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Saving Lives with Data

The Joint Trauma System is an Integrated Battlefield Trauma System that Saves Lives While Increasing Lethality

 

Col. Jennifer M. Gurney, U.S. Army
Dr. Alexander Miller

 

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Regardless of mission or user, data is often held up as the ends rather than the means. When leveraged effectively in combat, data saves lives, can increase morale, and improves combat readiness. The Joint Trauma System (JTS), the Department of War’s (DoW) Center for Excellence for Trauma, has proven this assertation by demonstrating the lifesaving capabilities of combat casualty care (CCC) data leveraged to improve clinical outcomes. The JTS emerged from a critical need in 2003 during U.S. Central Command (USCENTCOM) operations when it was realized that there was no communication in the battlefield continuum of care, which resulted in service members dying from survivable injuries.¹ For data to save lives, it must be readily available, of high or sufficient quality, and properly analyzed. However, this is not enough; the data must be nested with the proper trauma system in place to allow for collection, analysis, feedback, and response in operations.

The character of warfare is going through disruptive changes, and without change, U.S. dominance is not guaranteed. The United States must leverage the latest technology as the generation of data, the access to data, and the appropriate use of data will be decisive on the next battlefield. This is especially true for operational medicine—the operational medicine landscape is complicated. It is the convergence of various personnel, complex environments, constrained resources, long evacuation times, communication challenges, and of course, clinical care of complex injuries. To optimize patient outcomes, decrease attrition, and support the combatant commands (COCOM) with casualty care, data about the operational medicine landscape must be timely, accurate, and shared between warfighting systems.

When the United States engaged in combat operations during the Global War on Terrorism (GWOT), it lacked a comprehensive trauma system to rapidly assess combat care, use relevant data to update practices, and field new solutions. Consequently, between October 2001 and June 2011, one in every four deaths of U.S. service members was from a potentially survivable injury such as extremity hemorrhage.² Entering the next conflict without an established trauma system will come at a large cost, not just in service member lives but also in operational effectiveness if up to 25 percent of deaths on the battlefield are from potentially survivable injuries.

During GWOT operations in the USCENTCOM theater, medical professionals realized that there was no existing process to collect, analyze, and act on the data. The JTS was established to fill this critical need; since then, the JTS has produced more than 450 peer-reviewed publications documenting the lifesaving outcomes of utilizing CCC data effectively. Through systematic analysis and a commitment to data-driven improvement, the JTS has established a battlefield trauma system that has decreased battlefield death and disability and thereby improved operational effectiveness. No system is perfect and without limitations. This article aims to show the history and capability of the JTS as well as the evolution and future directions for data-driven CCC.

The Joint Trauma System: Evolution from Grassroots to Global Impact

The JTS is not a system in the traditional sense but a system in the broader sense of people, organization, function, and governance. The JTS, established in 2004 by the assistant secretary of defense for health affairs, was codified in DOD Instruction 6040.47, Joint Trauma System, in 2016.³ It is important to note that the JTS is not merely a repository of medical data but is mandated to improve trauma care at all levels of the force. This includes the codification of lessons observed during combat operations and the deliberate modification of doctrine, training, and clinical practices so that those observations are transformed into actionable lessons learned.

The JTS story began in 2003 when a small team was deployed to USCENTCOM to collect casualty care data. This effort quickly highlighted critical challenges but also enabled the development of solutions such as need for tourniquets, resuscitation triggers, burn care, whole blood utilization, and hypothermia prevention/management. This initial effort evolved into a system of feedback and actions (shown in figure 1) that transformed CCC, pulling it from a data-starved abyss into an informed, lifesaving enterprise. The JTS provides access to and analysis of previously unavailable clinical data, enabling rapid feedback to providers, surgical teams, and commands. This capability supports the “act, learn, adjust” battlefield healthcare system, which has been proven to not only save lives but also act as a force enabler for commanders.

