Authors
1 Health Information Management Department, Tehran University of Medical Sciences, Tehran, Iran
2 Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan
Abstract
CONTEXT: Disaster patient tracking consists of identifying and registering patients, recording data
on their medical conditions, settings priorities for evacuation of scene, locating the patients from
scene to health care centers and then till completion of treatment and discharge.
AIM: The aim of this study was to design a model of patient tracking system for natural disaster in Iran.
MATERIALS AND METHODS: This applied study was conducted in two steps in 2016. First, data
on disaster patient tracking systems used in selected countries were collected from library-printed
and electronic references and then compared. Next, a preliminary model of disaster patient tracking
system was provided using these systems and validated by Delphi technique and focus group. The
data of the fi rst step were analyzed by content analysis and those of the second step by descriptive
statistics.
RESULTS: Analysis of the comments of key information persons in three Delphi rounds, consisting
of national experts, yielded three themes, i.e., content, function, and technology, ten subthemes,
and 127 components, with consensus rate of over 75%, to provide a disaster patient tracking system
for Iran.
CONCLUSION: In Iran, there is no comprehensive process to manage the data on disaster patients.
Offering a patient tracking system can be considered a humanitarian and effective measure to promote
the process of identifying, caring for, evacuating, and transferring patients as well as documenting
and following up their medical and location conditions from scene till completion of the treatment.
Keywords
1. Rothenhaus TC, Facep M, Kamens D, Faaem MF, McClay J,
Coonan K. Emergency Department Information Systems (EDIS)
Functional Profile; EDIS Functional Profile Working Group
and Emergency Care Special Interest Group Health Level 7.
version1.02, 2007.
2. Fristoe JC. Challenges and Recommendations Towards a NationalSystem for Patient Tracking. U.S. Army War College. DTIC
Document and U.S. Department of Health & Human Services.
2010. Available from: http://www.dtic.mil/dtic/tr/fulltext/
u2/a545048.pdf. [Last accessed on 2016 Jul 26].
3. Practitioner Steering Group and STEP Steering Committee.
Emergency Data Exchange Language (EDXL); Emergency
Patient Tracking Data & Messaging Standards. Evolution
Technologies, Inc. at the direction of the DHS S & T-OIC EDXL
Program, 2009.
4. Quinn NM. A model for nationwide patient tracking. MSc Thesis.
Monterey University, California: Naval Postgraduate School;
2009.
5. Pennathur PR, Cao D, Sui Z, Lin L, Bisantz AM, Fairbanks RJ, et al.
Development of a simulation environment to study emergency
department information technology. Simul Healthc 2010;5:103-11.
6. Sidler M, Jackowski C, Dirnhofer R, Vock P, Thali M.
Use of multislice computed tomography in disaster victim
identifi cation – Advantages and limitations. Forensic Sci Int
2007;169:118-28.
7. Walderhaug S, Meland PH, Mikalsen M, Sagen T, Brevik JI.
Evacuation support system for improved medical documentation
and information fl ow in the fi eld. Int J Med Inform 2008;77:137-51.
8. Tom Rich PB, Zane R, Hassol A, Savitz L, Warren M.
Recommendations for a National Mass Patient and Evacuee
Movement, Regulating, and Tracking System. Contract
No. 290-00-0003, Task Order No. 12. USA: Agency for Healthcare
Research and Quality; 2005.
9. Pate BL. Identifying and tracking disaster victims: State-of-the-art
technology review. Fam Community Health 2008;31:23-34.
10. Turcu C, Popa V, editors. An RFID-Based System for Emergency
Health Care Services. International Conference on Advanced
Information Networking and Applications Workshops. IEEE;
May 2009.P: 624-9.
11. Marres GM, Taal L, Bemelman M, Bouman J, Leenen LP. Online
Victim Tracking and Tracing System (ViTTS) for major incident
casualties. Prehosp Disaster Med 2013;28:445-53.
12. Tavakoli N. Yarmohammadian MH. Safdari R. Keyvanara M.
Patient tracking in earthquake emergency response in Iran:
A qualitative study. World J Emerg Med 2017;8:91-8.
13. Tavakoli N, Jahanbakhsh M, Fooladvand M. Developing health
information documentation in disaster. Int J Health Syst Disaster
Manag 2013;1:11.
