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Electronic documentation for patient encountersduring USNS Comfort's humanitarian assistance deploymentCalling on the technology community to develop more effective handheld devicesBy Navy Lt. Cmdr. Deirdre O. Smith, Retired Air Force Lt. Col. Kevin Riley, Keith Curley,Jeffery Zimmerman and Retired Navy Capt. Claire PagliaraSoft PowerThe U.S. military has been performinghumanitarian missions since the endof the Cold War, sometimes in a supportrole to other agencies, often as the leadagency. Medical missions are typically,short-term, occur outside of the continentalUnited States and involve the U.S.military providing care to large numbersof patients.These missions are an integral part ofnational security. They serve as a deterrentto conflict because a forward militarypresence enhances peaceful cooperationand contributes to regional stability.Department of Defense Directive3000.05, "Military Support for Stability,Security, Transition, and Reconstruction(SSTR) Operations," states that stabilityoperations have a priority status comparableto combat operations. It alsomandates that we develop measures ofeffectiveness that evaluate progress inachieving the mission’s goals.But despite the large number of missionsover the past decade, there is adearth of information in the literature regardingpatient encounters. The few publicationsthat are available show that datacollection techniques vary widely and arelaced with problems.In 2007, USNS Comfort (T-AH 20) completeda four-month humanitarian assistancedeployment as part of the President’spolicy on “Advancing the Cause ofSocial Justice in the Western Hemisphere.”This narrative will provide historical background,describe the method used by thecrew to document patient encountersand discuss lessons learned.Accurate clinical documentation is imperativeto monitor and evaluate patientcare and assess effectiveness. We welcomehelp from the technology communityto develop tools to aid in this effort.Problems IdentifiedIn a “Descriptive analysis of patient encounterdata from the Fleet Hospital FIVEhumanitarian relief mission in Haiti,” fromthe Naval Health Research Center (NHRC),San Diego, researchers describe usingpaper free-text forms and pencil to documentthe diagnosis and treatment of patientsduring a 1997 deployment to Haiti.The report outlines the limitations in thismethod, including illegible handwriting,lack of conformity of language and manyform areas left blank.For a later study from 2001, researcherscollected patient encounter data fromNaval Medical Center San Diego (NMCSD)physicians who traveled with a nongovernmentalorganization (NGO), HELPS International,on a humanitarian assistancemission to Guatemala. The completedforms were entered into an electronic databaseand analyzed by NHRC San Diego.Although the study, “Documenting Patientencounters during a humanitarianassistance mission to Guatemala,” showedthat a revised, forced-choice patient encounterform alleviated the problems ofillegibility and nonstandard languageoften found in free-text forms, there werestill problems because this method didnot successfully link diagnostic data withtreatment and prescription information,and often diagnoses were miscoded.Data were collected on diagnoses, treatments,medications, surgeries and type ofprovider specialty.In the experience of the 48th CombatSupport Hospital’s 2003 deployment toAfghanistan, an eponymous report revealedsimilar findings. Data were collect-Suriname (Oct. 4, 2007) -Ship's Serviceman SeamanDominique Gray, assignedto hospital ship USNS Comfort(T-AH 20), checks in apatient at the Zanderij Clinic.Comfort is on a four-monthhumanitarian deploymentto Latin America and theCaribbean providing medicaltreatment to patients ina dozen countries. U.S. Navyphoto by Mass CommunicationSpecialist 2nd ClassBrandon Shelander.ed using a paper and pencil method. Demographicswere collected at the nursingtriage station. The medical care providersdocumented the chief complaint, examination,diagnosis and treatment on thereverse side of the same form after eachencounter.Data were later compiled, and the resultsentered by hand into an electronicdatabase. Limitations included incompleteforms, subjective analyses of patientconditions and small sample size.In January 2005, West Coast-basedUSNS Mercy (T-AH 19) sailed to the Philippinesand Indonesia where care wasprovided to 100,000 victims of the catastrophictsunami. Various tools were usedto capture patient data. Shipboard caredata were captured without issue usingthe Composite Health Care System (CHCS).Care data ashore were designed tobe captured using the Army’s BattlefieldMedical Information System–Telemedicine(BMIS-T), the CHCS2-T system andNHRC’s Access database. However, severalproblems were identified, including inadequatetraining for BMIS-T and a lack ofappropriate data fields.BMIS-T is similar to a handheld computerwith special programming developedto assist deployed medical personnelwith diagnosis and treatment. It can beused to record patient clinical encountersand transmit those records to a centralrepository.BMIS-T is also programmed with healthcarereference manuals and can providemedical personnel with suggested diagnosisand treatment plans.But BMIS-T was found to be inefficientwhen treating large numbers of patients.Reports indicate that an alternative paper-basedsystem was created, but lackCHIPS October – December 2008 45