Military Health Systems-Resources Information Technology Program Office

The Defense Occupational and Environmental Health Readiness System – Industrial Hygiene (DOEHRS-IH) is a Department of Defense (DoD) project managed by the Military Health System (MHS). DOEHRS-IH is an environmental monitoring and analysis medical system and data warehouse that captures, stores, and analyzes the exposure history of all military related exposures throughout the life of both military personnel and DoD civilians. Records are transferred to the Veteran’s Administration upon separation from the military for lifetime tracking and potential follow-up.

DOEHRS-IH provides the ability to capture exposure information, support industrial hygiene decisions, and enroll service personnel into medical surveillance programs based on individual exposure history. If “an ounce of prevention is worth a pound of cure,” then DOEHRS-IH support of preventive environmental, safety, hearing conservation, and occupational health programs will save the U.S. taxpayer billions of dollars throughout its lifecycle.

DOEHRS-IH enhances readiness by providing information to enable exposure-based medical surveillance and enhance IH risk reduction. Early detection and identification of environmental hazards enables prompt federal, state, and local response to potential life threatening scenarios affecting both the military and the general population. The MHS operates 76 medical centers and hospitals, and more than 460 ambulatory clinics worldwide supporting a beneficiary population exceeding nine million. Over 40,000 direct care providers and a total staff of approximately 160,000 provide definitive care in a challenging environment that supports a global presence and highly mobile beneficiary population. The sheer size and geographic dispersal of the military population provides an opportunity for environmental exposure monitoring, sampling, and analysis that can be applied to the civilian sector. Emerging customers (including the National Security Agency) will use the system for early detection, identification, and analysis of advent of nuclear, biological, chemical, and environmental threats to the general population.

DOEHRS-IH, a mission critical system developed as a Web-based application, follows the DoD Joint Technical Architecture and MHS guidelines. DOEHRS-IH provides the first near-to real-time environmental monitoring capability to a highly mobile population replacing the standard hard copy forms that were filed in patient’s records. During a patient encounter paper copies of local environmental threats often were not available to the provider and consolidated information was incomplete and dated. As such, sound analytical assessments could not be used to prevent or contain large-scale incidents. DOEHRS-IH will save lives and protect the military and general public by accomplishing real- to near-time monitoring and analysis of environmental information. It will also decrease medical costs as potential personnel exposures will be identified and addressed before they become health issues. Early detection of potential threats and health hazards not only makes it possible for personnel to avoid exposure but it also enables prompt treatment and follow-on care for individuals or populations affected by adverse agents.

Department of Defense industrial hygienists are tasked to anticipate, recognize, evaluate, and control occupational health hazards at medical treatment facilities and installations worldwide. In order to accomplish these tasks, industrial hygienists conduct evaluations or surveys at the workplace to determine personnel exposure to chemical, physical, biological, and ergonomic hazards. Information gathered during these evaluations, including worker exposure monitoring results, is entered into DOEHRS-IH. This database collection system will be deployed throughout the DoD and to other federal agencies.

DOEHRS-IH records contain the history of an individual workers pre-deployment, deployment, and post-deployment exposures. The data is analyzed and used by environmental, safety and occupational health practitioners to prioritize preventive medicine actions. Actions include establishing a baseline to facilitate exposure-based medical surveillance and post-deployment follow-up, allocating resources, implementing controls, and developing appropriate training programs. All these measures enhance combat readiness by focusing efforts to reduce workplace exposures, illnesses and injuries.

The terror attack on 9/11 as well as other incidents worldwide confirms that early detection of environmental hazards is no longer limited to military forces in combat environments. The threat of future terror attacks on military as well as civilian targets has created new requirements for early detection and identification of environmental hazards. Prompt detection and identification of applicable agents enables prompt federal, state, and local response to potential life threatening scenarios affecting both the military and the general population. DOEHRS-IH integrates Force Health Protection (FHP) information by providing automated support for the MHS industrial hygiene, environmental health, and hearing conservation communities. DOEHRS-IH also supports health care demand management by enabling exposure based occupational medicine and industrial hygienist interventions.

