Providing Care in the Combat Environment
An interview with Colonel Patrick D. Sargent
U.S. Army Commander
Task Force 62 Medical Brigade
Multi-National Corps Iraq
Colonel Pat Sargent is Commander Task Force 62, a deployed Joint Medical Task Force, consisting of 4,000 personnel responsible for providing world-class health service support for the Iraqi theater of operations. The Task Force consists of three combat support hospitals and one Air Force hospital providing Level III care from seven dispersed locations and three multifunctional medical battalions. As the senior tactical medical commander, he anticipates force health protection support to a population at risk—450,000 personnel including coalition partners, contractors, U.S. soldiers, sailors, airmen and Marines and Iraqi Security Forces. Conduct nested medical operations, including Cooperative Medical Engagement plan across the entire Corps battlespace to increase the GOI health care system; and provide technical supervision over medical assets.
Sargent was a Distinguished Military Graduate and commissioned as an adjutant general corps officer from the Florida State University ROTC Program in 1985. His first duty assignment was with the 502nd Personnel Services Company, 2nd Armored Division; Fort Hood, Texas, where he served as the assistant chief administrative services division, company executive officer and chief, Soldier Actions Branch. In April 1987, he branch transferred to the Medical Service Corps and reported to Fort Rucker, Ala., to attend flight school and the UH-60A Transition. In October 1988, he served in Korea as a flight platoon leader and company flight operations officer with the 377th Medical Company (Air Ambulance), 52nd Medical Evacuation Battalion. Upon returning to the States in 1989, he joined the 2nd Armored Division for a second tour as the chief, Division Medical Operations Center.
Sargent deployed to Operation Desert Shield/Storm as an aeromedical evacuation pilot with the 236th Medical Company (Air Ambulance) and later commander, Charlie Company, 115th Forward Support Battalion in Saudi Arabia, and Iraq. He changed command in June 1992 to become an instructor with the Army Medical Department’s Officer Basic and Advanced Courses, Fort Sam Houston, Texas. In June 1994, he returned to Korea to become the S-2/3, 52nd Medical Evacuation Battalion. Upon returning to the States in 1995, he served as a Medical Service Corps Branch career manager in Alexandria, Va. He graduated from the U.S. Army Command and General Staff College at Fort Leavenworth, Kansas in 1997 and returned to Fort Hood, Texas.
From 1997 to 2000, Sargent served as the executive officer, 36th Medical Evacuation Battalion, 1st Medical Brigade and later commander, 507th Medical Company (Air Ambulance), 36th Medical Battalion. In April of 2000, he was selected as an Army Congressional Fellow and reassigned to Washington, D.C., serving in the Army Senate Liaison Division on Capitol Hill. In January 2001, he was selected to serve as a legislative assistant to U.S. Senator Richard J. Durbin. At the conclusion of the 106th Congress, he became the director of Congressional operations for the Army surgeon general.
From June 2002 to June 2004, Sargent was commander of the 421st Medical Evacuation Battalion, Wiesbaden, Germany, deploying to Iraq in support of Operation Iraqi Freedom. During his tenure in command his unit deployed to over 15 different countries, most notably: Afghanistan, Bosnia, Iraq and Kosovo. In July 2004, he returned to the States to attend the National War College. His most recent assignment was as the executive officer to the chief of Army Legislative Liaison, Office of the Secretary of the Army.
Sargent holds a Master of Arts degree in human resource development from Webster University, and a Master of Science degree in national security strategy from the National Defense University, and a Bachelor of Arts degree in political science from Florida State University. Sargent is a member of the Order of Military Medical Merit and Order of Saint Michael. In 2003, he was selected by the Tuskegee Airman, Inc. as their DoD recipient of the prestigious General Benjamin O. Davis Jr., National Military Award. Most recently, Sargent was awarded the Army Surgeon General’s prestigious “9A” Proficiency Designator for being eminently qualified as an aeromedical evacuation officer.
Q: Briefly describe the Task Force 62nd Medical Brigade’s mission in support of Operation Iraqi Freedom.
