Lessons Learned Prompt Better Medical Recordkeeping

WASHINGTON, Aug. 13, 1999 (GulfLINK) -The office of the special assistant for Gulf War illnesses released today an information paper on medical recordkeeping during and after the Gulf War. This review of medical recordkeeping policies and practices was prompted by comments and concerns voiced by veterans regarding the handling of medical records during that conflict. Some veterans, for example, have commented that some of the medical care and immunizations received during Operations Desert Shield and Desert Storm were not recorded in their medical records. Still others have expressed concerns that medical information is missing from their health records, or that the records themselves could not be located.

"The Gulf War taught us it's not enough to simply care for casualties," said Dr. Bernard Rostker, the Defense Department's special assistant for Gulf War illnesses. "We should more fully document health care, maybe even hazardous exposures, to better address post-deployment health concerns among servicemembers and veterans."

With the release of this latest information paper on medical recordkeeping, analysts anticipate that veterans will have a better understanding of how recordkeeping problems may have occurred during the Gulf War. The paper also addresses post-Gulf War recordkeeping policies and practices, as well as future initiatives for improved medical records management, especially during deployments.

"Many of the recordkeeping problems associated with the Gulf War resulted from not being prepared for such a rapid, large-scale, multi-service deployment," said Tom Rupp, one of the authors of the information paper. "The DoD is now more focused on standardizing medical records and documenting the health of deployed forces."

Medical records broadly fall into two categories: individual health records and inpatient hospital records. Individual health records typically include documentation of clinic visits, diagnostic tests, physical examinations, immunizations, and summaries of inpatient care. These records represent a history of a servicemember's military health care and accompany him or her throughout their military career. Upon a servicemember's separation or retirement, the individual health records are sent to the Department of Veterans Affairs Records Management Center in St. Louis, Mo. Prior to the early-mid 1990s, individual health records were stored at the National Personnel Records Center, also located in St. Louis.

Inpatient records are created each time a servicemember is admitted to a medical treatment facility. These records document all treatments and procedures performed during hospitalization. Military service policies call for the inpatient records to be sent to the National Personnel Records Center, where they are stored under the name of the military hospital transferring the records. Inpatient records are not combined or archived with a servicemember's individual health records, but are stored in separate groups based on the individual medical facility and the year in which the hospitalization occurred.

Medical recordkeeping policies prior to the Gulf War generally focused on peacetime health services and did not appear to fully address the special requirements of maintaining a health record during deployments. For example, some servicemembers deployed with abbreviated health records while others deployed with their complete individual health record. And although there was detailed guidance on routine immunizations, investigators found the policy on the use of investigational drugs and the documentation of vaccines requiring operational security was problematic.

The rapid deployment of a large and diverse military force (including each of the active duty and Reserve components) may have contributed to problems with medical recordkeeping during the Gulf War. Concerns included the adequacy of medical records for pre-deployment screening, the deployment of abbreviated medical records, the documentation of immunizations, the transfer of deployment medical information to permanent individual health records, and the availability of - and access to - medical records after the Gulf War.

For Operations Desert Shield and Desert Storm, the Army and the Air Force directed that one-page health summary forms be prepared at the time of mobilization. These "abbreviated health records" were to be sent with deploying soldiers and airmen in place of full individual health records. Sailors and Marines, however, were to deploy with their complete health records. Information contained in after-action reports and obtained from veterans indicated that health records - full or abbreviated - and medical record forms were not always available at the time care was given.

There was also confusion during the Gulf War about how, where, and even whether vaccines such as anthrax and botulinum toxoid, and drugs like pyridostigmine bromide, would be recorded in medical records. The issue of operational security surrounded the administration of both vaccines. In addition, botulinum toxoid was an investigational product, which created additional documentation questions and concerns. Little specific guidance was provided for the documentation of pyridostigmine bromide, which was widely distributed to servicemembers and self-administered under the direction of operational commanders. Following the war, some veterans experienced difficulty locating their medical records or finding documentation of all care received in the Gulf.

In the period following the Gulf War, medical recordkeeping emphasized the documentation of deployment health-related activities and the development of automated information systems. Increasingly, the health of servicemembers is being addressed as an important element of military doctrine, plans, and directives. The Army and the Air Force have continued their policies of deploying personnel with abbreviated health records, while full health records continue to accompany Navy and Marine Corps personnel on deployments. "One of the most encouraging results of the Gulf War � from a medical recordkeeping perspective � is greater cooperation between the DoD, the VA, and the NPRC. It has made medical records more accessible for the veteran, and it needs to continue," said Rupp.

Expectations of the medical recordkeeping component of force health protection remain high as military personnel continue to deploy overseas in support of operational missions. The services now use standardized pre- and post-deployment health assessments, automated immunization tracking systems, and efforts to develop uniform records management and disposition policies during deployments.

Accessibility to medical records has improved thanks to closer cooperation between the Departments of Defense and Veterans Affairs and the National Archives and Records Administration. As part of an initiative to identify and facilitate veterans' access to their Gulf War inpatient records, staff from the special assistant's office searched through records at the National Personnel Records Center in St. Louis - permanent storage site for all records of hospitalizations in military medical facilities. The team located more than 25,000 inpatient records of deployed Gulf War servicemembers and entered the information into a database. Veterans can call OSAGWI at (800) 497-6261 for a database search and assistance in obtaining copies of their records. Since this service was offered in August 1998, nearly 200 veterans have been able to retrieve copies of their inpatient health records.

The DoD is currently looking at technology for meeting many of its medical record-keeping challenges. The computerized patient record and the personal information carrier - a dog tag-like device that holds a computer chip containing medical data - are two major cornerstones of future military recordkeeping. Each of these new technologies, however, will require substantial time and effort to acquire, deploy, and fully integrate into the existing military records systems.

"Computerized medical recording is clearly the way to go," said Rupp. "At the same time, DoD should continue improving its paper records as a foundation for - and bridge to - the future."

The Gulf War has shown that we can no longer rely solely on a traditional peacetime system of paper-based medical records, Rupp said. New medical recordkeeping initiatives and total force protection programs are essential to the health of our servicemembers and the effectiveness of our armed forces.

"Uniformity of medical recordkeeping among the military services is both achievable and desirable. It is also timely, since deployments increasingly involve closely integrated forces from all branches of the armed services and all components - active duty, National Guard and Reserve," said Rupp.