14. Archnet I. Technical report-sheltering, from relief to reconstruction:
One year after the 2010 East Azerbaijan Province Earthquake
(Alireza Fallahi). International J Architectural Research
2013;7:122-9.
15. Mmzfskssa MR. A review of health managers’ experiences with
challenges of aiding in Bam earthquake: A qualitative study. J Mil
Med 2013;15:225-32.
16. Rathore FA, Gosney JE, Raissi GR, Li J. Experience and
preparedness of major incidents in developing countries. Disaster
Med Public Health Prep 2013;7:127-8.
17. White D. Advanced Health and Disaster Aid Network Final
Report. Contract No. NSTD-07-896. USA: Johns Hopkins
University Applied Physics Laboratory, Medicine NLo, Health
NIo; 2007.
18. Berg WR. A case study on the need for and availability of patient
tracking systems. Monterey, California: Naval Postgraduate
School; 2007.
19. Jahanbakhsh M, Tavakoli N, Hadadpour A. Designing disaster
victims’medical record; a step toward crisis management. Health
Inf Manag 2011; 17(4); 400-409.
20. Chan TC, Griswold WG, Buono C, Kirsh D, Lyon J, Killeen JP,
et al. Impact of wireless electronic medical record system on the
quality of patient documentation by emergency fi eld responders
during a disaster mass-casualty exercise. Prehosp Disaster Med
2011;26:268-75.
21. Park H. Pervasive healthcare computing: EMR/EHR, wireless
and health monitoring. Healthc Inform Res 2011;17:89-91.
22. Aloudat A, Michael K, Yan J. Location-Based Services in
Emergency Management-from Government to Citizens: Global
Case Studies. Faculty of Informatics-Papers; 2007. p. 562.
23. Dove K. Emergency Management Information Systems:
Application of an Intranet Portal for Disaster Training and
Response. An Examination of Emerging Technologies in a Local
Emergency Operations Center. PhD Dissertation. Pepperdine
University: ProQuest; 2007.
24. FEMA. Evacuee Support Planning Guide. Contract No. 09049-2.
USA: Federal Emergency Management Agency; 2009.
25. Amin S, Cox M, Goldstein M. Using data against disasters:
Overview and synthesis of lessons learned. The International Bank
for Reconstruction and Development/The World Bank Report;
2008. p. 1.
26. George L, Foltin MG, Treiber M, Cooper A, editors. Pediatric
Disaster Preparedness: A Resource for Planning, Management
and Provision of OutofHospital Emergency Care. New York:
Center for Pediatrics Emeregency Medicine; 2008.
27. Bengtsson L, Lu X, Thorson A, Garfi eld R, von Schreeb J. Improved
response to disasters and outbreaks by tracking population
movements with mobile phone network data: A post-earthquake
geospatial study in Haiti. PLoS Med 2011;8:e1001083.
28. Enders A, Brandt Z. Using geographic information system
technology to improve emergency management and disaster
response for people with disabilities. J Disabil Policy Stud
2007;17:223-9.
29. Ondos EJ. An examination of the information technology used by
Western Pennsylvania disaster managers for disaster readiness,
response and relief efforts, and coordination. PhD Dissertation.
Robert Morris University; USA. 2007.
30. Mahdian S, Nasr M. Radio Frequency Identifi cation in Victim
Monitoring. The Third International Conference on Disaster
Management; Tehran; 2007.
31. Chan TC, Killeen J, Griswold W, Lenert L. Information technology
and emergency medical care during disasters. Acad Emerg Med
2004;11:1229-36.
32. Maltz J, C Ng T, Li D, Wang J, Wang K, Bergeron W, et al. The
Trauma Patient Tracking System: Implementing a wireless
monitoring infrastructure for emergency response. Conf Proc
IEEE Eng Med Biol Soc 2005;3:2441-6.
33. Arisoylu M, Mishra R, Rao R, Lenert LA. 802.11 wireless
infrastructure to enhance medical response to disasters. AMIA
Annu Symp Proc 2005; P: 1-5.
34. Fry EA, Lenert LA. MASCAL: RFID tracking of patients, staff and
equipment to enhance hospital response to mass casualty events.
AMIA Annu Symp Proc 2005; P: 261-5.
