Major Shannon Ellis, a preventive medicine physician with the 1st Area Medical Laboratory, is one of 23 scientists and technicians deployed to Afghanistan to perform medical threat analysis on numerous agents that may threaten the health of Service members. With the unique mission to solve medical problems in theater, the team may be thought of as the medical crime scene investigators of the Afghanistan Theater.
Among Ellis' responsibilities is the evaluation of theater-wide medical systems. His efforts led to improved reporting capabilities of disease and injury (D&I), formerly disease and non-battle injury (DNBI), via the medical surveillance tool Medical Situational Awareness in the Theater (MSAT). By building upon the efforts of his predecessor, Lt. Col. Laura Pacha, Ellis provided greater visibility of the medical data generated throughout theater and tapped into the infrequently used dynamic data. Today, commanders have a clearer medical picture and more medical personnel understand the potential of MSAT.
Why were commanders not reviewing reports based upon dynamic data?
Previously, the process of generating reports with the dynamic data within MSAT was challenging for medical operation personnel. Basic medical queries using International Classification of Diseases Version 9 (ICD-9) codes have always been relatively easy, but no one was trending dynamic D&I data or reviewing the medical data generated throughout theater in any substantial way.
- “The bottom line is that the electronic medical record (EMR) is now being fully utilized in the manner in which it was intended.”
For example, when respiratory issues increase or gastrointestinal conditions decrease, commanders can better understand the health of their troops and respond accordingly. Previously, they only had a partial picture of their troop’s health. In addition, it was a constant challenge to remind units to do their weekly static reports, with considerable time and resources wasted to improve reporting capabilities based upon the data received.
Today, using dynamic data, units only need to complete a joining report when they arrive in theater. After a provider completes a patient encounter, the data automatically transmits to theater databases and it is ready for review. I can analyze real data from real patients receiving care from providers and physician assistants. The bottom line is that the electronic medical record (EMR) is now being fully utilized in the manner in which it was intended.
How did you increase the visibility of theater-wide medical data?
Every week, medical personnel deployed to Afghanistan generate approximately 1,200 face-to-face patient encounters. For surveillance purposes, I review these encounters for significant trends for early detection of problems with troop health.
Initially, I downloaded and combed through numerous spreadsheets generated throughout the five regions of Afghanistan. It was a slow and tedious process since global filters for each region didn't exist. Typically, commanders would create local filters based upon their local area or mission.
For example, there are approximately 500 medical reporting units dispersed throughout Afghanistan. Each commander creates a filter to monitor a set of these units. One may set a filter for 20 units and another might choose 100 units. The problem with conducting surveillance in this manner is that it doesn't offer any consistency since units rotate in and out of theater. For trending purposes, there needs to be a consistent, organized manner to view and trend the data.
One day I mentioned my frustration regarding the data compilation process to MC4's site lead for Afghanistan, Louis Carrion. I learned that his teams located throughout theater maintained partial regional filters. MC4's filters were not available globally and were not strictly organized by region. These filters were the missing key element to standardize D&I reporting. MC4's filters were constantly updated when units rotated.
I suggested to change the MC4's filters to official, globally available filters and to reorganize them by regional command (RC) boundaries. This would allow all medical personnel the ability to see and trend the same data by regions.
What did it take to push the filters out globally?
- “When I'm tracking respiratory illnesses or fevers of unknown origin and those numbers are trending up, the data shows that something is happening with the larger population.”
With permission from Louis, we reorganized the filters by region and renamed them. Each title now begins with the words Official RC, followed by the specific region. While it sounds simple, this was the key component of my efforts. It was important to have global filters to effectively trend the data. Changing the existing filters was a far better option than creating similar filters from scratch.
With the official filters in place, I was able to track the data, evaluate the trends and generate accurate charts based upon the information. I could provide a better snapshot of the medical picture throughout theater, allowing commanders to make informed decisions based upon physician-generated patient encounters.
How did commanders react to your efforts?
The reactions were very positive. When I generated the first report and presented it to the Medical Task Force Commander, Col. Donald West, he was impressed with the capabilities of the MC4 system and MSAT portal. Now, veterinarians, nurses, optometrists, mental health staff and others realize the wealth of data available to be mined and evaluated to improve the health of deployed Service members.
Previously, the higher levels of command were partially in the dark about the true state of health of their troops in the field. By spreading the word of the power of dynamic, provider-generated medical data, commanders throughout the task force have a powerful new tool to improve the health of the troops.
How does the data help to pinpoint the cause of injuries or illnesses?
One example is if a provider uses the word fever in an encounter. I can search for this word and investigate the cause of the fever. With my preventive medicine background, public health is very important to me. A fever can be from the flu, an infection or one of the numerous exotic diseases in this part of the world, such as Q fever or malaria.
When a Soldier visits a provider or physician assistant who dispenses over-the-counter medication, they're told to return the following day if the condition continues. Typically the fever does go away since the person received fever-reducing medicine. The problem is that the cause of the fever might never be known. A fever is the last thing on a Soldier's mind while being shot at and confronting explosions on the battlefield. The fever is important to me because I want to determine the root cause of the problem since some health conditions with fevers can cause long-term consequences.
When I'm tracking respiratory illnesses or fevers of unknown origin and those numbers are trending up, the data shows that something is happening with the larger population. While separate cases of fever may mean little individually, when they appear throughout theater I see a problem that requires attention.
- “I refer to this system as the honest broker in the injury reporting process, ensuring that everyone has the most comprehensive view of injuries throughout the region.”
What are some D&I issues you monitor?
One of the recent concerns has been the excessive weight of equipment that Soldiers carry. The body armor and other protective gear worn to protect Service members from blast injuries is very heavy, causing back and knee injuries. Musculoskeletal injuries are the predominant D&I trend in theater. We see trends where back pain and pinched nerves in the lower back cause incapacitating injuries. The frequency of the injuries is persistently increasing throughout the theater.
I mentioned these findings to the regional safety officers to bring light to these injuries and to help prevent further injuries. They were very excited about the power of the system. When they saw the data, they wanted training so they could review and trend similar issues. Now, they can investigate individual medical encounters for the root cause of injuries, instead of solely relying on units to report their injuries. I refer to this system as the honest broker in the injury reporting process, ensuring that everyone has the most comprehensive view of injuries throughout the region.
Other examples are injuries from vehicle rollovers and individuals who fall from bunks and injure their heads. Without this system, we would likely not be aware of these type of problems.
How do commanders utilize the surveillance reports to reallocate medical assets for the appropriate level of care?
This data has helped the Tele-behavioral Health Initiative. When I saw a spike in mental health consultations I mentioned the findings to the psychiatrists. They are then better able to schedule additional classes and therapies to these areas accordingly.