A: Task Force 62nd Medical Brigade [TF62 MED] is a deployed joint medical task force, consisting of 4,000 personnel responsible for providing world-class health service support for the Iraqi theater of operations. The task force consists of three combat support hospitals and one Air Force hospital providing Level III health care from seven dispersed locations and three multifunctional medical battalions covering the full spectrum of health service support within the Military Health System.
Q: What has been your focus for the task force during your unit’s OIF 07-09 rotation?
A: Historically the medical task force has focused almost exclusively on delivering a robust and accessible set of Level II and III care and force health protection support since operations began here five years ago. Immediately upon assuming the mission, we noted the task force is charged to deliver three essential dimensions of combat health support: 1) provide world-class warrior health care to U.S. and coalition forces, 2) protect the health of the U.S. and coalition forces, and 3) support self-reliant Iraqi Security Forces and government of Iraq health care and public health systems. Since the transfer of authority, I discovered two areas of great concern that compelled the task force to develop a more systematic approach to delivering world-class medical care to our warriors.
First, the high rate of turnover of units led to gaps or seams in our services. Each newly arrived unit essentially re-invented their approach to executing the mission that their predecessors had refined during their tours. This resulted in an unacceptably high degree of variance in the quality and accessibility of services across the battlespace.
Additionally, despite five years of stable positioning, security and infrastructure within our bases there were no discernable standardization of health care support, clinical quality or medical equipment beyond what the units chose to adopt.
Q: Discuss your strategy for quality healthcare improvement for the warriors in theater.
A: TF62 MED systematically implemented and rigorously executed a strategy map known as the TF62 MED Combat Healthcare Support System [CHSS] throughout the task force at the lowest unit levels. Performance improvement and patient safety are the task force’s main effort ensuring desired outcomes are realized and systematic fixes are established. Leaders ensure every member of their section or unit are able to describe how they fit into the CHSS model and support the three major purposes of the medical task force. All members of the task force are also charged to describe a specific systematic performance improvement initiative they are working on.
Q: Describe how you see this strategy impacting the Military Health System.
A: This strategy enables me and my senior leaders to show how to create a customized strategy map that allows the Task Force to:
- Clarify task force strategies and communicate them across the organization.
- Identify the key internal processes that drive strategic health service support success in the Iraqi theater of operations.
- Align the DoD’s investment in people, technology and organizational capital for the greatest impact in combat casualty care.
- Expose gaps in the Military Health System strategies and take early corrective action.
Q: Briefly describe the TF62 MED responsibilities as they relate to electronic medical records [EMR].
A: A system to document viable electronic medical records currently exists in theater. However, the medical task force needs our EMR optimized to enhance performance improvement, patient safety, risk management, disease surveillance and clinical quality/peer review.
The EMR system, as well as the program for training providers to use the Medical Communications for Combat Casualty Care [MC4], must be enhanced. Additionally the momentum achieved by the recent Theater Medical Data Server [TMDS]/Joint Patient Tracking Application [JPTA] merge, as well as the many othersystemupgradesimplementedby DHIMS, must be capitalized on…the success and timeliness of these actions must be replicated.
Our EMR must contain robust quality documentation, at all points of care, and from all medical disciplines. Additionally, this documentation must be fully queryable and be able to produce information that facilitates command decision making on all levels of medical leadership, both operational and strategic.
The strategic impact of our longitudinal EMR is the capturing of the world-class quality treatment America’s sons and daughters receive in theater and the provision of this documentation from the foxhole through Veteran’s Administration hospitals.
Q: How is this strategy impacting the quality of electronic medical record documentation in the Iraqi theater of operations?
A: Basing our objectives on the delivery of world-class health service support we have imbedded quality, performance improvement and safety into the electronic clinical documentation as part of our warrior health care system. This system provides care for our soldiers, contractors, civilians and detainees.
This quality is evident in the inpatient documentation of transferred patients where detailed notes and summaries provide accepting doctors with the clinical information that is needed to care for patients. The EMR is also being effectively used to provide a QA assessment in our peer review program where reports are read and then graded against the same professional standards that are used in civilian practice.
The importance of quality electronic documentation also has a direct affect on force health protection; data entered processes through Joint Medical Electronic Work Station [JMeWS] thereby influencing operational and strategic command decision-making. With the pending release of the Medical Situational Awareness in the Theater, the quality of JMeWS data will have increased significance in the execution of theater medical operations.
