E. Post-Gulf War Practice
Deployments in Bosnia and Southwest Asia are currently providing major opportunities for ongoing development, testing, and refinement of medical recordkeeping initiatives to resolve issues emanating from the Gulf War. Operation Joint Endeavor in Bosnia has tested improved recordkeeping proceduresand demonstrated continuing problems in documenting medical care during deployments and consolidating medical records after deployments. Significantly, these continuing deployments are occurring at the same time as traditional military medical recordkeeping is evolving into a computer-driven, health-focused, and functionally-shared (among the medical, personnel, and operational communities) information system. Access to medical records has been improved by closer cooperation between the Departments of Defense and Veterans Affairs, and the National Archives and Records Administration. A new program initiated by the Office of the Special Assistant has also facilitated veterans access to Gulf War hospital records.
A noteworthy aspect of post-Gulf War medical recordkeeping practice involves processes undertaken by the Joint Staff to ensure that the concept of force health protection is appropriately addressed through the review and update of all joint publications. Joint publications are being rewritten and theater operation plans are being revised to include force health protection requirements. In conjunction with the concept of full dimensional protection contained in the Chairman of the Joint Chiefs of Staffs Joint Vision 2010, this might be viewed as recognition of the increasingly important role of healthand medical recordkeepingin military operations.
Content of the record: Implementation of DoD policy on medical surveillance has required that deployment-related health activities (for example, pre- and post-deployment health screening assessments, health threat assessments, blood serum samples, and preventive medicine countermeasures) be documented in individual health records. As a result, the health record is transitioning from a document which was narrowly focused on medical events and clinical interventions, to a document which encompasses broader force health protection measuresand which contains more standardized information across the military medical departments. Although more force health protection information may be desirable, the amount of such information should be balanced against operational requirements. For example, a 21-question medical surveillance document initially prepared for Southwest Asia deployments was subsequently reduced to eight questions. (See Tab C.)
Uniformity of medical recordkeeping is an item of interest within the DoD as well as among other federal and non-governmental agencies. In its 1997 instruction on joint medical surveillance for deployments, the DoD directed that the pre- and post-deployment health screening assessments would be conducted on standardized forms. A 1998 policy memorandum from DoD (Health Affairs) introduced the standardized deployment health assessment forms and provided guidance on their usage. The DoD is also working actively with the VA on joint medical recordkeeping initiatives, particularly in the arena of developing a life-long, comprehensive, computer-based patient record. Members of the United States Congress have endorsed " a computerized central database for medical records during a military deployment and the use of a standardized system of recordkeeping among the military branches." Likewise, the Institute of Medicines Committee to Review Health Consequences of Service During the Persian Gulf War noted the value of a single (VA/DoD) service-connected health record.
The Presidential Advisory Committee on Gulf War Veterans Illnesses (PAC), in addition to noting DoD progress in improving medical recordkeeping in-theater and stateside, has also recommended compatibility among computerized medical recordkeeping databases and standardization of medical recordkeeping between the DoD and the VA. These recommendations are further reflected in the Action Plan of the Persian Gulf Veterans Coordinating Board, which cites numerous medical recordkeeping initiatives in response to the PACs recommendations. The initiatives include a joint DoD and VA reengineering effort to facilitate compatibility and exchange of health information, a variety of formally established VA/DoD sharing groups, and a project that successfully shared data between the DoD and the VA health information systems. Lastly, the final report of the Congressional Commission on Servicemembers and Veterans Transition Assistance comments on the importance of breaking down barriers between the DoD and the VA. The Commission also notes the need for the two agencies to move toward a closer partnership in such areas as information technology systems if they are to provide their common beneficiaries with access to a full continuum of healthcare services.
Another important aspect of uniformity in medical recordkeeping is the standardization of data. As part of a major defense-wide program, DoD (Health Affairs) is leading an effort to enhance data sharing and increase interoperability within the military health system, as well as among other defense (especially military personnel) and civilian systems. A 1998 conference sponsored by DoD (Health Affairs) brought together representatives from public and private sectors to exchange information on current initiatives and to identify future opportunities for collaboration. Standardization of health data would seem critical to the development of the computer-based patient record and the full-scale deployment of the personal information carrier. Standardization should also be an important consideration for existing paper-based military medical recordkeeping systems.
The PAC noted significant medical recordkeeping failures involving the documentation of tick-borne encephalitis (TBE) immunizations during Operations Joint Endeavor/Joint Guard in Bosnia. Citing determinations made by the Food and Drug Administration (FDA) that federal regulations pertaining to investigational products may have been violated, the PAC report included DoDs acknowledgement that difficulties of compliance with FDA regulations had been underestimated. The report also noted the DoDs formation of a committee to address future work with investigational products.
One final post-Gulf War issue touching on the content of military health records involves their role in conducting research on Gulf War illnesses. At the request of Congress, the General Accounting Office (GAO) examined the adequacy of current data sourcesincluding medical recordsto determine the incidence of tumors among Gulf War veterans. The GAO concluded that none of the data sources providing information on Gulf War veterans could be used to reliably estimate the incidence of tumors or other illnesses. DoD medical recordkeeping (in its present configuration) cannot provide many of the answers to questions surrounding certain illnesses among Gulf War veterans for the following reasons: health care may be obtained outside the DoD or VA systems; the DoDs automated system for outpatient care is not fully implemented; DoD and VA health information systems are not fully integrated; and there is currently no comprehensive life-long medical record for military personnel. In fact, the GAO believes, and the DoD concurs, that epidemiological research studies will likely continue to be needed to supplement current and future health information systems.