35. Gao T, Greenspan D, Welsh M, Juang R, Alm A. Vital signs
monitoring and patient tracking over a wireless network. Conf
Proc IEEE Eng Med Biol Soc 2005;1:102-5.
36. Lenert LA, Palmer DA, Chan TC, Rao R. An intelligent 802.11
triage tag for medical response to disasters. AMIA Annu Symp
Proc 2005; P: 440.
37. Herold S, Sawada M, Wellar B, editors. Integrating Geographic
Information Systems, Spatial Databases and the Internet:
A Framework for Disaster Management. Proceedings of the
98th Annual Canadian Institute of Geomatics Conference; 2005.
38. Aetreos LB. Rhode Island Patient Tracking System – EMT User
Guide. Department of Health Rhode Island; August, 2012.
Available from: http://health.ri.gov/publications/userguide/
PatientTrackingSystem.pdf. [Last accessed on 2016 Jun 30].
39. Kunnath AT, Pradeep P, Ramesh MV. ER-track: A wireless device
for tracking and monitoring emergency responders. Procedia
Comput Sci 2012;10:1080-5.
40. Martínez Pérez M, Cabrero-Canosa M, Vizoso Hermida J,
Carrajo García L, Llamas Gómez D, Vázquez González G, et al.Application of RFID technology in patient tracking and medication
traceability in emergency care. J Med Syst 2012;36:3983-93.
41. Chang CH. Smart MCI tracking and tracing system based on
colored active RFID triage tags. Int J Eng Bus Manag 2011;3:32-7.
42. Li P. Investigating information technologies in disasters: Three
essays on micro-blogging and free and open source software (foss)
environment: PhD Dissertation. Department of Management
Science and Systems School of Management. Buffalo University.
State University of New York; 2011.
43. Eren A, Peeters W, Farrow J, editors. The Use of Space
Technologies to Monitor and Respond to Earthquakes Economic
Perspective.3rd International Conference on Recent Advances in
Space Technologies. IEEE. June 2014.
44. Chan TC, Killeen JP, Kelly D, Guss DA. Impact of rapid entry
and accelerated care at triage on reducing emergency department
patient wait times, lengths of stay, and rate of left without being
seen. Ann Emerg Med 2005;46:491-7.
45. Lenert LA, Chan TC, Kirsh D, Kirsh D. Wireless Internet
Information System for Medical Response in Disasters. National
Library of Medicine. University of California San Diego &
California Institute for Telecommunications and Information
Technology. Final Report; February 2008.
46. Defense Statistics(Health) Bi-Annual Tracking Afghanistan VSI/
SI Operational Casualties. United Kingdom: Ministry of Defense;
2015. Available from: www.gov.uk/government/ organisations/
ministry-of defence/about/statistics. [Last accessed on 2016 Feb 26].
47. Teratani T. Public Health Emergency Preparedness and Response
in Ministry of Health, Labour and Welfare (MHLW). Offi ce of
Public Health Emergency Preparedness and Response Ministry
of Health, Labour, and Welfare (MHLW) Japan; 2014.
48. Salman YB, Cheng HI, Patterson PE. Icon and user interface design
for emergency medical information systems: A case study. Int J
Med Inform 2012;81:29-35.
49. Case T, Morrison C, Vuylsteke A. The clinical application of
mobile technology to disaster medicine. Prehosp Disaster Med
2012;27:473-80.
50. Koenig KL, Schultz CH. Koenig and Schultz’s Disaster Medicine:
Comprehensive Principles and Practices. USA: Cambridge
University Press; 2009.
51. Gao T, White D. A next generation electronic triage to aid mass
casualty emergency medical response. Conf Proc IEEE Eng Med
Biol Soc 2006 ; P: 6501-4.
52. Nasu Y, Ashida N, Kanzaki H, Sagawa S, Tsuji M. Effi cient health
information management systems using wireless communications
technology to aid disaster victims. J Med Syst 2012;36:2689-95.
53. Toshiba. Disaster and Mass Casualty Information Management
System with Smartphone and IC Tag Saiwai-ku, Kawasaki,
Kanagawa, Japan. Available from: https://www.toshiba.
co.jp/tecs/english/electronictriage_sys.html. [Last cited on
2016 Sep 06].
54. Sonoda T, Ishibaei K. Project on information-support solution in
emergency medical services. Fujitsu Sci Technol J 2015;51:39-49.