The data collection modules in the DOEHRS-IH are based on the DoD Industrial Hygiene Exposure Assessment Model developed by the DoD IH Working Group. This model describes an 8-step exposure assessment strategy for use by field level hygienists to collect and evaluate IH exposure data throughout DoD. The model applies to IH risk assessments performed on DoD operations ranging from peacetime fixed facilities to military field deployments and afloat; and for exposures ranging from repetitive industrial maintenance operations to one-time exposures to ambient chemical, biological, and physical stresses.

Preventive medicine environmental health capabilities support the anticipation, identification, assessment, communication, and management of health risks posed by environmental health hazards associated with military activities. The scope of these capabilities addresses environmental health issues that impact military personnel, their families, and the civilian work force. These capabilities can also address the health impacts of military activities or surrounding communities. Preventive medicine environmental health capabilities address the environmental health risks of the military environmental program by providing medical oversight of environmental programs to prevent disease and injury.

DOEHRS-IH is based on the DoD IH Exposure Assessment Model and contains menus that were built on this process. The system is web-based with a mobile capability that enables users to capture data on PC Tablets not connected to the NIPRNet and then synchronize their tablets with the web-based system when they have NIPRNet access.

The Department of Defense and the military Services were the internal sponsors of the system. A formal working group comprising all stakeholders or users, worked directly with providers and support personnel to reshape the overall business processes involving environmental monitoring and analysis capabilities.

There were no dissenting sponsors on the overall concept but there were proprietary issues involving Service unique legacy systems and requirements. One of the hardest tasks in systems development that turns off legacy systems for multiple users and agencies is to properly define the requirements. However, accurate requirements must be accomplished to ensure that each user will have capability that matches or exceeds current legacy capabilities. To offset any mistrust or concern with stakeholders, the program manager used meticulous attention to detail and customer focus to create an air of confidence and trust with the military Services.

Stakeholders worked together to redefine the business processes and then integrated technology as an enabler. Meticulous attention to every detail and constant oversight resulted in a three-year deployment delay being totally overcome in less than 18 months. This in itself is unparalleled, but the comprehensive understanding and resultant reengineering greatly enhanced data collection and analysis affecting the individual patient encounter.

The DOEHRS-IH team consistently updates and publishes user manuals, software release notes, and table downloads for customer reference. In addition, the team provides customers with periodic on-site training and coaching sessions.

This entire process was a joint venture with all of the military Services (Army, Navy, and Air Force) -- from kick-off through briefings, training, limited-rate deployment, and full-rate deployment. The DOEHRS-IH integrated team was fully engaged in every aspect of the development and deployment processes. DOEHRS-IH uses Joint Application Configuration (JAC) sessions with at least two members from each of the Services, Information Management (IM), Systems Integration, Technical Services, and Support Services to develop initial and follow-on requirements. JAC also validates requirements and has begun to redevelop business processes that streamline and improve patient flow and individual encounters.

JAC business sessions also review both commercial and government business processes and government and commercial software products through a series of concept explorations that involve having vendors exhibit their products for a particular system. They also select COTS products, configure COTS products, and select beta sites for the configured product.

The DOEHRS-IH team provides the MHS with the ability to capture accurate, auditable environmental monitoring data in a standardized, electronic format. DOEHRS–IH benefits were documented in two different categories: direct and indirect. Direct benefits include enhanced collection, analysis, modeling, and reporting functionalities. Indirect benefits include enterprise-wide analytical capability and clinical care initiatives such as disease management.

Following a proven process, the DOEHRS-IH team has successfully worked with the customer (the Services) by forming a cohesive team with all the vendors and Service representatives throughout the full cycle of requirements baselining, acquisition, configuration, testing, integration, selection of beta sites, limited-rate deployment, and full-rate deployment.

The greatest challenge in any software or systems development initiative is communication. The program manager for this project not only formed a cohesive team, but he enabled the process by closely monitoring the project and paying close attention to all details. Through these actions, he gained the trust and cooperation of all parties involved.

Immediate need for the system was another significant challenge. Following 9/11, the unknown level of threat caused by terror-related activities and the protection of military and civilian personnel from environmental hazards became a high priority. Requirements for near- to real-time access to, and analysis of, environmental information formed the catalyst for DOEHRS-IH development and deployment. Prior to 9/11, initial deployment of DOEHRS-IH had slipped three years and the program was in danger of being cancelled because the user community could not agree on minimum essential system requirements necessary for initial deployment. The integrated management team initiated Scope Management practices as the starting point for the turn around. Functional proponents advocated additional capabilities that exceeded the budget authorization, therefore, change management control was the key to executing what the provided funds were to deliver.

