The Gateway

Telebehavioral health (TBH) is becoming an increasingly popular tool for deployed medical personnel and Soldiers alike to connect across battlefields. With a vast area of responsibility that makes up the U.S. Central Command (CENTCOM), it has become vital to ensure the capability is applied consistently across theater.

Col. Carol Pierce, chief of clinical operations at the U.S. CENTCOM Surgeon’s Office, oversees the development of TBH policies for CENTCOM. As a nurse who deployed in 2008 with the MC4 system, she also recently provided input into pre-deployment training requirements for the electronic medical record (EMR) system.

Telebehavioral health has been really effective in helping providers connect with Soldiers at remote locations. What guidance has CENTCOM delivered to the field regarding this capability?
In 2011, telebehavioral health was already being utilized in Afghanistan somewhat. It was our hope to standardize policy in Afghanistan and other clinical operations across CENTCOM to expand the use of this capability.

Around January of this year [2012], Maj. Gen. William E. Rapp, deputy commander for support, United States Forces-Afghanistan, signed a policy for telebehavioral health in Afghanistan. The policy directed the use of TBH applying a hub-and-spoke concept that virtually connected locations where behavioral health providers were located to far-forward, remote sites.  The policy included measures of effectiveness and delineated standards of care. In March 2012 the U.S. CENTCOM administrative guidance for use of TBH, titled Medical Tele-Behavioral Health Care Services within the USCENTCOM Area of Responsibility (AOR), was published. The guidance encouraged services to consider TBH as a behavioral health modality in other areas within the CENTCOM AOR. The guidance identified processes for the documentation of TBH care specifying the use of diagnostic codes and practice codes to be used for tracking utilization of TBH.

Why was it necessary to standardize the use of the TBH capability?

The issue became one of processes. When there is a TBH encounter, questions about whether a consent form is necessary or determining if there are enough providers credentialed in each facility arise. We needed to standardize the processes for CENTCOM to ensure consistency and uniformity. We needed to ensure we had appropriate patient information and safety measures in effect because we don’t want to risk patient or staff when there’s an element of counseling from a distance.

From a broader IT infrastructure perspective we looked at expanding TBH and telemedicine. We set out to determine what systems we should actually be utilizing for these capabilities. We took the opportunity to offer guidance so we weren’t looking at the IT infrastructure as a limiting factor.

The CENTCOM general administrative guidance is already in the field. We also disseminated to our service counterparts to include the Army Central Command (ARCENT), Air Force Central Command (AFCENT), Marine Forces Central Command (MARCENT) and Navy Central Command (NAVCENT) and the medical treatment facilities that would most likely use it in a theater of operations. Right now, we’re working closely with Army units in Kuwait on using TBH. They’ve had the capability, but it’s not necessarily exercised a much as it could be. The 3rd Medical Support Command and the 325th Combat Support Hospital (CSH) in Kuwait are using our guidance to help execute TBH as a system and establish their own policies and procedures because the policy in Afghanistan is not applicable to Kuwait. The CENTCOM General Guidance for Telebehavioral Health is very broad. Each region implementing TBH will need to establish local policies and procedures for the day-to-day use of TBH in their practice environments.

What types of requirements have you been working on regarding pre-deployment training and the use of the Medical Situational Awareness in the Theater (MSAT)?
The CENTCOM guidance for MC4 is really focused on the clinician level and requires our physicians and nurses to participate in the standard MC4 training on clinical systems, such as AHLTA-T. I’ve worked closely with deploying medical brigades and participated in pre-deployment exercises for the last two brigades that have deployed downrange. I emphasized that as medical brigades they should be using the MC4 system, particularly the MSAT application for decision making at the brigade level and for tracking disease outbreaks in theater.

While it’s not in the CENTCOM guidance, we’ve certainly been recommending at higher headquarters that medical brigades use MSAT for their own decision-making process. When Task Force 44th Medical Brigade was in Afghanistan, I worked closely with them during their validation exercise, emphasizing that if they feel comfortable pulling data, they can make decisions without having to ask for further information from their subordinate units.

We’ve seen success with the use of this application. For example, when the Army was looking at mild traumatic brain injuries (mTBI) in theater and wanted to know the specific number of TBI occurrences, MSAT was used to pull the information instead of sending a request for information inquiry to their units. With the information extracted from MSAT, they were able to determine the actual volume of head injuries and TBIs that were occurring and from that established mTBI concussive centers and fielded MRI machines in theater.