Q: Are there any differences in the documentation of behavioral health records in theater?
A: No. Electronic behavioral health records aren’t really any different from other outpatient medical records, so there really aren’t any distinct differences in the documentation trail. The main success electronic medical records documentation provides for behavioral health is establishing a permanent record of any treatment for post traumatic stress disorder or mild traumatic brain injury here in theater, improving our ability to establish a longitudinal history of such problems if the servicemember ever requires a medical evaluation board or disability evaluation.
Q: Describe several Health Information System challenges your command has witnessed in the Iraqi theater of operations.
A: EMR documentation starts with training and MC4 predeployment training is inconsistent. Predeployment MC4 training is not currently a requirement; additionally there are no formal task, conditions and standards. Training needs to be scenario-based and incorporated into MRX’s and field exercises.
90/180 Rotators
90/180dayrotatorsneedrealistictrainingbefore arriving in theater. A new Professional Filler System [PROFIS] rotation policy increases our rotator footprint by 62 percent with the deployment of the 10th Combat Support Hospital [CSH], and this number will grow upon future deploying CSHs.
MC4 Contracting Officer Representative (COR)
Furthermore these challenges have been compounded by the inconsistencies in the quality of some MC4 contractors. Exact feedback from TF62 units includes 19 reports evaluating MC4 support; 12 were favorable while seven were not favorable.
MC4 has recently confirmed their commitment to theater with the planned forward positioning of a COR as well as taking significant efforts to improve the delivery and depth of their support. We applaud and welcome this effort and thank Lieutenant Colonel Clayson and Colonel Hines for their extensive interaction and initiatives resulting in positive gains in the development of our EMR.
Strategic Theater Radiology Solution
Our theater radiology situation is another issue I would like to present. The bottom line is that the standard of care is not always met given our current radiology capability. There are approximately 12,000 radiology studies taken each month with one-third of these not being read. Additionally, none of these studies are stored in the longitudinal record. More importantly our MEDWEB servers do not have directional communication with our EMR causing inefficiencies in the provision of health care.
The Digital Health Information and Management System is undertaking an initiative to produce a strategic theater radiology solution and we look forward to the continued opportunity to contribute to this process.
Full functionality of AHLTA-T/TC2
The last issue I would like to present addresses the full functionality of our EMR. Patients are still evacuated with a stack of paper records. The Armed Forces Health Longitudinal Technology Application-Theater and the Theater Medical Information Program Composite Healthcare System Cache do not fully facilitate the documentation of the EMR to the point where the paper record can be replaced. Locally created Access and Excel solutions are used to fill parts of this void. A more robust documentation tool is required.
Q: Discuss your command’s efforts to improve these challenges.
A: TF62 has aggressively pursued the electronic documentation of care in the Iraqi theater of operations. Through the development of policy and changes in business practices electronic inpatient documentation in the past year has approximately equaled all encounters electronically documented in the previous two years.
Between March 2005 and April 2008 TF62 has accounted for 43 percent of all electronically documented inpatient admissions; additionally, TF62 was responsible for 53 percent of all pharmacy and laboratory electronic documentation during this same period.
A comparison of static and dynamic reporting in JMeWS demonstrates that 99.1 percent of our outpatient encounters are electronically documented.
Perhaps most significant is that an audit of 75 patients evacuated to Landstuhl Army Regional Medical Center [LRMC] showed 100 percent TMDS documentation. This reflects the success of our EMR and provides the opportunity to focus on the quality of care that is provided.
Q: What do you see as your top HIS technology challenges that the U.S. health information system and electronic health record community needs to help solve?
A: I see the main health information System challenge that the U.S. health information system and electronic health record community can help solve is the strategic theater radiology solution. Specifically in the following areas:
1. Capability to store radiology in the longitudinal EMR.
2. Enable MEDWEB servers to have directional communication with EMRs.
Q: Is there anything else you would like to add?
A: Yes. My health information systems officer, Major Leslie Smith, can be reached at Leslie. This e-mail address is being protected from spambots. You need JavaScript enabled to view it . It has been truly an honor to command the best medical task force ever assembled during the last year. The force has delivered world-class health care while serving the nation and the warrior magnificently! ♦