55. Hamilton J. An Internet-based bar code tracking system:
Coordination of confusion at mass casualty incidents. Disaster
Manag Response 2003;1:25-8.
56. Tia Gao, Massey T, Selavo L, Crawford D, Bor-Rong Chen,
Lorincz K, et al. The advanced health and disaster aid network:
A light-weight wireless medical system for triage. IEEE Trans
Biomed Circuits Syst 2007;1:203-16.
57. Services NH. NTF First Round Portfolio With Project Descriptions.
UK: National Health Services; 2014.
58. Fravell D. Joint Patient Tracking Application/Veterans Tracking
Application: A Joint Platform for Interdepartmental Data
Exchange. DTIC Document.U.S. Army War College, 2007.
Coonan K. Emergency Department Information Systems (EDIS)
Functional Profile; EDIS Functional Profile Working Group
and Emergency Care Special Interest Group Health Level 7.
version1.02, 2007.
2. Fristoe JC. Challenges and Recommendations Towards a NationalSystem for Patient Tracking. U.S. Army War College. DTIC
Document and U.S. Department of Health & Human Services.
2010. Available from: http://www.dtic.mil/dtic/tr/fulltext/
u2/a545048.pdf. [Last accessed on 2016 Jul 26].
3. Practitioner Steering Group and STEP Steering Committee.
Emergency Data Exchange Language (EDXL); Emergency
Patient Tracking Data & Messaging Standards. Evolution
Technologies, Inc. at the direction of the DHS S & T-OIC EDXL
Program, 2009.
4. Quinn NM. A model for nationwide patient tracking. MSc Thesis.
Monterey University, California: Naval Postgraduate School;
2009.
5. Pennathur PR, Cao D, Sui Z, Lin L, Bisantz AM, Fairbanks RJ, et al.
Development of a simulation environment to study emergency
department information technology. Simul Healthc 2010;5:103-11.
6. Sidler M, Jackowski C, Dirnhofer R, Vock P, Thali M.
Use of multislice computed tomography in disaster victim
identifi cation – Advantages and limitations. Forensic Sci Int
2007;169:118-28.
7. Walderhaug S, Meland PH, Mikalsen M, Sagen T, Brevik JI.
Evacuation support system for improved medical documentation
and information fl ow in the fi eld. Int J Med Inform 2008;77:137-51.
8. Tom Rich PB, Zane R, Hassol A, Savitz L, Warren M.
Recommendations for a National Mass Patient and Evacuee
Movement, Regulating, and Tracking System. Contract
No. 290-00-0003, Task Order No. 12. USA: Agency for Healthcare
Research and Quality; 2005.
9. Pate BL. Identifying and tracking disaster victims: State-of-the-art
technology review. Fam Community Health 2008;31:23-34.
10. Turcu C, Popa V, editors. An RFID-Based System for Emergency
Health Care Services. International Conference on Advanced
Information Networking and Applications Workshops. IEEE;
May 2009.P: 624-9.
11. Marres GM, Taal L, Bemelman M, Bouman J, Leenen LP. Online
Victim Tracking and Tracing System (ViTTS) for major incident
casualties. Prehosp Disaster Med 2013;28:445-53.
12. Tavakoli N. Yarmohammadian MH. Safdari R. Keyvanara M.
Patient tracking in earthquake emergency response in Iran:
A qualitative study. World J Emerg Med 2017;8:91-8.
13. Tavakoli N, Jahanbakhsh M, Fooladvand M. Developing health
information documentation in disaster. Int J Health Syst Disaster
Manag 2013;1:11.
14. Archnet I. Technical report-sheltering, from relief to reconstruction:
One year after the 2010 East Azerbaijan Province Earthquake
(Alireza Fallahi). International J Architectural Research
2013;7:122-9.
15. Mmzfskssa MR. A review of health managers’ experiences with
challenges of aiding in Bam earthquake: A qualitative study. J Mil
Med 2013;15:225-32.
16. Rathore FA, Gosney JE, Raissi GR, Li J. Experience and
preparedness of major incidents in developing countries. Disaster
Med Public Health Prep 2013;7:127-8.
17. White D. Advanced Health and Disaster Aid Network Final
Report. Contract No. NSTD-07-896. USA: Johns Hopkins
University Applied Physics Laboratory, Medicine NLo, Health
NIo; 2007.