How the JTS Functions

The DoW entered the GWOT in the USCENTCOM area of responsibility without an established trauma system. This absence came at a terrible cost—service members died from injuries that should have been survivable. When the JTS was established, so was the battlefield trauma registry, referred to as the Joint Theater Trauma Registry, in 2004.⁴ Collecting, analyzing, and then turning CCC data into actionable insights has led to the best casualty outcomes in the history of war. The Joint Theater Trauma Registry evolved into the Department of Defense Trauma Registry (DODTR), where clinical data documented across the range of operations is housed. Data in the DODTR are analyzed to inform guidelines, education, training, and other aspects of casualty care. Through this operational cycle, as shown in figure 1, the JTS has driven medical performance optimization (MPO) through iterative learning and adaptive battlefield trauma care. MPO is the use of clinical data to inform combat injury management (e.g., clinical practice guidelines), training and preparedness (e.g., tactical combat casualty care, predeployment medical training), policy development (e.g., Golden Hour Policy), procurement decisions (e.g., eye protection, Nomex gloves, changes in body armor), and surgical resource allocation.⁵ Even given this, data from the DODTR is neither real-time nor standardized. It requires people to manually abstract data from a variety of clinical records after events that produce casualties.

Why Commanders Should Care

As noted, between October 2001 and June 2011, one in every four deaths of U.S. service members was from a potentially survivable injury.⁶ Based on this astonishing reality, substantial investments in improving prehospital care and the deployed trauma system were implemented. Maturation and continuous evidence-based MPO of the trauma system over time resulted in a 44 percent decrease in deaths from battlefield trauma.⁷ This substantial improvement in survivability preserved the fighting strength and improved combat morale—which in turn increased the lethality of the warfighter.

The memorandum for record in figure 2 highlights the impact seen by the USCENTCOM commander in 2013 and the need to advance the JTS processes and tactical combat casualty care (TCCC) training.⁸ Commanders at every echelon hold a pivotal responsibility to ensure the effective implementation of TCCC principles, training, and education within the battlefield trauma system.

Trauma Systems

An effective trauma system hinges on seamless communication and shared medical capabilities, ensuring the right patient receives the right care at the right time and at the right place. It leverages clinical data not only to improve subsequent care but also to shape policies, procedures, and training across the force. While this mission may appear straightforward, in practice it represents a highly complex undertaking. Achieving meaningful improvement requires a systems approach that integrates data, doctrine, and decision-making, as well as a “team of teams” construct—linking clinicians, commanders, policymakers, and trainers into a unified network that continually adapts and improves trauma care. Driven by data, trauma systems continuously evolve through strong leadership and coordinated care across the entire continuum from point of injury to rehabilitation.

A battlefield trauma system is a commander’s asset—it enables execution of warfighting and integrates all the knowledge and decision-making aids necessary to provide care and save lives across the range of military operations. Battlefield trauma systems have many components that extend from the point of injury upward and span the entire continuum of battlefield care.

As alluded to previously, the Department of Defense did have elements of a trauma system in place within the USCENTCOM area of responsibility in 2002 and 2003: medics and corpsmen provided point-of-injury care, battalion aid stations were established forward with maneuver units, Role 2 forward surgical teams were dispersed across the battlespace, and Role 3 theater hospitals were stood up at strategic evacuation hubs. This network of providers lacked the connectivity to communicate and leverage data and execute MPO—thus did not create a layered trauma system that could leverage data effectively nor learn, self-correct, and improve. The Department of Defense fundamentally lacked both the system and the domain expertise—people familiar with the CCC delivery—at the theater level to aggregate and analyze CCC data in a meaningful way. Domain expertise for CCC means understanding the nuances of every aspect of CCC delivery—from point of injury to theater evacuation—to capture the data and determine which data points are relevant and which analyses can lead to improved outcomes.

At the inception of the JTS, data on all combat casualties with substantial traumatic injuries were entered into the JTS trauma registry, a positive byproduct of being the first system of its kind. Unlike service-specific approaches, there was no separate registry for soldiers, sailors, marines, airmen, or other government agencies. Instead, the JTS registry included all combat casualties from all services and even coalition and host-nation partners. Establishing stovepiped, service- or nation-specific registries would have been a poor architectural choice and would have failed to meet the very intent of a truly joint capability. However, while the registry succeeded in centralizing casualty data, it suffered from predictable limitations: the tools, data formats, and methods of entry lacked commonality and did not reflect shared best practices. This lack of standardization hindered interoperability, a challenge that continues to echo across both mission and business systems throughout the joint force today.