The DOEHRS-IH working group immediately reached consensus on minimum essential system requirements for initial deployment, and a firm baseline was defined to ensure there was no scope or requirements creep. Daily team meetings were initiated with government and Services’ representatives and the contractor to focus on issues that would have delayed development and deployment of DOEHRS-IH.

Improved time management processes were also considered key to the DOEHRS-IH turn around. Developing DoD systems is a complex environment. The program manager not only must worry about sequencing and scheduling the technical work but he also must integrate this within the Defense Acquisition System’s requirements and constraints. The government support team prepared a road map for completing all of the DOD 5000 acquisition documentation necessary for a successful Milestone C decision. The combination of agreement on system requirements, tight contract management, and an understanding of the DOD 5000 acquisition process led to the DOEHRS-IH Milestone C approval.

Change is inevitable in any information technology endeavor. However, control of the change process and development of new and revised requirements must be managed extensively to ensure constant change does not bog down the program.

The DOEHRS-IH team followed standard configuration management processes to track, prioritize, fund, and schedule approved changes. The working group is also tasked to look at potential solutions that would improve the system workflow while resolving many of the shortcomings of the stand-alone processes and applications. These integrated solutions provide prompt interfacing and retrieval of data. The DOEHRS–IH working group follows a general format in evaluating any and all recommendations for change.

• Improvement to response time or data analysis capabilities
• Support for quality of care initiatives – automated patient record
• Improvement to population health studies and disease management
• User friendly system application – easy to use and effective
• Improvement of data quality and consistency
• Streamlined provider/patient encounter – clinical and business processes
• Patient centric results retrieval for clinical information
• Integrated application that provides health assessment and plan
• Improved and automated medical surveillance for designated populations
• Improved business processes

The Together Control Center (TCC) tool was used to maintain DOEHRS-IH design. TCC is a modeling and development tool that supports the lifecycle by providing tools to model software, develop code, and keep model and code synchronized throughout the lifecycle. TCC provides tools that support the standard Unified Modeling Language, the industry standard for object-oriented designs and entity relationship diagrams, the defacto standard for relational data modeling. This tool enabled the design staff to complete preliminary and detail design phases of the project much more rapidly.

AllFusion ERWin Data Modeler was used to develop and maintain data models. It modeled the system and created both logical and physical data models as well as the data dictionary. AllFusion ERWin data models help visualization of data structures to facilitate the organization, management, and moderation of data complexities; database technologies; and the deployment environment. AllFusion Model Manager supports multi-user data model development. This tool was essential for the database engineers as DOEHRS-IH has over 565 database tables and very complex data entity relationships.

Yes. Mercury Interactive Test Director was used to manage test activities, test cases, and defect tracking. Test Director maintains traceability between software requirements and test cases. Mercury Interactive Quick Test Professional was used to automate testing during system integration, system testing, and regression testing. JUnit and Jakarta Cactus were used write and run repeatable tests during unit testing.

If so, when were they used?

JUnit and Jakarta were used during unit testing by the developers of individual components. Test Director was used during integration and system testing to manage test activities, test cases, and defect tracking. Quick Test Pro was used to automate testing during system integration, system testing, and regression testing.

Was the testing cost-effective?

Yes. The use of testing tools, particularly Test Director, enabled Northrop Grumman to conduct testing with one full time tester augmented by CM and QA personnel on an as needed basis.

Yes. The DOEHRS-IH project followed the QUality Engineering STandard (QUEST) Incremental Design Lifecycle methodology as defined in the Northrop Grumman Mission Systems Policy & Requirements Manual (PRM) and the Standard Process Manual (SPM). DOEHRS-IH utilized an Incremental Design life-cycle methodology as the system requirements were initially established on the first contract but the design, development and testing was performed in an iterative fashion in three separate versions of the system that built on each other. The Northrop Grumman Mission Systems Policy & Requirements Manual (PRM) and the Standard Process Manual (SPM) were developed based on the Software Engineering Institute Capability Maturity Methodology Integrated (SEI-CMMI) software development processes. Northrop Grumman was assessed at CMMI Level 5 in December 2004.