18. Berg WR. A case study on the need for and availability of patient
tracking systems. Monterey, California: Naval Postgraduate
School; 2007.
19. Jahanbakhsh M, Tavakoli N, Hadadpour A. Designing disaster
victims’medical record; a step toward crisis management. Health
Inf Manag 2011; 17(4); 400-409.
20. Chan TC, Griswold WG, Buono C, Kirsh D, Lyon J, Killeen JP,
et al. Impact of wireless electronic medical record system on the
quality of patient documentation by emergency fi eld responders
during a disaster mass-casualty exercise. Prehosp Disaster Med
2011;26:268-75.
21. Park H. Pervasive healthcare computing: EMR/EHR, wireless
and health monitoring. Healthc Inform Res 2011;17:89-91.
22. Aloudat A, Michael K, Yan J. Location-Based Services in
Emergency Management-from Government to Citizens: Global
Case Studies. Faculty of Informatics-Papers; 2007. p. 562.
23. Dove K. Emergency Management Information Systems:
Application of an Intranet Portal for Disaster Training and
Response. An Examination of Emerging Technologies in a Local
Emergency Operations Center. PhD Dissertation. Pepperdine
University: ProQuest; 2007.
24. FEMA. Evacuee Support Planning Guide. Contract No. 09049-2.
USA: Federal Emergency Management Agency; 2009.
25. Amin S, Cox M, Goldstein M. Using data against disasters:
Overview and synthesis of lessons learned. The International Bank
for Reconstruction and Development/The World Bank Report;
2008. p. 1.
26. George L, Foltin MG, Treiber M, Cooper A, editors. Pediatric
Disaster Preparedness: A Resource for Planning, Management
and Provision of OutofHospital Emergency Care. New York:
Center for Pediatrics Emeregency Medicine; 2008.
27. Bengtsson L, Lu X, Thorson A, Garfi eld R, von Schreeb J. Improved
response to disasters and outbreaks by tracking population
movements with mobile phone network data: A post-earthquake
geospatial study in Haiti. PLoS Med 2011;8:e1001083.
28. Enders A, Brandt Z. Using geographic information system
technology to improve emergency management and disaster
response for people with disabilities. J Disabil Policy Stud
2007;17:223-9.
29. Ondos EJ. An examination of the information technology used by
Western Pennsylvania disaster managers for disaster readiness,
response and relief efforts, and coordination. PhD Dissertation.
Robert Morris University; USA. 2007.
30. Mahdian S, Nasr M. Radio Frequency Identifi cation in Victim
Monitoring. The Third International Conference on Disaster
Management; Tehran; 2007.
31. Chan TC, Killeen J, Griswold W, Lenert L. Information technology
and emergency medical care during disasters. Acad Emerg Med
2004;11:1229-36.
32. Maltz J, C Ng T, Li D, Wang J, Wang K, Bergeron W, et al. The
Trauma Patient Tracking System: Implementing a wireless
monitoring infrastructure for emergency response. Conf Proc
IEEE Eng Med Biol Soc 2005;3:2441-6.
33. Arisoylu M, Mishra R, Rao R, Lenert LA. 802.11 wireless
infrastructure to enhance medical response to disasters. AMIA
Annu Symp Proc 2005; P: 1-5.
34. Fry EA, Lenert LA. MASCAL: RFID tracking of patients, staff and
equipment to enhance hospital response to mass casualty events.
AMIA Annu Symp Proc 2005; P: 261-5.
35. Gao T, Greenspan D, Welsh M, Juang R, Alm A. Vital signs
monitoring and patient tracking over a wireless network. Conf
Proc IEEE Eng Med Biol Soc 2005;1:102-5.
36. Lenert LA, Palmer DA, Chan TC, Rao R. An intelligent 802.11
triage tag for medical response to disasters. AMIA Annu Symp
Proc 2005; P: 440.
37. Herold S, Sawada M, Wellar B, editors. Integrating Geographic
Information Systems, Spatial Databases and the Internet:
A Framework for Disaster Management. Proceedings of the
98th Annual Canadian Institute of Geomatics Conference; 2005.
38. Aetreos LB. Rhode Island Patient Tracking System – EMT User
Guide. Department of Health Rhode Island; August, 2012.