Casualty-Centric not Service-Centric

The DODTR and JTS have come a long way from where they were at the start of GWOT. Today, each service (e.g., Army, Navy, and Air Force) establishes sites of care delivery in each theater; however, the care delivered at each of these sites is not limited to members of that service. As an example, consider this CCC mission thread:

During Operation Enduring Freedom, a marine is injured in Helmand Province, Afghanistan, and receives care by a Navy corpsman on the objective. The corpsman recorded vitals and patient data between paper and digital tools; Army Dedicated Unhesitating Service to Our Fighting Forces (DUSTOFF) flight medics provide care en route on the helicopter, recording what data they can, as the casualty is evacuated to Role 3 at Camp Shorabak (formerly Bastion), also within Helmand Province, which rotates between Army and Navy units. After resuscitative surgical care, the marine’s charts and data are updated and the marine is flown by the Air Force to the Air Force Role 3 strategic evacuation hub in Bagram. The Air Force Role 3 is augmented with specialty care by non-Air Force providers. The marine is then flown by Air Force Critical Care Air Transport to Landstuhl, Germany. Although primarily an Army installation, Landstuhl also has Air Force and Navy clinicians on staff.

A service-centric, or even COCOM-specific, trauma system registry would not provide the agility needed to care for a casualty across all these care facilities and combat care instances from point of injury through rehab, including all the en route care environments. If casualties had to be linked to their service’s unique registry, the results would be ineffective—like trying to establish new accounts after each permanent change of station—and potentially catastrophic. Trauma systems must be casualty-centric and require synchronized communication, follow up, integration, systems and processes, and access to high quality (e.g., digital rather than handwritten notes) clinical data to mature and function effectively.

The JTS today enables the battlefield chain of survival through data and a feedback loop to deployed medical teams, and it has been consistently educating CCC providers.⁹ Since 2005, the organizational components of the JTS have conducted over 990 weekly conferences to discuss near-real-time CCC, identify improvement opportunities, and share critical information with the medical and nonmedical force. These synchronous learning opportunities, enhanced by educational presentations since 2017, have awarded over forty-four thousand hours of Continuing Medical Education credits, showcasing the educational aspects of MPO. Additionally, the integration of multinational forces into these discussions has strengthened coalition trauma systems, promoting interoperability and shared best practices.

JTS’s data-centric approach to battlefield medicine directly informs and accelerates the development of lifesaving guidelines, informs education, and supports the development of medical technology and equipment. It is a learning and data-driven system and thus needs new data constantly to continuously feed, develop, inform, and grow the battlefield trauma system.

To demonstrate this point, during the GWOT, data from clinical documentation demonstrated an increased risk of death casualties with hypothermia; when the JTS identified this trend, the Hypothermia Prevention and Management Kits, which provided self-heating kits for tactical care to prevent hypothermia, were developed and fielded. While a bespoke example, table 1 highlights examples of how the data-driven approach to learning and maturing the trauma system can improve care while increasing operational effectiveness. Commanders are critical in ensuring timely adoption and integration of these advancements to maintain superior medical support in future operations. Establishing a framework and a means to leverage data also allowed the JTS to shift from managing paper to collecting data at the edge to employing mobile capabilities like the Battlefield Assisted Trauma Distributed Observation Kit, an Air Force Research Lab phone-based tool to digitize records.¹⁰

Evolving Trauma System: Data Driven Lessons Learned

Battlefield lessons are only truly learned when codified into practice. The JTS serves as a vital learning healthcare system, directly enhancing operational effectiveness and readiness. By addressing specific combat medical challenges with data-driven actions, JTS has mitigated the consequences of severe injuries. These successes underscore JTS’s ability to evolve and scale its medical capabilities, rapidly disseminating lessons and their operational implications. Even now, JTS ensures rapid dissemination of lessons learned, updates clinical and TCCC guidelines, and provides crucial feedback to medical training, thereby enhancing both operational effectiveness and readiness.

