Dental readiness of army reserve components: a historical review, part two.
In a previous article in the AMEDD Journal, (1) I presented a historical review of dental readiness of the Army Reserve components from 1968 to the end of September 2005. This article focuses on the progress of dental readiness for the Army Reserve components (RC), which consist of the Army National Guard (ARNG) (component 2) and the US Army Reserve (USAR) (component 3), for the period October 2005 through September 2010. During this period, the US Army Dental Command (DENCOM) processed over 192,000 ARNG and 88,000 USAR Soldiers through mobilization stations. The dental-ready report rate to the mobilization station for ARNG Soldiers improved from 56% to 86%, and that for USAR Soldiers improved from 36% to 64%. These improvements reduced dramatically the "just in time" dental exams and treatment that had historically been performed at mobilization stations in order to deploy dentally fit Soldiers. In August 2008, DENCOM initiated the RC Demobilization Dental Reset which, through the end of Fiscal Year (FY) 2010, had examined and treated over 141,000 RC Soldiers and reset 92% of them to the dental deployment standard before their release from active duty status. Through the implementation of programs and electronic processes described in this article, the RC baseline dental readiness as identified by the Army Medical Protection System improved from approximately 42% dental-ready in FY 2006 to approximately 71% dental-ready by the end of FY 2010.
By the end of FY 2005, RC dental-ready report rates to mobilization platforms had improved to 56% for the ARNG and 36% for the USAR, from 13% dental-ready at the beginning of FY 2004. In November 2005, MG Joseph G. Webb, Chief of the Dental Corps and Deputy Surgeon General, directed the creation of the Dental All Army Working Group (DAAWG) to continue the improvement in dental-ready report rates and foster cooperation among the dental stakeholders of the three Army components. This group consisted of dental surgeons from the Army National Guard Bureau (NGB), the Army Reserve Command, the Office of The Army Surgeon General (OTSG), and the DENCOM. This core group of stakeholders would be instrumental in directing the future paradigm shifts in RC dental readiness. Two issues had to be addressed: (a) the development of an all Army synchronized electronic dental database which would improve dental readiness validation processes at mobilization stations; and (b) an Army directed and funded RC dental readiness program that operates outside of alert status which would improve baseline RC dental readiness, leading to dental-ready RC Soldiers presenting to mobilization installations.
SYNCHRONIZED ELECTRONIC DATABASES
In the absence of an Active Component (AC) electronic dental record, by 2006 the NGB dental surgeon's office had developed DENCLASS, an electronic dental record and dental readiness tracking system. At the same time, the DENCOM Information Management and Technology Division (IM&TD) had developed and implemented the Digital Enterprise Viewing and Acquisition Application (DEVAA) for use within the Active Army Dental Care System (AADCS). DEVAA permitted the standardized storage of digital radiographs, regardless of sensor type used by any dental treatment facility within the AADCS. By June 2007, IM&TD began development of the Army Dental Digital Repository (ADDR) to which DEVAA images taken at local dental treatment facilities could be uploaded, permitting viewing of dental digital radiographs worldwide. At the same time, images taken by the Federal Strategic Health Alliance (FEDS_HEAL), a primary provider network performing premobilization RC dental readiness exams, radiographs, and treatment, started transmitting digital radiographs to the ADDR. By early 2008, the USAR started using DENCLASS for their electronic dental record. This initiated a series of DENCLASS improvements which permitted radiographs and electronic examination records produced by the Reserve Health Readiness Program (which replaced FEDS HEAL) or direct contracted networks to be placed into the ADDR using DENCLASS as the entry portal. This improved Soldier Readiness Processing (SRP) validation at mobilization stations when paper records were lost or incomplete. In early 2009, the DAAWG directed that all RC dental readiness data must be placed into the ADDR through the DENCLASS portal starting October 1, 2009. In early 2010, the DAAWG directed that a digital panograph would be on file in the ADDR for all Army Soldiers starting October 1, 2010. DENCLASS also had portal links to the DENCOM Corporate Dental Application (CDA) database, allowing RC contracted entities to see radiographs and dental record documentation, regardless of whether that data was produced by the RC dental readiness system and recorded in DENCLASS or was produced within the AADCS and recorded in CDA. These improvements gave new tools to all three components to reduce duplication of examination and radiographic processes.
