CHIPS Articles: Electronic documentation for patient encounters during USNS Comfort's humanitarian assistance deployment

The U.S. military has been performing humanitarian missions since the end of the Cold War, sometimes in a support role to other agencies, often as the lead agency. Medical missions are typically, short-term, occur outside of the continental United States and involve the U.S. military providing care to large numbers of patients.

These missions are an integral part of national security. They serve as a deterrent to conflict because a forward military presence enhances peaceful cooperation and contributes to regional stability.

Department of Defense Directive 3000.05, "Military Support for Stability, Security, Transition, and Reconstruction (SSTR) Operations," states that stability operations have a priority status comparable to combat operations. It also mandates that we develop measures of effectiveness that evaluate progress in achieving the mission's goals.

But despite the large number of missions over the past decade, there is a dearth of information in the literature regarding patient encounters. The few publications that are available show that data collection techniques vary widely and are laced with problems.

In 2007, USNS Comfort (T-AH 20) completed a four-month humanitarian assistance deployment as part of the President's policy on "Advancing the Cause of Social Justice in the Western Hemisphere." This narrative will provide historical background, describe the method used by the crew to document patient encounters and discuss lessons learned.

Accurate clinical documentation is imperative to monitor and evaluate patient care and assess effectiveness. We welcome help from the technology community to develop tools to aid in this effort.

Problems Identified

In a "Descriptive analysis of patient encounter data from the Fleet Hospital FIVE humanitarian relief mission in Haiti," from the Naval Health Research Center (NHRC), San Diego, researchers describe using paper free-text forms and pencil to document the diagnosis and treatment of patients during a 1997 deployment to Haiti. The report outlines the limitations in this method, including illegible handwriting, lack of conformity of language and many form areas left blank.

For a later study from 2001, researchers collected patient encounter data from Naval Medical Center San Diego (NMCSD) physicians who traveled with a nongovernmental organization (NGO), HELPS International, on a humanitarian assistance mission to Guatemala. The completed forms were entered into an electronic database and analyzed by NHRC San Diego.

Although the study, "Documenting Patient encounters during a humanitarian assistance mission to Guatemala," showed that a revised, forced-choice patient encounter form alleviated the problems of illegibility and nonstandard language often found in free-text forms, there were still problems because this method did not successfully link diagnostic data with treatment and prescription information, and often diagnoses were miscoded. Data were collected on diagnoses, treatments, medications, surgeries and type of provider specialty.

In the experience of the 48th Combat Support Hospital's 2003 deployment to Afghanistan, an eponymous report revealed similar findings. Data were collected using a paper and pencil method. Demographics were collected at the nursing triage station. The medical care providers documented the chief complaint, examination, diagnosis and treatment on the reverse side of the same form after each encounter.

Data were later compiled, and the results entered by hand into an electronic database. Limitations included incomplete forms, subjective analyses of patient conditions and small sample size.

In January 2005, West Coast-based USNS Mercy (T-AH 19) sailed to the Philippines and Indonesia where care was provided to 100,000 victims of the catastrophic tsunami. Various tools were used to capture patient data. Shipboard care data were captured without issue using the Composite Health Care System (CHCS).

Care data ashore were designed to be captured using the Army’s Battlefield Medical Information System–Telemedicine (BMIS-T), the CHCS2-T system and NHRC’s Access database. However, several problems were identified, including inadequate training for BMIS-T and a lack of appropriate data fields.

BMIS-T is similar to a handheld computer with special programming developed to assist deployed medical personnel with diagnosis and treatment. It can be used to record patient clinical encounters and transmit those records to a central repository.

BMIS-T is also programmed with healthcare reference manuals and can provide medical personnel with suggested diagnosis and treatment plans.

But BMIS-T was found to be inefficient when treating large numbers of patients. Reports indicate that an alternative paper-based system was created, but lack of ownership of the process stalled implementation. An Excel spreadsheet was employed, but it only captured 9,500 patient encounters. The lesson learned from this experience is the need to continue to experiment with the various tools for docu¬menting patient encounters during humanitarian assistance missions.

The use of information management tools in the health care industry has exploded in the past decade. Electronic documentation is rapidly replacing manual documentation due to multiple advantages. Electronic medical records (EMR) offer increased access, patient confidentiality and integration with other information sources, such as laboratories and radiology consultants.

In addition, EMR eliminates the issue of lost or forgotten charts, illegible handwriting or fragmented care. Handheld platforms also offer the advantages of simplicity and portability over a desk or laptop computer.

Handhelds are ideal documentation collection devices because they are small in size, low in cost and easy to use. Handheld tools for surveillance activities are invaluable in the field because they allow providers to collect large amounts of data with immediate access.

A field comparison of handheld devices for data collection was completed in Uganda in 2004 by the World Health Organization. The evaluations measured reliability, accuracy, logistics and ease of data transfer and showed that handhelds were far superior to any other method of collecting patient data.

Further Investigation

To advance the body of research, Comfort, the Center for Disaster and Humanitarian Assistance Medicine (CDHAM) and the Western Reserve Systems Group (WRSG) jointly tested and evaluated the military application and usability of patient encounter forms uploaded into a handheld hardware platform when Comfort sailed to Latin America and the Caribbean on a four-month deployment to provide medical treatment to patients in a dozen countries in June 2007.

Handheld users were asked to evaluate and assess interface and collection performance in the following areas:
• Ability to collect and consolidate data;
• Test data transmission (ship-to-shore, shore-to-ship and OCONUS-to-CONUS); and
• Adaptability of user-developed survey and patient collection forms.