Available from: http://health.ri.gov/publications/userguide/
PatientTrackingSystem.pdf. [Last accessed on 2016 Jun 30].
39. Kunnath AT, Pradeep P, Ramesh MV. ER-track: A wireless device
for tracking and monitoring emergency responders. Procedia
Comput Sci 2012;10:1080-5.
40. Martínez Pérez M, Cabrero-Canosa M, Vizoso Hermida J,
Carrajo García L, Llamas Gómez D, Vázquez González G, et al.Application of RFID technology in patient tracking and medication
traceability in emergency care. J Med Syst 2012;36:3983-93.
41. Chang CH. Smart MCI tracking and tracing system based on
colored active RFID triage tags. Int J Eng Bus Manag 2011;3:32-7.
42. Li P. Investigating information technologies in disasters: Three
essays on micro-blogging and free and open source software (foss)
environment: PhD Dissertation. Department of Management
Science and Systems School of Management. Buffalo University.
State University of New York; 2011.
43. Eren A, Peeters W, Farrow J, editors. The Use of Space
Technologies to Monitor and Respond to Earthquakes Economic
Perspective.3rd International Conference on Recent Advances in
Space Technologies. IEEE. June 2014.
44. Chan TC, Killeen JP, Kelly D, Guss DA. Impact of rapid entry
and accelerated care at triage on reducing emergency department
patient wait times, lengths of stay, and rate of left without being
seen. Ann Emerg Med 2005;46:491-7.
45. Lenert LA, Chan TC, Kirsh D, Kirsh D. Wireless Internet
Information System for Medical Response in Disasters. National
Library of Medicine. University of California San Diego &
California Institute for Telecommunications and Information
Technology. Final Report; February 2008.
46. Defense Statistics(Health) Bi-Annual Tracking Afghanistan VSI/
SI Operational Casualties. United Kingdom: Ministry of Defense;
2015. Available from: www.gov.uk/government/ organisations/
ministry-of defence/about/statistics. [Last accessed on 2016 Feb 26].
47. Teratani T. Public Health Emergency Preparedness and Response
in Ministry of Health, Labour and Welfare (MHLW). Offi ce of
Public Health Emergency Preparedness and Response Ministry
of Health, Labour, and Welfare (MHLW) Japan; 2014.
48. Salman YB, Cheng HI, Patterson PE. Icon and user interface design
for emergency medical information systems: A case study. Int J
Med Inform 2012;81:29-35.
49. Case T, Morrison C, Vuylsteke A. The clinical application of
mobile technology to disaster medicine. Prehosp Disaster Med
2012;27:473-80.
50. Koenig KL, Schultz CH. Koenig and Schultz’s Disaster Medicine:
Comprehensive Principles and Practices. USA: Cambridge
University Press; 2009.
51. Gao T, White D. A next generation electronic triage to aid mass
casualty emergency medical response. Conf Proc IEEE Eng Med
Biol Soc 2006 ; P: 6501-4.
52. Nasu Y, Ashida N, Kanzaki H, Sagawa S, Tsuji M. Effi cient health
information management systems using wireless communications
technology to aid disaster victims. J Med Syst 2012;36:2689-95.
53. Toshiba. Disaster and Mass Casualty Information Management
System with Smartphone and IC Tag Saiwai-ku, Kawasaki,
Kanagawa, Japan. Available from: https://www.toshiba.
co.jp/tecs/english/electronictriage_sys.html. [Last cited on
2016 Sep 06].
54. Sonoda T, Ishibaei K. Project on information-support solution in
emergency medical services. Fujitsu Sci Technol J 2015;51:39-49.
55. Hamilton J. An Internet-based bar code tracking system:
Coordination of confusion at mass casualty incidents. Disaster
Manag Response 2003;1:25-8.
56. Tia Gao, Massey T, Selavo L, Crawford D, Bor-Rong Chen,
Lorincz K, et al. The advanced health and disaster aid network:
A light-weight wireless medical system for triage. IEEE Trans
Biomed Circuits Syst 2007;1:203-16.
57. Services NH. NTF First Round Portfolio With Project Descriptions.
UK: National Health Services; 2014.
58. Fravell D. Joint Patient Tracking Application/Veterans Tracking
Application: A Joint Platform for Interdepartmental Data
Exchange. DTIC Document.U.S. Army War College, 2007.
)