The foundation had been laid for the three Army components to synchronize their electronic dental databases. The fact that the AC and RC databases were not synchronized by a common electronic dental record posed a significant challenge. All databases were awaiting full development of an AHLTA * electronic dental record. In late 2009, a strategic pause was ordered for the AHLTA electronic dental record throughout Department of Defense (DoD) dental treatment facilities. However, the AADCS required an electronic examination document that was simple to use for mass events, such as the RC demobilization dental reset. In early 2010, the DAAWG agreed to an aggressive October 1, 2010 deadline to produce an AADCS electronic examination document for mass events, and to synchronize all databases in order to produce an RC electronic dental SRP validation system. A CDA program team developed the Mass Event Module (MEM), creating an electronic dental examination record which recorded charting of disease, diagnosis, treatment procedures required, and the Dental Readiness Class (DRC) of a Soldier. By August 2010, the MEM was tested and released for system-wide implementation for RC mobilizations and demobilizations. The use of the MEM eliminated multiple paper record processing steps required to place data into the ADDR, and provided more accurate, standardized examination documentation for the RC.
[FIGURE 1 OMITTED]
Another CDA program team tackled synchronizing the databases to produce an electronic dental SRP validation process. By 2009, the DAAWG realized that the way dental data was fed to the Army's Medical Protection System (MEDPROS), which reports the medical and dental readiness of AC and RC individuals or units, lacked data integrity. Nondental unit personnel with MEDPROS write-access could change dental readiness data without any electronic dental data input or paper proof of dental readiness. In addition, CDA and DENCLASS were sending dental data to MEDPROS independent of each other, which led to system overwrites of DRC status and exam dates. Thus, paper records were required at the mobilization station in order to verify one source of information. By late 2009, the DAAWG agreed to a circular system of data flow, illustrated in Figure 1, which could only be accessed and changed by authorized AC or RC dental personnel using either CDA or DENCLASS. In December 2009, MEDPROS access was limited to dental personnel with write-access in DENCLASS or CDA, which led to an immediate improvement in dental readiness data quality. Then, by August 2010, the single pathway flow of dental readiness data was developed whereby CDA became the entry point for all dental data to MEDPROS. Data produced by DENCLASS would update CDA, which in turn would update MEDPROS. Data first entered into CDA would then update MEDPROS and then update DENCLASS. With a single pathway flow of real-time dental readiness data, 6 common data elements could be used to electronically determine if a RC Soldier could be validated as dental-ready without the use of paper dental records. The RC electronic dental SRP validation process was tested in September 2010 and fully implemented throughout DENCOM operated mobilization and demobilization stations on October 1, 2010. The RC Soldier's dental readiness status could now be validated electronically using trusted electronic dental data.
PROGRAMMATIC RC DENTAL READINESS SYSTEM
By 2005, dental examinations and DRC 3 treatment at no charge to the RC Soldier were based on the RC Soldier's alert for mobilization. Outside of this alert status, no dental readiness program was available for RC Soldiers. Dental readiness care was being delivered by FEDSHEAL for the USAR and by FEDSHEAL and direct contractors for the ARNG. By 2007, DoD directed the creation of a contracted medical and dental readiness provider network for the RC, the Reserve Health Readiness Program (RHRP), to replace FEDSHEAL. After the RHRP contract was approved in September 2007, the RHRP DoD representative became a sitting member of the DAAWG. In the meantime, the Army leadership was developing the Armed Forces Generation cycle (ARFORGEN), a rotational plan involving pools (reset/train; ready and available) of Army AC and RC units. However, except for Soldiers in the alert status of the AFORGEN available pool, there was no Army directed RC dental readiness program. In December 2006, the OTSG Dental Staff Officer (action officer), COL James Honey, focused the DAAWG to work toward an Army directed dental readiness system which would provide annual exams and DRC 3 treatment throughout the ARFORGEN cycle. This system would require an electronic database for dental readiness tracking and authorization to use RC Operation and Maintenance funding to purchase contract dental readiness care at home station. The necessary authorization for funding was made possible in January 2007 when the Secretary of Defense directed that RC mobilizations would be limited to one year. This meant that RC units did not have the luxury of staying at the mobilization platform for 60 to 120 days prior to deployment but would now be deployed within 30 to 60 days of arriving at the mobilization