Today’s Challenges with Data-Driven Trauma Care

While the JTS has been a learning and maturing system, challenges remain, including protracted processes for implementing change, the difficulty of dealing with medically unique and nonstandard data, and the burden of cumbersome documentation tools that hinder both providers and data analysis. This section provides an overview of these challenges.

Protracted processes for implementing change. The Department of Defense entered the GWOT without a functioning trauma system—a gap that contributed to roughly 25 percent of U.S. service members with otherwise potentially survivable injuries dying. As illustrated in figure 3, it took years for the emergent JTS to make a substantial impact on the case fatality rate (CFR)—injured service members who were killed in action or died of their wounds. Even in an operational environment where the United States had control over most tactical and operational variables, with unfettered access to airspace and resources, it still required nearly five years to improve the CFR.

This reality underscores the risk for future battlefields. In a large-scale combat operations (LSCO) environment, where conditions will be far less permissive, the absence of integrated medical and operational data will almost certainly replicate the preventable losses experienced at the start of GWOT. The eventual, radically low CFR achieved despite a rising Injury Severity Score—the standardized measure of the overall severity of a patient’s traumatic injuries—was largely the product of data access and the systematic innovations enabled by the JTS (see figure 3).

Building a battlefield trauma system during an ongoing conflict inevitably carries a costly lag time—measured in the deaths of service members from otherwise survivable or potentially survivable injuries. Table 2 highlights the strategic impacts of the JTS, which has proven its value but continues to face pressing challenges. Chief among these are the time, strategy, and resources required to build the kind of integrated data ecosystem truly needed. Although Congress codified the JTS as a statutory requirement, it did so without providing corresponding “top-line” increases in funding. This has forced the services to make difficult tradeoffs, accepting risk in some areas in order to sustain others.

To address theater-specific demands, each COCOM is working to establish its own COCOM trauma system. These efforts aim to adapt JTS principles to the unique operational realities of each region. Yet developing such frameworks is inherently difficult, especially in periods of low casualty flow, when the system lacks the data necessary to test, refine, and mature its processes.

Dealing with medical unique and nonstandard data. Medical data presents a unique challenge for a battlefield trauma system. It contains protected health information and personally identifiable information (PII), which are typically siloed from mission command systems and operational data. This constraint directly impacts the ability to rapidly move data immediately after injury. Limitations on PII often prevent integration with the commander’s common operational picture, even though such integration could enhance situational awareness, resource allocation, and decision-making.

The Health Insurance Portability and Accountability Act (HIPAA) imposes strict controls on the sharing of medical information, and these requirements apply even in operational environments. Sharing medical data across operational networks risks violating these protections and undermining the ethical responsibilities of medical professionals to safeguard patient confidentiality. This creates a persistent balancing act: weighing lethality and operational risk against trust, ethics, and medical privacy.

For this reason, in the battlefield trauma system the tactical data set must be clearly defined—a tailored set of data points sufficient to support battlefield operations and enable clinical care without overexposing protected information. While common sense suggests that soldiers in combat would prefer lifesaving care over absolute privacy of their injuries, current policy gaps remain. There is no consistent framework defining when a soldier’s data transitions into “medical data” subject to privacy protections, nor clear guidance on how those protections should be balanced against operational risk to force and mission. Until this policy gap is addressed, commanders and clinicians alike will face uncertainty that could delay or limit the integration of lifesaving data.

Cumbersome documentation tools. Beyond the uniqueness of medical data is the variety of mediums for medical data. During times of chaotic and highly kinetic activity (like during a firefight or after an explosion), medical documentation, if it occurs at all, is on paper. Figure 4 shows a handwritten transfusion medical record provided to the JTS. These records are supposed to be scanned into a web-based Theater Medical Data Store system, but many times they are not. Over the years, the JTS has received medical records from the deployed environment in boxes, envelopes, and duffle bags.