We also hoped to establish a baseline for power and logistical requirements for extended humanitarian assistance missions with the results from the survey.

Comfort’s joint forces crew included personnel from Military Sealift Command, U.S. Navy, U.S. Air Force, U.S. Coast Guard, U.S. Army and Canadian Forces, and NGOs, Project Hope and Opera¬tion Smile. Twenty-five handheld devices were received through a grant from CDHAM.

Patient encounter forms were designed for medical (adult and pediatric) primary care patients, dental and ophthalmology. Patient encounter forms were recorded using an interface developed by Case Western Reserve University. The interface was edited and approved by the administrative command of Comfort and the heads of the medical, dental and optometry departments.

Key members of the crew who used the tool were trained by a representative from CDHAM. They were given opportunities for hands-on training with follow-up sessions with the CDHAM trainer for questions and feedback. Minor modifications were made to the format based on user suggestions and group consensus.

Once underway, users were asked to provide feedback and suggest content modifications. The director of Medical Operations was also available to answer questions and troubleshoot problems. A resource manual was provided by Case Western, and representatives were available via electronic or phone communications. A quality assurance program was established to ensure user reliability and data validity.

At each of Comfort's destinations, multidisciplinary teams were deployed ashore. The number of teams sent ashore varied depending on the nation’s requests and capabilities of the host nation and Comfort’s crew. Each team had an assigned tracker who was responsible for documentation of the patient encounter.

After the teams returned to Comfort, the handheld was placed in a docking station to upload the data. Stored data from the day’s activities were then downloaded into a spreadsheet. The data were tabulated for the daily report requested by Comfort’s commanding officer.

Evaluation

The handheld’s utility in documenting patient encounter performance was measured using the Logical Framework Matrix initially developed in the 1970s in concert with CDHAM and the Defense Department's HIV/AIDS Prevention Program.

LogFrame is a tool used to clarify objectives, design activities, monitor progress and review accomplishments. Using 16 cells in a four by four project table, the LogFrame flows according to the following progression: Inputs, Activities, Outputs, Purpose and Goal. To conduct a comprehensive evaluation this log flow was integrated with the five basic concepts of monitoring and evaluation: Relevance, Effectiveness, Efficiency, Impact and Sustainability.

Simply stated, LogFrame uses a "temporal logic model" that runs through the matrix which forms a series of connected hypotheses:
• If these Activities are implemented, and these Assumptions hold true, then these Outputs will be delivered.
• If these Outputs are delivered, and these Assumptions hold true, then this Purpose will be delivered.
• If this Purpose is achieved, and these Assumptions hold true, then this Goal will be achieved.

After establishing the relevance of the project, inputs were identified which included all resources required for the mission: equipment, training and personnel.

Since the handheld devices are lightweight and portable they are ideal for field work. The waterproof encasements were important due to climatic conditions. Because use of handhelds is increasing, user training was easy.

Initial findings showed that the handheld provided a comprehensive platform obtaining all the data elements needed to accurately capture the population served (demographics) and the services provided. The interface provided area for free-text and allowed reasonable modifications.

A shortcoming identified is the need for a clear-cut definition of what constitutes a patient encounter and how that will be quantified. But while resources were used in the best possible way, there were many factors that contributed to the inefficiency of this method due to the scale of the mission.

Comfort’s crew served a staggering number of 98,000 patients, conducted 1,170 surgeries, performed 380,000 procedures, administered 32,322 immunizations, dispensed 122,245 pharmaceuticals and issued 24,242 eyeglasses. The dental department alone treated 25,000 patients.

Because of the size of the handheld’s screen the crew could only record data for one patient at a time, and they were not able to keep up with the high patient volume. After several countries were visited, the crew was directed to revert to written documentation, and the staff assigned to record data had to be increased.

Additionally, due to periodic lapses in the advanced infrastructure required to sustain connectivity, the amount of time involved in uploading data from the handheld averaged 9 minutes and frequently one-third of the devices needed to be uploaded twice each day. Both conditions were unacceptable and contributed to inefficiencies.

Discussion

Although we did not meet all of the objectives, we feel that we contributed to the body of evidence that tests the use of handheld devices for patient care in humanitarian assistance missions. By utilizing a handheld device, empirical data can be efficiently recorded and then downloaded for coding, analysis and interpretation.

However, the problems of connectivity that were encountered threaten their utility. Since humanitarian assistance missions are a Navy priority, it is imperative that we continue to plan, train and prepare to conduct and support stability operations.

A vital component in mission preparation and implementation is the ability to monitor and evaluate productivity and the effectiveness of outcomes. We feel that it is essential to pursue this trajectory of exploration and encourage and welcome as¬sistance from the technology community.

Navy Nurse Corps Lt. Cmdr. Deirdre O. Smith is the assistant medical operations officer for USNS Comfort. She has a master’s of science degree, is a Ph.D. candidate and is adult nurse practitioner board-certified.
Retired Air Force Medical Service Corps Lt. Col. Kevin Riley is the deputy director for the Center for Disaster and Humanitarian Assistance Medicine Uniformed Services University of the Health Sciences. He has a Ph.D. in international health.
Keith Curley is a principal with Western Reserve Systems Group, LLC.
Jeff A. Zimmerman is an information technology manager in the Center for Disaster and Humanitarian Assistance Medicine Uniformed Services University of the Health Sciences.
Navy Nurse Corps Retired Capt. Claire Pagliara has a Ph.D. in nursing, and is head of Research Resources in the National Naval Medical Center. She was the medical operations officer for USNS Comfort at the time the study was conducted.