The Military Health System's Joint Trauma System is an example of the "Learning Health System" concept, which was first introduced by the Institutes of Medicine in 2013.
Courtesy of Jessica C. Rivera, MD


Published 11/1/2017
Jessica C. Rivera, MD; Mary Ann Spott, PhD; Renee M. Greer, RN; Anthony E. Johnson, MD

EWI XII Highlights Joint Learning

Orthopaedic stakeholders provide response to the National Trauma System

The 12th Extremity War Injuries Symposium (EWI)—hosted by the AAOS, the Orthopaedic Trauma Association, the Society of Military Orthopaedic Surgeons, and the Orthopaedic Research Society—was held earlier this year. EWI XII focused on the lessons of war and how the military and civilian trauma communities can move forward together, based on joint learning.

EWI XII was a collaborative event, with military and civilian orthopaedic and general surgery trauma stakeholders joining forces to synthesize a collective response to the National Trauma System, which was proposed in a report from the National Academies of Sciences, Engineering, and Medicine.

The National Academies report
A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury is the result of an independent panel review of the current state of trauma care. The report concludes with 11 recommendations on the requirements for establishing an integrated trauma system.

The report also addresses how such a system must also provide for the continuum of care following injury toward decreasing disability. Military orthopaedics has made great leaps in understanding impairment and disability following combat injury. While general surgery traumatologists have traditionally plotted the larger strategies around trauma care, given that the long-term sequelae of combat trauma fall heavily on us in orthopaedics and our rehabilitation colleagues, we must be more proactive in this arena.

The concept of the "Learning Health System," introduced by the Institutes of Medicine in 2013, provided a backdrop to the report, enabling the panel to discuss recommendations for how care practices should evolve based on evidence. The Military Health System's Joint Trauma System (JTS), as implemented at Fort Sam Houston, Texas, provides an example of what this looks like for trauma care and process improvement.

Over the course of conflicts in Iraq and Afghanistan, the JTS has leveraged the robust Department of Defense Trauma Registry (DoDTR) to assess care delivered to wounded service members and has used outcome information to generate and promulgate trauma clinical practice and critical care air transport guidelines. Currently, 46 guidelines address a spectrum of injuries. The guidelines have evolved as the data on combat outcomes, namely survival, have informed them.

The Military Orthopaedic Trauma Registry
The implications of the report for an orthopaedic surgeon may be difficult to define outside of the encouragement to connect more effectively with general surgery trauma colleagues. However, the Military Orthopaedic Trauma Registry (MOTR) provides an example of the JTS' capability in a learning healthcare system as it is a platform for continuous improvement, innovation, and knowledge advancement.

The report's Recommendation #5 calls for a joint effort among government, military, and civilian trauma systems to "collect and share common data spanning the entire continuum of care." It also recommends that measures and outcome data be accessible and useful. MOTR is already accomplishing this in several ways.

First, MOTR provides a platform for compiling data across the continuum of care. It includes care documented in "far-forward" hospital locations near the point of injury, as well as care received at each hospital along the transport chain back to the United States, the comprehensive care received in Department of Defense (DoD) facilities stateside, to the last follow-up, for example, the Veteran's Affairs medical record (if available). This care-continuum timeline documents an injured service member's initial trauma care and rehabilitation as well as the aftercare provided for secondary health effects from the trauma and any emerging chronic conditions.

Second, MOTR is directly linked to the DoDTR, which collects intake data and initial laboratory results, vital signs, blood products, and other data. This data merging not only prevents duplication of effort but also serves as an example of how information technology can support integrated programs when integration is part of the initial infrastructure. MOTR also has the ability to integrate en route care data, other databases that include patient-reported outcomes, and medical examiner data.

In addition to the DoDTR, MOTR is actively collaborating with the Trauma Infectious Disease Outcomes Study, the Global War on Terrorism Vascular Injury study, and the Military Extremity Trauma Amputation/Limb Salvage II study. Furthermore, MOTR is a collaboration partner with the National Quality Registry Network (NQRN), a voluntary network of organizations operating registries and others interested in increasing the usefulness of clinical registries to measure and improve patient health outcomes. The NQRN is an initiative of the Physician Consortium for Performance Improvement of the American Medical Association.

Third, Recommendation #5 calls for making data accessible to relevant providers. As with the DoDTR, the JTS can analyze internal data specifically for process improvement and to share those data with the DoD and other federal collaborators for research.

This capability enables MOTR to support the following additional recommendations of the report:

  • Recommendation #6: To support the development, continuous refinement, and dissemination of best practices. MOTR representatives participate in a weekly combat casualty care conference, a forum intended to provide deployed providers feedback proximal to the time of the rendered care and monitor the use and utility of deployed clinical practice guidelines (CPGs). The JTS supports CPGs on acute compartment syndrome, amputation wounds and high bilateral amputation injuries, cervical and thoracolumbar spine injuries, extremity fractures, pelvic fractures, management of war wounds, infection prevention in combat-related injuries, and invasive fungal infections. MOTR data will continue to support the compliance and effectiveness monitoring of these and future orthopaedic-related CPGs.
  • Recommendation #7: To strengthen trauma research. MOTR data have already been presented in national forums such as the EWI symposia, the Military Health Systems Research Symposia, and the annual meetings of the Society of Military Orthopaedic Surgeons. Beyond military specific venues, the JTS practices and technology can also transfer into civilian trauma care.
  • Recommendation #9: To participate in structured trauma quality improvement processes. Aside from the weekly combat casualty care conference supporting Recommendation #6, MOTR representatives participate in several other forums related to process improvement such as regular mortality conferences. The JTS CPGs each contain monitoring metrics so they may be reevaluated and improved, based on pertinent data collected by MOTR.

The National Academies Report offers the trauma and orthopaedic communities with an important opportunity. Improvements in the care offered trauma patients requires increased cooperation between providers and specialties. Regardless of how proximal or distal that care is to the point of injury, optimization requires data. A learning healthcare system is one willing to evolve based on these principles. Thanks to the original vision of EWI, MOTR's capabilities are in line with the National Academies' report's recommendations in several ways, positioning JTS and MOTR to help lead the way forward.

Jessica C. Rivera, MD, is the division chief of research for the San Antonio Military Medical Center department of orthopaedic surgery and MOTR cocustodian. Mary Ann Spott, PhD, is the deputy director of the JTS. Renee M. Greer, RN, is the branch chief of the MOTR within the JTS. Anthony E. Johnson, MD, chairs the San Antonio Military Medical Center department of orthopaedic surgery and is a MOTR custodian.


  1. National Academies of Sciences, Engineering, and Medicine. 2016 A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. Washington, DC: The National Academies Press. Accessed at:
  2. Cross JC, Ficke JR, Hsu JR, Masini BD, Wenke JC:. Battlefield orthopaedic injuries cause the majority of long-term disabilities. J Am Acad Orthop Surg 2011;19 Suppl 1:S1-S7.
  3. Institute of Medicine. 2007. The Learning Healthcare System: Workshop Summary. Washington, DC: The National Academies Press.
  4. The JTS Operational Cycle. Accessed at: (Should be used as credit line for graphic)
  5. Stinner DJ, Johnson AE, Pollak A, et al: 'Zero Preventable Deaths and Minimizing Disability' – The challenge set forth by the National Academies of Sciences, Engineering, and Medicine. J Orthop Trauma 2017; 31(4):e110-e115.