Paper records are the most common form of clinical documentation from prehospital care through Role 2 “damage control surgery.” During GWOT, much of Role 3 documentation could be done electronically, albeit in disparate data systems that did not work together in an ecosystem to produce a “provider-friendly” documentation platform across all providers and care. And with much of the clinical records on paper, this system is subject to volatility from a range of issues, including bad handwriting, missing or incomplete data, and data that is simply incorrect. One of the biggest improvements that would support the trauma system is standardized, provider-friendly documentation and electronic tools to facilitate documentation.

The JTS accesses at least ten different data sources to identify, review, and abstract clinical information from the medical records into the DODTR.¹¹ This is a labor-intensive, manual process that requires trained individuals to normalize and standardize the clinical data. Complicating this process is that medical documentation is not uniform and comes from multiple different data sources to include the handwritten TCCC cards, operative notes (narrative) written by Role 2 surgeons, MEDEVAC records, etc. These documentation processes—which lack standardization and may be handwritten, photos, or typed—make evidenced-based MPO a challenge and completely dependent on data abstraction from each medical record.

MPO is a comprehensive effort that entails the use of CCC injury and treatment data to conduct performance improvement informing doctrine, organization, training, materiel, leadership and education, personnel, and facilities solutions in addition to clinical care and clinical practice guidelines.¹² The DODTR underpins the JTS and houses data on over ninety thousand combat casualties, which enabled better casualty outcomes during GWOT. Figure 5 depicts various changes, driven by the JTS, over time. Of note, the gray trend shows the decline in the CFR over time as more lessons were implemented.

Medical documentation, on and off the battlefield, is about creating and leveraging data. Documentation has the primary purpose of ensuring high-quality clinical care—recording the care delivered and facilitating communication among the provider teams. The data underpinning documentation takes many forms, such as doctor’s notes, audio files, transcriptions, prescriptions, electronic health records, and tactical notes.

Like our mission command systems, medical systems during GWOT never had the opportunity to simply stop and reset. Instead, they evolved into a patchwork architecture, held together with “duct tape and bubble gum,” where emerging technologies were unevenly layered atop a sea of outdated systems. The result has been cumbersome platforms that often require excessive training just to achieve basic proficiency, further complicating efforts to modernize and integrate battlefield medical capabilities.¹³ These capabilities have lacked the integration of users and our clinical and operational expertise steadily guiding the development, leading to unwieldly and sometimes unusable systems. The JTS, despite being the DoW’s statutory designated “reference body for trauma care,” is not the solution owner for CCC.¹⁴

While the JTS is centralized, the implementation of documentation is highly fragmented. For example, the Battlefield Assisted Trauma Distributed Observation Kit point-of-injury software tool was originally developed in 2015 for frontline medics and was functional. Fully deployed in 2019 after multiple process iterations, the system remains inextricably complicated, built largely to the specifications of informaticists and nonclinical developers rather than the frontline medical providers who depend on it. As a result, the very clinicians who were meant to benefit from this tool are now often unwilling, or in many cases unable, to use it effectively.

Similarly, “brick and mortar” nurses and physicians who have never deployed and who lack knowledge of the operational environment and the clinical care delivered (and documented) in complex tactical environments have oversight of the development of these documentation tools. This results in unrealistic expectations for documentation. An example of this was when a senior medical officer insisted that medics document a full “PAMPI”—a medical history to include problems, allergies, medications, procedures, and immunizations—and behavior health visits prior to placing a tourniquet on a bleeding casualty.

Given the complexity and tedium of documentation (it is the most laborious and least rewarding part of the job), electronic tools must be made feasible and acceptable for providers. To illustrate this, if a trauma surgeon operates on ten casualties at a Role 2 care facility, they have a series of tasks, all of which require the use of previous clinical notes and generation of new documentation. The surgeon runs the resuscitations, decides to go to the operating room, performs the operation, and writes the postoperative orders; afterward, the surgeon must do the paperwork—the documentation. Documentation is laborious, time consuming, and is not direct bedside patient care; it is the “ankle-biter” that all providers must perform as part of their duty. Documentation occurs after the care is delivered for medics, en route care providers, and surgeons.

