Between 20 percent and 30 percent of troops who have served combat tours in Afghanistan and Iraq suffer from mental health problems, but a Nextgov investigation shows the Army currently has no way to consistently track the mental health status of soldiers deployed to the two countries and the service finds itself overwhelmed by paper records.
An internal message sent Jan. 11 from the Army Office of the Surgeon General obtained by Nextgov said Army units in the U.S. Central Command Area of Operations, which includes Iraq and Afghanistan, have become "saturated" with paper behavioral health records because mental health providers who treat these soldiers are not entering data into the theater electronic health record known as AHLTA-T.
What's more, the Army does not have a system to scan and code these paper records to support search and retrieval from the Defense Department electronic heath record, Nextgov discovered.
This has serious implications for troops who seek follow-up mental health care when they return from deployment. The message noted, "As a result, soldiers returning from deployment are experiencing delays with continued health care and/or filing medical claims to the Department of Veterans Affairs."
Sen. Ben Cardin, D-Md., said he was "deeply concerned" the Army does not use the AHLTA-T electronic health record to track mental health encounters. In a statement to Nextgov, Cardin said:
"As a nation, we ask so much of our men and women in uniform without knowing the full extent of the mental trauma inflicted by combat, so it is discouraging to hear that within the Army [there] exists such an unmanageable backup of paper-based behavioral health records."
Cardin added, "News that the military mental health providers are failing to use the operational electronic health records, as required, only serves to exacerbate both administrative and continuity-of-care problems. I am deeply concerned that the required electronic health record is not fully utilized, and am concerned about the impact of this on our servicemen and -women's mental health."
A spokesman for the Military Health System said it is a matter of clinical practice, not policy, to record mental health encounters in AHLTA. The spokesman added that the undersecretary of Defense for personnel and readiness has chartered a work group to evaluate a policy for mental health records. This seems to conflict with the Army's published regulation on medical record administration and documentation, which requires all encounters with behavioral health specialists be recorded in AHLTA with the headings "Sensitive Clinical Note."
Read the entire Broken Warriors series.Nonetheless, the MHS spokesman said the work group will establish an official definition for a mental health record and develop a policy for retention and disposition of such records in all the services.
Veterans groups also expressed serious concerns with the Army's management of behavioral health records and urged Lt. Gen. Eric Schoomaker, the Army surgeon general, to make the issue a top priority.
The Army message on behavioral health records indicates the service plans a complex process to ship, store and eventually scan the paper records of deployed soldiers at its Patient Administration Systems and Biostatistics Activity, located at Fort Sam Houston in San Antonio.
The message directs that all "loose" paper records be collected, collated and identified by patient name and Social Security number. Any that cannot be positively identified "will be destroyed," the message said.
Records that can be identified, the message said, should be boxed up for shipment to the San Antonio facility with an electronic and hard copy inventory list, the message said.
In a response to an e-mail query from Nextgov about the disposition policy, Lt. Col. Deidra E. Briggs, medical records informatics officer in the Office of the Army Surgeon General, said scanned behavioral health records would be available to clinicians through a new technology called the Healthcare Artifact and Image Management Solution, which interfaces with the AHLTA system.
The Military Health System developed HAIMS in 2009 and 2010 for the Army, Navy and Air Force medical commands primarily to scan and store diagnostic imagery such as X-rays and MRIs.
Briggs said the patient administration systems facility in San Antonio maintains a listing of each box of behavioral health records received. The records will be scanned into an optical repository that will be linked to HAIMS. The optical repository will enable facility administrators to retrieve records upon request, she said.
But an MHS source told Nextgov on Feb. 17 that HAIMS was "not ready for prime time" as there was no budget to purchase the scanners and computers to support the deployment of the system.
In addition, the source said HAIMS had not been installed at the patient administration systems facility and estimated it would cost $17 million to buy the hardware required for a global deployment and take a least a year to install a functional system at the San Antonio facility.
A December 2010 internal newsletterof the Defense Health Information Management System, part of MHS, said nine Army, Navy and Air Force hospitals would conduct a limited user test of HAIMS Release I through June of this year.
Another Defense Health Information Management System newsletter said HAIMS will not incorporate electronic health record links until Release II is developed and fielded.
An MHS spokesman said HAIMS Release I can scan a single document at a time; Release II will enable bulk scanning. He said the deployment timeline will be based on the results of the limited user test. The MHS spokesman said the patient administration systems facility in San Antonio logically should be one of the first organizations to receive bulk scanning capabilities.
In addition, the spokesman said the 2010 budget for HAIMS was $13 million and MHS had requested a $27.5 million for the program in 2011 and $28 million in 2012.
Briggs, in an e-mail to Nextgov, acknowledged that the San Antonio facility "is not on the rollout schedule of HAIMS as yet" and added that paper behavioral health records will be "scanned into a local data repository for availability until such time it can be linked to AHLTA via HAIMS."
Joe Davis, a spokesman for the Veterans of Foreign Wars, said it appears the "Army is slow to scan the paper records into electronic health records, which could have a tremendous impact on proper care and benefits. The VFW urges the Army Surgeon General's Office to make this a top priority and not relegate it to a to-do list."
One Army doctor told Nextgov the records developed by mental health providers in the field are essential to ongoing care when soldiers return home, seek treatment at a VA hospital or file disability claims. The doctor is concerned the policy outlined in the Jan. 11 memo will make it difficult to access those records.
Though the HAIMS system promises to eventually link scanned paper mental health records to AHLTA, this doctor said that in itself offers little help to clinicians because scanned paper records are in a format that is not searchable. The MHS spokesman said the scanned files would be searchable in the future.
According to the Army doctor, a clinician will have to pull up every scanned paper record and read it before proceeding with treatment, a daunting task for clinicians faced with a heavy patient load.
Dr. Grace Jackson, a former Navy and VA psychiatrist now in private practice in Greensboro, N.C., said caring for soldiers and veterans with mental health problems requires access to accurate records of past treatment. "Competent medical care depends upon a careful delineation of past treatments," she said.
Tom Moore, program manager for Lawyers Serving Warriors, part of the National Veterans Legal Services Program, said he viewed access to comprehensive behavioral health records as vital to determining proper medical treatment.
Cardin agreed. "When we have soldiers in a war zone taking maintenance psychotropic medications, ensuring that all providers have immediate access to their recent behavioral health history is paramount," he wrote. In January, Nextgov reported that the U.S. Central Command has provided some soldiers with a 90- or 180-day supplies of highly addictive psychotropic drugs before they deployed to combat.
Jackson said the most important part of medical records maintained in the field is a chronology of drug treatments to identify potential drug interactions.
In addition, comprehensive records are essential when soldiers go before Medical Evaluation and Physical Evaluation Boards, which determine if they have long-term medical conditions that could lead to discharge from active duty. The boards also establish troops' eligibility for disability compensation, Moore said.
When it comes to evaluation of conditions related to a post-traumatic stress disorder diagnosis, Moore said if mental health providers don't have access to records, they will not be able to understand the combat stressors related to PTSD.
Moore also expressed concern that the Army message on behavioral health records applied only to troops who deployed as of Aug. 30, 2010, and he questioned what policy the service has to manage records compiled after that date.
Paul Sullivan, executive director of Veterans for Common Sense, said the Army's mismanagement of behavioral health records in Afghanistan and Iraq will jeopardize soldiers' access to mental health care at bases when they return home. Also, the Army's record-keeping risks additional delays for veterans seeking VA health care and benefits, he said.
"Failed Army leadership and a lack of accountability are causing bureaucratic nightmares for our troops," Sullivan said.