What efforts have been made to synchronize ICD-9 codes with telebehavioral health for documentation purposes?
When we have an initiative like TBH, we want to have the ability to evaluate how we are actually using the system. In other words, if we put infrastructure in place we need to make sure we have a perspective of how often TBH is being utilized. Looking at it from a higher headquarter perspective, it would be ideal to do a query in MSAT for TBH encounters so we could see how we’re using it and where it’s being used most often in theater.

To get that theater-level view, we looked at how we should be documenting TBH in the EMRs. When we first started looking at this in Afghanistan, the policy that was currently in place stated that the first diagnostic code entered would be for TBH; the second would be the disorder the patient was seen for such as depression. The problem with this practice is that TBH is a modality, not a medical diagnosis. We provided new instructions that a provider should always use whatever the patient’s diagnosis was as the first code. Other information and the modality such as TBH should be identified by a specific V-code, or user code, following the diagnosis code.

This now allows us to use MSAT to build a report that shows how the capability is being used. We’ve put a lot of effort into TBH and it’s important to assess how it’s being used. We’re working with the chief psychiatrist in Kuwait to implement this new process. I’ve also been speaking with the senior psychiatrist in Afghanistan. Our intent will be to ultimately create an accurate query using our systems to see how TBH is being utilized. We did something very similar with tracking concussions and TBI. We can now pull reports that show the number of folks who have had concussions between certain dates.

What changes will the Army consider making based on the telebehavioral health encounter data?
The TBH data will be part of our decision-making process, especially in Afghanistan where forces are very widely distributed. In remote locations, access to in-person behavioral health practitioners is very limited because of time and safety concerns. What Afghanistan has done to overcome these challenges is establish a hub-and-spoke concept so that a provider may be in a larger location and will meet with patients at smaller locations via TBH on a scheduled basis. This will help us as we make decisions about the post-surge recovery concept in Afghanistan as we reduce our forces.

We recognize that while our medical forces expanded during the force surge efforts, they will need to be significantly reduced as forces draw down. We want to make sure that we have enough behavioral health providers available. If we can show that we can effectively use our behavioral health providers using this TBH capability, we will be able to use a hub-and-spoke concept to connect several sites and maximally use our behavioral health personnel. We can put our behavioral health personnel at larger sites and have them service the smaller sites using TBH, reducing our footprint, which is part of our strategy.

Telebehavioral health is not a substitute for in-person consultations; it’s simply an encounter using a different modality. The Public Health Command found that patients are very happy and satisfied using this capability. I think TBH has been successful because the younger generations are comfortable using communication technologies.

We continue to emphasize in CENTCOM that all patient encounters and medical care is to be documented using the EMR. I feel strongly that every encounter be an EMR encounter. With MC4, we’ve been able for the most part to ensure that the EMR is being used.

As a former MC4 user, what changes have been for the better and what areas need improvement?
One of the improvements that I’m very happy to see occur is the direct link that puts laboratory values right into the system. Radiologists are also able to write their interpretations into the MC4 system–that’s a huge positive step forward. I routinely review information using the Theater Medical Data Store (TMDS) and I’m seeing better quality laboratory and radiology reports than I have historically.

The other area that I’m really very impressed with is the development of templates for providers. It’s absolutely wonderful that there’s a template for documenting TBH interactions. These help standardize documentation processes and make it easier for new providers in theater to document care.

But there’s always room for improvement. I’ve been in Kuwait and Qatar doing quality assurance visits and the best practice I see happening in Kuwait are the weekly reviews. If for some reason a unit-level provider fails to close out a medical record, both locations have established a weekly review process to identify open records and ensure that the provider completes the record. This ensures that the patient encounter actually ends up in the patient’s medical record.

This has been a continuing problem over the years. When providers don’t close out a record, the encounter doesn’t end up going into the system and it becomes a lost record. The 325th CSH in Kuwait and the 379th Expeditionary Medical Group in Qatar have this review process in place.

Another improvement I would like to see is broader use of Dragon NaturallySpeaking. The more we use voice recognition software, the easier and quicker it will be for providers to document care.

Additionally, we need better synchronization of immunization data. Right now we have a requirement across services where the lot number and expiration date of vaccines must be documented when immunizations are administered. In theater, there is no link between the EMR system and our service specific system for immunizations. It requires dual entry to document this information and very often the Medical Protection System (MEDPROS) isn’t up to date. It would be nice to have a link established to make sure our immunization tracking through our military systems is documented without requiring dual entry.

Col. Carol Pierce, Chief Clinical Operations, U.S. Central Command Surgeon’s Office, MacDill Air Force Base, Fla.