Without effective electronic documentation tools, providers will inevitably revert to paper records—or worse, jotting critical information on scrubs, uniforms, scraps of paper, or even the patient (figure 6). When clinical data cannot be captured and moved effectively, the JTS’s ability to generate best-practice guidelines and conduct meaningful MPO is severely hindered.

The stakes are even higher in LSCO. If casualty data cannot reach a tactical operations center, where commanders make time-sensitive decisions, the battlefield trauma system itself becomes degraded. This not only undermines clinical care—resulting in preventable deaths—but also disrupts other warfighting functions by depriving commanders of the situational awareness required to allocate resources, synchronize operations, and maintain combat power.

Evolving CCC Data to Support the Modern Battlefield

CCC data can be understood across three phases (designated as left of boom, at boom, and right of boom) and three domains (tactical, operational, and strategic) as depicted in figures 7 and 8.

• Left of boom (before an event that produces casualties) is where readiness and preparedness are realized. This includes implementing tools and lessons learned in advance, ensuring logistics are in place, and understanding where and how care can be delivered.
• At boom (the point of injury or event) is where the true value of an integrated battlefield trauma system is realized by enabling immediate data capture of the tactical data set to be used as a commander’s decision tool enabling rapid decision-making for battlefield support, resource distribution, and timely medical intervention.
• Right of boom (after casualties occur) is where observations are collected from clinical documentation to inform the strategic data set. Lessons are updated (clinical practice guidelines and TCCC guidelines), MPO is executed, and plans are refined for future battlefield medical care delivery.

In LSCO, where casualty numbers will be higher, communications more degraded, and mobility more contested, the fusion of these domains into one adaptive battlefield trauma system is imperative. Such a system must be able to see, sense, and respond to injuries as they unfold, ensuring data and care are synchronized across all levels of war.

Good data empowers the JTS to drive lifesaving care, enhance operational effectiveness, and maintain force readiness. While the JTS compiles vital battlefield data, the current processes for adapting systems to create the strategic data set and take advantage of modern data are too slow. The future operational environment requires a faster, more adaptable battlefield trauma system that is capable of transforming raw information into actionable insights that refine trauma care protocols and improve casualty outcomes.

Next-Generation Trauma Registry: Optimizing Data Relative to Boom

To be fully effective with data modernization, CCC data must be integrated into commanders’ mission command processes and systems as part of the maneuver commander’s tools for battlefield situational awareness and resource allocation (tactical data set at boom). The tasks are clear: data from documentation should be standardized at creation and easily accessible in a common way across the operational medicine ecosystem. This will enable common care with clinical data for Role 1 through Role 4 care.¹⁵

On top of the above foundational issues, the current rate of data extraction and abstraction that the JTS can move into DODTR (the strategic data set) is 1.7 to 2.6 full cases per day per abstractor.¹⁶ The human capital and time required to manually extract and abstract data from the clinical records will not be feasible given the casualty volume anticipated during LSCO. Casualty modeling indicates that the JTS would need six hundred to nine hundred fully trained data abstractors (1,020-2,340 cases/day) on day one of LSCO to simply maintain a three-to-six-month backlog of data entry into the DODTR.

The entire battlefield trauma system must evolve to address the increasing complexity and volume of data to ensure integration occurs faster than current processes allow. Technical solutions to support this must (1) automate the extraction of medical records from unstructured data to support the tactical, operational, and strategic data sets into a common data model; (2) improve data integration into the DODTR in a traceable way; and (3) boost the quality and reliability of data access to accelerate MPO processes. Currently, the JTS is working with DoW and technology partners to allow for the automation of data from multiple systems for abstraction and analysis. However, the engineering timelines are slow, and they lack the integration of automation tools to help automate the abstraction of text from PDFs or other paper documentation.

The next generation DODTR is the System for Injury and Outcomes Monitoring Nexus (SIMON). It is intended to allow for seamless data acquisition, integration, and analysis at boom and right of boom to rapidly enable each domain of data for both operational decision support and MPO. SIMON’s development aligns with the DoW’s strategic objectives to improve medical readiness and operational capability by ensuring that trauma data is captured accurately, efficiently, and in near real-time. The current DODTR has been moved into a common data model (CDM) with standardized tables, data fields, and vocabularies but is hindered by the “front-end” data collection and normalization.

