for diagnosis of exposureto biological agents and chemical toxics

Although the USAMRMC has recently started spon-soring research in some of these areas, such as thecollection and analysis of prehospital trauma data forthe identification of salient physiologic parameterspredictive of clinical outcome, research efforts inemerging, less mature areas are yet to be formalized.For instance, bioinformatics, linking data-drivenmachine-learning computational algorithms capableof analyzing huge quantities of gene and protein datain an expeditious manner to gain insight into therapy,drug targeting, and diagnosis of biological threats,provides one such example that would be of particu-lar benefit as it cuts across all four major researchfocus areas of the Command.1


Table 4 ■

Major Research Needs for Bioinformatics and Biomedical Computation

Data Management Data Analysis

Develop improved Develop Web-based tools Develop algorithms for Develop algorithms for NEAR-TERMsystems for data/ locating and integrating automated image analysis of gene and < 2 yearsinformation search and information from dis- synthesis + protein array expressionretrieval * tributed and diverse patterns for diagnosis of

database sources * exposure to toxic andbiological threats ‡

Develop intelligent Develop new networking Develop HPCC systems Develop HPCC systems MID-TERMnatural language processing algorithms to harness the for medical simulation, for modeling molecules 2–5 yearscapabilities for database power of thousands of visualization, and and simulating proteinquerying ‡ dormant computers + training * structures to improve

basic understanding * $

Establish standard data Develop innovative data- Conduct research on pre- Develop algorithms forexchange formats that base technologies and dictive algorithms that can extracting knowledge fromallows for seamless system standard query that handle high-dimensional protein primary and tertiaryinteroperability + accommodate multiple data in sparse data sets + structure information and

data representations + identify functionalmarkers * $

Develop a comprehensive biological Investigate evolutionary programming LONG-TERMthreat database that transforms dispersed algorithms capable of automatically >5 yearsbiological threat resources into integrated writing and debugging software _and interconnected information resources ‡


The USAMRMC and the research community at largeshould benefit from the findings summarized here asthis paper provides increased awareness of both thechallenges and opportunities that lie within the realmof Biomedical Informatics and the particular Armyneeds in this field. Furthermore, it provides sufficientinformation to craft a science and technology pathwayfor guiding funding priorities and future solicitations.

The authors would like to thank E. Shortliffe for his help in identi-fying some of the reports cited in the Introduction. The first authorwas supported by the U.S. Army Medical Research and MaterielCommand, Combat Casualty Care and Military OperationalMedicine Research Area Directorates.

References ■

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Military Research Needs in Biomedical Informatics - … · unique military needs. Reference 2 provides details about the meeting, including the agenda, copies of the presentations,