The DOEHRS-IH project operates in accordance with the QUEST policies and processes. The goal of QUEST is to continuously improve system, software and information engineering practices in order to develop a standard, tailorable, high quality methodology to maximize process efficiency. QUEST provides policies and processes for all aspects of software engineering program management through the Policy & Requirements Manual (PRM) and Standard Process Manual (SPM).

The PMP, QAP, and CMP comprise the primary planning documentation for the DOEHRS-IH. The Risk Management plan is contained in the PMP.

Northrop Grumman uses established project control procedures to monitor the costs associated with DOEHRS-IH. Key to effective project control is the monitoring of labor and costs. Northrop Grumman uses a SAP implementation called TEMPO to provide Project Managers and Program Control with real-time access to contract cost accounting data. Northrop Grumman includes earned value and an integrated project schedule that clearly identifies critical path, time, milestones, deliverables and links to other tasks in each monthly report.

A systematic, disciplined risk analysis method is used to ensure that project risks are identified, that probability of occurrence and impact on the DOEHRS-IH are determined, and that plans to reduce or eliminate the risks are developed. The risk assessment is documented using the Risk Radar Tool, a Microsoft Access-based tool that organizes risk by severity and timeframe, and provides a framework for identifying and tracking the action to be taken to mitigate each risk.

Yes. The software quality metrics were defect density by phase and defect containment by phase. The defect containment aided the project as were able to identify defects that occurred as early as the requirements phase but weren’t identified until testing. Based on this data we were able to improve our peer review process for the requirements and design phase thereby reducing defect leakage from one phase to the next during the last version of the DOEHRS-IH system.

The biggest technical challenge faced by the development team on DOEHRS-IH was the need to have a PC tablet able to operate the DOEHRS-IH system while disconnected from the web based application. The data gathered during standalone operation had to be synchronized with the central server for the web based system. This requirement was not part of the initial contract and was implemented by an ECP with very tight development timelines.

How did the team respond to those challenges?

The team decided to reuse the majority of the server components on the mobile system, which facilitate development of the required mobile functionality as well as system maintenance and extensibility. The mobile DOEHRS-IH system provides the user with access to most web system application functions, as well as apply the same business rule processing. Reusing a tailored version of the DOEHRS-IH web system components obviated the need to re-implement significant portions of the custom-developed components for the mobile client, thereby accelerating development of the mobile system. This approach also facilitated maintenance by ensuring that updates to custom-developed components convey to both the main web system, as well as mobile clients. This decision also ensures that the application’s user interface remains consistent regardless of which mode the user is operating, thereby facilitating user training. In addition to the existing server components, database synchronization between laptop/tablet and server; and external data synchronization between laptop/tablet and server were essential for DOEHRS-IH stand alone operation to meet the user needs. The development team rapidly identified Marimba and Oracle Advanced Replication as the best COTS product to solve this major technical challenge.

DOEHRS-IH leverages existing solutions by integrating with industry-proven products. The selections of third party components favor companies that comply with industry-accepted standards such as J2EE. As detailed in the DOEHRS-IH Application Server Trade Study, Oracle 9iAS is the application server selected as the cornerstone of the DOEHRS-IH system architecture. Some of the complementary components were favored to promote a single vendor solution. This approach takes advantage of optimization features not available with other vendor components. Although, the design team has developed a largely single vendor solution, the design is not precluded from “upgrading” to other certified components. Because J2EE components offer plug and play-like features, as DOEHRS-IH evolves, components can be upgraded to meet these extensibility needs without affecting other components in the system and without the burden of re-factoring the architecture. This loose coupling of components allows for right sizing the architecture and adapting to the changing needs of the customer. The purchase of third party components can also provide a savings to the government and preclude a stovepipe solution. These components provide a majority of the infrastructure in DOEHRS-IH.

All third party components are operationally configured based on the relevant DISA Security Technical Implementation Guides (STIG) produced by DISA Field Security Operations.

The rationale for the selection of the components used in the DOEHRS-IH application is included above with the discussion of the individual components.