SIMON will leverage a data fabric deployed on cloud infrastructure, allowing access to data and the necessary controls to protect PII and other unique medical data. The architecture will automate ingestion of source records from various systems and in various formats (Theater Medical Data Store, Operational Medicine Data Service, MHS Information Portal, etc.) and store normalized data in an object store. Validation of the records will be a combination of human validation where necessary and automated validation where possible through optical character recognition and natural language processing. Source records are automatically mastered, deduplicated, and evaluated with a data quality engine, then mapped to the CDM and stored in a trauma-specific data mart. All data coming into SIMON will come into this CDM, and the new trauma registry capability will allow users and auditors to read, audit (write), and finalize extracted data.

Information in the specific data marts will be made available for units and theaters to use on their common operational picture. Once the end-to-end data pipeline for the trauma system is clearly established, it paves the way for other data marts, such as a NATO-specific trauma registry, heat injury-specific registry, or global health engagement-specific registry, etc. This approach is essential to empower the Army’s Next-Generation Command and Control and enable ground commanders to have rapid access to the tactical and operational data sets and situational awareness tools to help inform and allocate battlefield resources and understand emerging battlefield health threats.

To enable this, SIMON will have two pathways for data flow. The first is into the clinical system that is currently being managed by Joint Operational Medicine Information Systems and into an integrated, modular operational data system. The second is moving trauma data from the SIMON to external mission command systems enabling the integration of vital CCC data into a broader network that supports decision-making on and off the battlefield.

As discussed in the challenges section, the uniqueness of medical data often hinders sharing. To address this, figure 9 shows how a minimum data set from SIMON, cleared of HIPAA and PII restrictions, will support operations. This minimum data includes medical personnel (medics, surgeons, nurses); casualty status with real-time data on casualties; their triage levels, locations, and statuses (e.g., awaiting evacuation, in treatment, stabilized); medical resource availability; and evacuation capabilities (availability and readiness of evacuation assets, routes, and capacity to handle casualties in transit).

Access to SIMON data will ensure trauma data remains accessible in hostile or compromised communications environments. By using automated data prioritization, commanders can maintain access to critical CCC insights, adjusting tactics to protect forces based on real-time health and readiness assessments. While the integration of SIMON on the operational network has clear benefits, particularly for enhancing accessibility to maneuver commanders and ensuring continuity of care during high-tempo operations, the insurance of HIPAA compliance and patient privacy would have to be mitigated with data governance, architecture, and stewardship.

Conclusion

The challenges of a future LSCO lie in the sheer scale and complexity of modern warfare. With larger forces, more extensive operational areas, and a contested information environment, the need for a coordinated, integrated, and data-driven trauma system becomes more critical than ever. Addressing these challenges requires a multifaceted approach that combines technological advancement, policy reform, trauma system expertise, and sustained investment in medical infrastructure.

Despite years of bottom-up work and impacts on data-driven CCC, the JTS remains a mostly unknown capability across the joint force. The JTS still relies heavily on manual data entry and does not operate at machine speed. Medical data systems remain siloed, leaving the United States without a fast, agile, data-driven, and threat-informed trauma system. The successes of GWOT, reflected in decreased CFR, occurred in an environment where the United States controlled most operational variables and had unfettered access to airspace and resources—conditions that will not exist in LSCO. For context, historical data shows a CFR of 19.1 percent in World War II, compared to 7.6 percent during GWOT. Without a connected and functional trauma system, LSCO could result in thousands of preventable deaths, as fragmented and isolated data systems hinder the integration of medical information into operational decision-making.

If the battlefield trauma system collapses during LSCO, it will jeopardize not only the care of individual soldiers but also the success of the mission itself. The longer the DoW delays codifying a globally integrated, data-driven trauma system to support the multidomain battlefield against a peer adversary, the longer it will take to realize the desired outcomes. That delay will almost certainly translate into unacceptable deaths from survivable injuries, diminished combat effectiveness, and a reduced ability to sustain a lethal force in LSCO.