Consolidation of the record: Consolidation of deployment-related medical documents and information in the individual health record is essential for the accurate assessment of post-deployment health and benefits issues. At the same time, having a paper-based medical recordkeeping system, providing care at multiple and remote locations, allowing individuals to hand-carry medical documents, and using an abstracted record (e.g., the DA 8007, the AF 1480A, or the newer DD 2267) all contribute to difficulties in maintaining a complete and accurate health record for deployed personnel.
In assessing medical surveillance in Bosnia, the GAO noted continuing shortfalls in documentation of medical events and consolidation of medical records during deployments. The DoDs written response to the GAO report does not directly address the recommendation that medical personnel maintain accurate and complete medical records; however, DoD plans for a computerized medical record and a computerized dog tag were noted by the GAO in its report.
Discussions with individuals from Army National Guard units that deployed to Bosnia in 1997 parallel the GAO findings. In 1988, staff from the Office of the Special Assistant visited two military units recently returned from deployment in order to inquire about more recent experiences with medical recordkeeping. Guard personnel noted that there was a lack of documentation in the medical record of either sick call visits or influenza vaccine ("flu shots") during deployment. They also indicated that the "yellow shot records" (PHS 731) remained stateside with the individual health records, and that the abstracted health record (DA 8007) was not routinely available when they received care at deployed medical treatment facilities.
The DoD explicitly addressed the importance of consolidating deployment health documents into permanent health records through a February 1999 memorandum to the services. This memorandum reminds both line commanders and medical personnel of the need for expeditious filing of all healthcare and surveillance information in the permanent records. Additionally, each service is being asked to review its policies, sample its recently-deployed units, and report to DoD (Health Affairs) on the overall effectiveness of deployment health documentation.
Custody of the record: Significant activities have occurred since the Gulf War on custodial issues surrounding medical recordkeeping, particularly with regard to the transfer of health documents/information and the storage of medical records. Much of this activity has involved cooperative efforts among the DoD, the VA, and the NPRC. There has also been productive interchange between the military personnel and medical communities on issues of increasingly mutual interest. (While the content of individual health records generally falls under the medical community, the transfer and storage of these records is generally considered a military personnel function. )
The Joint Requirements and Integration Office within the Office of the Under Secretary of Defense for Personnel and Readiness, USD(P&R)(JR&IO), serves as a coordinating point for improving personnel-related business processes within the DoD and among the services and external agencies. This office has taken the lead on several DoD/joint service projects that have a direct impact on medical recordkeeping. These include:
The transfer of individual health records (of servicemembers leaving active duty) directly to the VA Records Management Center in St. Louis. This has substantially improved the VAs ability to respond quickly to veterans health and benefits inquiries. In 1990, for example, the amount of time required to transfer medical records of separating servicemembers to the VA ranged from 37 to 132 days; by 1994 the time ranged from 10 to 16 days. While the revised procedures simplified the records transfer process, the GAO noted in 1994 that " the possibility of medical records being misplaced, which has been a longstanding problem, remains because there are still many locations where records could be found within the new system."
The archiving of military inpatient hospital records at the National Personnel Records Center (also in St. Louis). As noted previously, the services have different policies for transferring hospital records to the NPRC. (See section III.D. Post-Gulf War Policy.) At the same time, the NPRCs process for retrieving information from these records is cumbersome and essentially requires a manual check of physical records stored in packing boxes on shelves in order to locate a specific medical record. According to senior NPRC staff, approximately 1.7 million requests for information are received each year. The NPRCs turnaround time for a request averaged seven weeks in 1998; it previously had been as long as 14 weeks. The proposed changes include standardizing the inpatient and other medical record disposition policies among the three services and developing an automated system that would create an electronic medical record index. Implementation is now targeted for early 2000.
As noted by the GAO in testimony before Congress, the availability of and access to military medical records are key components of the process by which the VA is allowed to pay disability compensation to veterans with undiagnosed illnesses under the Persian Gulf War Veterans Benefits Act. The preceding projects should further simplify and expedite this process.
The transfer of medical information and documents has likewise been an important issue during post-Gulf War deployments. Official DoD lessons-learned and after-action reports have commented on the importance of transferring documentation of treatment (e.g., records, X-rays, laboratory test results) as patients are moved through successive echelons of care. A further observation noted the importance of both documenting medical information and reporting changes in duty status and similar health-related information to commanders of deployed personnel.
Another post-Gulf War practice involving custody of medical records is a new program to help veterans in obtaining copies of their inpatient records from hospitals deployed to the Gulf. Building on an Army effort and working closely with the other military services, the VA, and the NPRC, staff from the Office of the Special Assistant visited the NPRC in June and September 1998 to identify hospital records belonging to Gulf War veterans. This initiative resulted in a database of over 25,000 inpatient records. Previously, a veteran had to know the name of the hospital and the approximate timeframe of hospitalization, since that is how the NPRC receives and files inpatient records. Now, veterans can call the Office of the Special Assistant (1-800-497-6261) for a database search and assistance in obtaining copies of their Gulf War hospital records, thus improving accessibility to these medical documents.
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