station. Consequently, in February 2008, the Assistant Secretary of the Army, Manpower & Reserve Affairs (ASA-M&RA) issued a policy stating that all Selected Reserve Soldiers would deploy within 75 days of mobilization. All Selected Reserve Soldiers would now qualify as "early deployers" and therefore be entitled to dental readiness care in accordance with existing Federal law, 10 USC, [section] 1074a (d)(1). This policy provided key support for the ongoing staffing process to create the Army Selected Reserve Dental Readiness System (ASDRS). In April 2008, the ASDRS was staffed through Headquarters, Department of the Army in preparation for final approval through ASA-M&RA. At the same time, the Army's Chief of Staff also focused on Army Initiative Four to "operationalize" the Reserve component forces. Within his first 100 days as Army Surgeon General, LTG Eric Schoomaker directed a complete review of RC dental readiness. The Assistant Surgeon General for Force Projection assembled a multicomponent work group in March 2008 to conduct a capabilities-based assessment and develop a prioritized list of courses of action. In April 2008, I testified before the Subcommittee on Oversight and Investigations of the House Armed Services Committee,2 outlining the history of RC dental readiness and initiatives that were being reviewed by the Army leadership. Proposed initiatives included the expansion of the existing First Term Dental Readiness program, establishment of paid dental readiness days for the RC, creation of an Army Selected Reserve Dental Readiness System (ASDRS), development of an enhanced TRICARE ** dental program, and introduction of a demobilization reset. By May 2008, the Army's Vice Chief of Staff directed the dental reset of the RC forces upon demobilization, and by August 2008, DENCOM implemented the Reserve Components Demobilization Dental Reset. By September 2008, the ASA-M&RA approved ASDRS and issued a policy guidance memorandum which directed the Chief, Army Reserve and Director, Army National Guard to implement the ASDRS using base program readiness (operation and maintenance) funding. The memorandum included the requirement to achieve the DoD Health Affairs dental readiness policy standard (3) of 95% DRC 1 or 2 in support of all Selected Reserve Soldiers outside of alert for mobilization. ASDRS could use contingency funds for Ready Reserve Soldiers (Selected Reserve, Individual Ready Reserve, and Inactive National Guard) once they are alerted (and called or ordered to active duty for a period of more than 30 days), in accordance with 10 USC, [section] 1074a (f)(1). By FY 2010, RC Soldiers were being provided paid medical/dental readiness days which compensated Soldiers' time off from their civilian jobs to achieve medical and dental readiness standards.
[FIGURE 2 OMITTED]
The multiyear RC dental readiness improvement initiative outlined in this article met the original 2 requirements of the DAAWG:
* A seamless system of RC dental readiness access (Figure 2) throughout the ARFORGEN cycle at no cost to the RC Soldier. The DENCOM-commanded AADCS has operational responsibility for the First Term Dental Readiness program when the RC Soldier is in initial entry training; mobilization/demobilization station dental readiness deployment care; and the RC Demobilization Dental Reset. The ASDRS, as directed through the Chief, Army Reserve and Director, Army National Guard, has operational responsibility for RC dental readiness throughout the ARFORGEN reset/train, ready, and available pools.
* A trusted, synchronized, electronic dental readiness validation and record system which reduces duplication of processes and improves mobilization station efficiencies. Future improvements in RC dental readiness will require continued improvements in electronic data system synchronization and RC command-directed implementation of the ASDRS.
(1.) Bodenheim MB. Army Reserve components dental readiness: a historical review since the first gulf war. Army Med Dept J. January-March 2006:27-30.
(2.) Challenges Associated with Achieving Full Dental Readiness in the Reserve Component: Hearings Before the Subcommittee on Oversight and Investigations of the House Armed Services Committee, 110th Cong, 2nd Sess (April 23, 2008).
(3.) Assistant Secretary of Defense for Health Affairs. Memorandum: Policy on Oral Health and Readiness [HA Policy 06-001]. Washington, DC: US Dept of Defense; January 9, 2006. Available at: http:// www.health.mil/libraries/HA_Policies_and_Guide lines/06-001.pdf. Accessed November 23, 2010.
COL Mark B. Bodenheim, DC, USAR
* AHLTA is the current US military electronic medical record.
** TRICARE is DoD's health care program for members of the uniformed services, their families, and their survivors. Information available at http://www.tricare.mil.
COL Bodenheim is Chief of Reserve Components Operations, US Army Dental Command, and the Drilling Individual Mobilization Augmentee to the Dental Corps Chief, Fort Sam Houston, Texas.
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|Author:||Bodenheim, Mark B.|
|Publication:||U.S. Army Medical Department Journal|
|Date:||Jan 1, 2011|
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