 

The authors would like to acknowledge the contributions to this article of Brig. Gen. Jonathan Craig Taylor, Col. Scott D. Wence, and Dr. Jonathan Stallings.

 

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Notes

1. “History,” Joint Trauma System, updated 5 March 2019, https://jts.health.mil/index.cfm/about/origins.
2. Brian J. Eastridge et al., “Death on the Battlefield (2001–2011): Implications for the Future of Combat Casualty Care,” Journal of Trauma and Acute Care Surgery 73, no. 6 Suppl. 5 (2012): S431–S437; Matthew Martin et al., “An Analysis of In-Hospital Deaths at a Modern Combat Support Hospital,” Journal of Trauma and Acute Care Surgery 66, no. S4 (2009): S51–S61.
3. Department of Defense (DOD) Instruction 6040.47, Joint Trauma System (Office of the Under Secretary of Defense for Personnel and Readiness, 28 September 2016).
4. John B. Holcomb et al., “Understanding Combat Casualty Care Statistics,” Journal of Trauma and Acute Care Surgery 60, no. 2 (2006): 397–401; Robert Gates, memorandum for commander, U.S. Central Command, “Afghanistan MEDEVAC Assessment,” 15 June 2009.
5. Clinical practice guidelines are like recipe books for medics, doctors, and nurses. They give step-by-step advice on the best ways to take care of injured patients. These guidelines are based on research, evidence-based data from combat casualty care (CCC), and experience, so doctors/medics can be sure they’re doing what works best for CCC. For example, if a service member has a serious battlefield injury, tactical combat casualty care guidelines tell the medic exactly how to stop bleeding, treat pain, and manage the injury safely. It helps make sure every service member gets high-quality care, no matter which combatant command they are injured in or which medic or physician cares for them.
6. Brian J. Eastridge et al., “Utilizing a Trauma Systems Approach to Benchmark and Improve Combat Casualty Care,” Journal of Trauma and Acute Care Surgery 69, no. S1 (2010): S5–S9.
7. Jeffrey T. Howard et al., “Use of Combat Casualty Care Data to Assess the US Military Trauma System during the Afghanistan and Iraq Conflicts, 2001–2017,” Journal of American Medical Association Surgery 154, no. 7 (2019): 600–8.
8. James N. Mattis, memorandum for chief of staff, U.S. Army; chief of naval operations; chief of staff, U.S. Air Force; and commandant, U.S. Marine Corps, “Killed in Action (KIA) Reduction Initiative,” 18 January 2013.
9. Jennifer M. Gurney et al., “The ‘Survival Chain’: Medical Support to Military Operations on the Future Battlefield,” Joint Force Quarterly 112 (1st Quarter, 2024): 94–99.
10. Whitney Wetsig, “Popular AFRL Invention Supports Joint Military Needs with Mobile Medical Documentation,” U.S. Air Force, 3 September 2023, https://www.af.mil/News/Article-Display/Article/3510960/popular-afrl-invention-supports-joint-military-needs-with-mobile-medical-docume/.
11. For example, inputs into the DOD Trauma Registry (DODTR) include but are not limited to the Theater Medical Data Store (TMDS), the Defense Enrollment Eligibility Reporting System (DEERS), the Tri-Service Automated Cost Engineering System (TRACES), and the Joint Longitudinal Viewer (JLV).
12. Howard et al., “Use of Combat Casualty Care Data”; “Joint Trauma System,” Department of War Center of Excellence for Trauma, accessed 18 November 2025, https://jts.health.mil/.
13. One example of this is MHS Genesis, “the Military Health System’s modern electronic health record that provides a single health record for service members, veterans, and their families.” “MHS Genesis: The Electronic Health Record,” Military Health System, accessed 21 November 2025, https://www.health.mil/Military-Health-Topics/Technology/MHS-GENESIS.
14. DOD Instruction 6040.47, Joint Trauma System.
15. Role 1 care provides medical treatment, initial trauma care, and forward resuscitation, not including surgical care.
16. An abstractor is an individual trained in medical coding that goes into each record and pulls out the data elements and enters them into the DODTR. This is a manual and labor-intensive process.

 

 

 

 

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January-February 2026