An ad hoc committee will define the components of a learning health system necessary to enable continued improvement in trauma care in both the civilian and the military sectors (improving survival and reducing morbidity). Trauma care, for the purposes of this report, is defined as encompassing: integrated and coordinating emergency medical services and trauma care systems; point of injury or tactical care; en-route care or care during transport; initial resuscitation including care at small facilities prior to trauma center; care at the trauma center including emergency medicine, trauma surgery and specialty surgical care, anesthesia, and critical care; and transition to but not inclusive of rehabilitation and recovery. In this endeavor, the committee will characterize the military’s Joint Trauma System (JTS) and Defense Health Program research investment and their integrated role as a continuous learning and evidence-based process improvement model. The committee will examine opportunities to ensure that the advances in trauma care developed by the Department of Defense (DoD) over the past decade from experiences in Afghanistan (Operation Enduring Freedom) and Iraq (Operation Iraqi Freedom) are sustained and built upon for future combat operations. Finally, the committee will consider the strategies necessary to more effectively translate, sustain and build upon elements of knowledge and practice from the military’s learning health system into the civilian health sector and lessons learned from the civilian sector into the military sector.

Specifically, the committee will address the following 3 tasks:

1. Drawing from existing models, identify and describe the key components of a learning health system necessary to optimize care of individuals in military and civilian settings who have sustained traumatic injuries.
2. Characterize the components of the military’s Joint Trauma Systemand the trauma research investment of the Defense Health Program that together have enabled real-time, evidence-based or evidence-guided process improvement in trauma care consistent with the principles of a learning health system. Consider how these components can or should be expanded and, where appropriate, standardized across DoD, and how they should align with other learning health systems, including those in the civilian sector such as regional or statewide trauma systems. In doing so:
   1. Characterize the relative uniqueness of the military’s Defense Health Program and its investment in trauma and injury research compared to other private or federal investments in trauma research. Discuss the benefits, limitations and relative effectiveness of its capabilities- and gaps-driven research approach.
   2. Characterize how civilian education systems for medical, allied health, and other relevant professions, as well as the military-specific medical education at the nation’s Uniformed Services University of the Health Sciences and across the Military Health System, prepare individuals to be leaders in this trauma-specific learning health system.
3. Define how such a learning health system can ensure lessons learned from the military’s knowledge-generating research investment are sustained and built upon for future combat operations, and translated into the U.S. civilian health system. Consider the importance of relevant civilian and military trauma-related education and training systems, the need for military and civilian-sector trauma-focused research investment, systematic processes for changing system-wide protocols, and/or performance improvement processes for providers.
   1. Identify mechanisms to enable implementation of knowledge, interventions and/or trauma care processes from the military into practice by the civilian sector (civilian trauma systems, trauma centers, and relevant emergency medical services including first responders), and vice versa.
   2. Identify factors that promote or limit that translation, considering ethical considerations in defining evidence standards necessary for changes in clinical care or guidelines and the value of a “focused empiricism” approach.

To address the above tasks, the committee will draw upon 3-4 case studies centered around common combat-related injuries that are also relevant to civilian sector trauma cases and highlight the opportunities and challenges to establishing and sustaining a trauma care learning health system. The case studies may be based upon the following traumatic injuries, or other relevant examples, and should feature real life medical cases. One case study should include pediatric trauma care.

• Complex dismounted secondary blast injury with extremity amputation, face injuries, a compromised airway and hemorrhagic shock
• Secondary blast injury with penetrating fragment wounds to the head and extremities with an extremity vascular injury and shock
• 35% total body surface area burn with early renal and pulmonary failure
• Explosive injury resulting in tension pneumothorax, blunt solid organ injury with intra-peritoneal hemorrhage and shock
• High velocity gunshot wound to the thigh with soft tissue injury, open femur fracture, vascular injury and limb ischemia
• Closed complex pelvic and femur fractures with hemorrhagic shock

The case studies will highlight to the extent possible:

• Levels of evidence used to develop military and civilian (as applicable) clinical guidelines for the spectrum of trauma care in each case
• Pertinent innovative changes (devices, medications, equipment, methods) that have been incorporated into the spectrum of trauma care for each case as a result of the DoD’s evidence-based improvement process.
• Processes by which patient and injury information was collected, stored, reviewed and analyzed by the JTS; including how this information was used for the JTS’s evidence-based improvement process and made available for clinical and epidemiologic research
• How collection, storage, review and analysis of patient injury and management information differed for those killed in action versus those wounded in action (i.e., different system for those who die prior to arrival at a medical center thus eliminating ability to study ways to improve survival).
• Impact that evidence-supported changes in military trauma care and the JTS’s evidence-supported process improvement may have had on survivability.
• How the results of the military’s DHP research investment and elements of focused empiricism have been integrated into the JTS, its Clinical Practice Guidelines and usual military practice
• Evidence of how these changes may be effectively integrated into military training and doctrine (e.g. special units such as the Army Rangers) and how these lessons learned can be applied in the civilian sector.
• Time elapsed between the compilation/publication of evidence and development and implementation of clinical guidelines.