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Use of the army dental command corporate dental application as an electronic dental record in the Iraq theater of operations.

The US Army Dental Command (DENCOM) first fielded the Corporate Dental Application (CDA) in 1999 and completed full implementation throughout all DENCOM dental treatment facilities in 2000. Initially, the CDA focused on the collection of dental workload information or dental weighted values which were based on the Department of Defense (DoD) dental procedure codes. Dental providers entered treatment workload into the CDA and recorded treatment notes, treatment plans, and other information on paper dental records. In subsequent years, the CDA was enhanced to captured data on patient treatment needs, caries risk, and tobacco use. In 2006, a narrative capability was added to the CDA which enables providers to type treatment notes into the CDA. Further development of the CDA was halted as resources were focused on AHLTA *-dental as an electronic dental record (EDR). The Army Medical Command stopped the fielding of AHLTA-dental on November 1, 2009. (1) Following the cancellation, the Military Health System (MHS) planned to evaluate both AHLTA-dental and CDA for the comprehensive military EDR. (2) CDA is included in the evaluation process because a version of CDA is currently deployed in Army and Air Force dental clinics, CDA is in alignment with future EDR requirements and strategies, and CDA has some capabilities that are not supported by AHLTA. Until a final agreement is made by all 3 services, paper records will continue to be the standard of care in fixed facilities. Historically, theater-wide dental emergency and dental treatment data had not been collected from a deployed environment. Previous deployed dental treatment and dental needs studies were based on small sample sizes that may not have been representative of the entire patient population. (3) Multiple articles were published based on dental records maintained by a single dentist or small group of dentists. (4-6) In 1997, the Naval Dental Research Institute gathered data on dental treatment provided to US Marines in Desert Storm via a retrospective study of available temporary dental records. (7)

There are various legitimate reasons for the failure to collect auditable dental data on a sizeable sample population in a deployed environment. The technology to electronically capture such data was not available until the advent of the CDA. In 2003, the 502nd Medical Company (Dental Services) deployed to Iraq. At that time, Iraq was an immature theater of operations. The focus of the 502nd and other deployed dental providers was to provide emergency dental care in an austere environment using field portable dental equipment. Dental officers did not have the technology or internet capability to electronically record and capture dental workload or treatment needs data.

In 2005, the 502nd Medical Company (Dental Services) was redesignated as the 502nd Dental Company Area Support (DCAS) and became a direct reporting unit (DRU) to the 1st Medical Brigade. In October of 2005 the 502nd deployed to Iraq as a DRU to the Medical Task Force (TF MED) under the command and control of the 30th MED BDE. The 502nd occupied fixed dental clinics with established internet capability. The 502nd DCAS dutifully recorded dental workload in the CDA and maintained paper dental records in accordance with established policy. The dental records were offered to the unit or to the individual Soldier. It was not practical for the 502nd to maintain copies of the records for epidemiologic reasons, therefore, the 2006-2007 dental records cannot be retrieved for a retrospective study. Record audits were not performed. It is probable that not all of the in-theater dental workload was annotated in the CDA.

The 502nd deployed to Iraq as a direct reporting unit to the TF MED from June 25, 2009, to June 4, 2010. The mission of the 502nd was to "Envision, design, and maintain the highest quality patient care system for eligible beneficiaries while planning and executing the orderly transition of dental resources to an expeditionary HSS [Health Support System]. Support 1st Medical Brigade efforts to facilitate long-term, sustainable Iraqi health care delivery." One of the 5-unit Mission Essential Task List items was "Electronically collect patient treatment and treatment needs data." Coincidentally, DENCOM added an electronic disease and nonbattle injury (DNBI) survey form to the CDA in April 2009 as part of an effort to obtain detailed information on DNBI in a deployed environment.

In order to achieve an Army Dental Care System unity of effort for data collection, DENCOM incorporated several minor changes in the CDA which were designed to support the collection and analysis of dental data from a deployed environment. Prior to June 2009, CDA data for deployed providers was collected and "sorted" according to the parent unit of the clinician; not geographic location of the dental clinic. The various organizations from multiple theaters were listed in the DEPRDC (deployed; non-DENCOM clinics) section of the CDA data. Listed units included those currently deployed and units which had redeployed. Those units included multiple medical companies (dental services), combat support hospitals, area support medical companies, and brigade combat teams.

Dental data collected "by unit" could not be easily assigned to an area or geographic location, such as a forward operating base (FOB). In addition, it was not uncommon for more than one dental organization to have treatment teams at a single FOB. The inability to quickly and accurately assign dental workload to a particular location made it difficult for medical planners at the theater or task force level to objectively and equitably distribute dental assets in-theater. The CDA became a valuable tool for medical planners as data for deployed providers became retrievable in the same fashion as data from DENCOM dental treatment facilities (DTFs), individual providers, the DTF (geographic location), and region (theater of operations). Brigade combat teams and medical units with dental providers continued to have the ability to collect data for their respective providers.

The lack of a uniform theater policy for using the CDA to collect dental data meant that objective data was not available for use to request and justify dental resources for the theater based on patient demand. The 502nd sought to establish a policy to mandate the use of the CDA as an electronic dental record. The commander of the 1st Medical Brigade supported the concept. Prior to deployment, it became policy for all TF MED dental providers to use the CDA as an electronic dental record in lieu of paper dental records. This policy also mandated the use of the electronic DNBI survey for all military dental emergencies.

In cooperation with DENCOM, the 502nd developed written guidelines based on Army Regulation 40-66 (8) and Technical Bulletin MED 250 (9) for the utilization of the CDA as an electronic record. The process and standards were established to ensure that all providers would know the process to use the CDA as an electronic dental record. The first group (26 PROFIS ** dental officers from the 502nd DCAS) was trained to the new standard prior to deployment. The TF 1st MED, with the 502nd, had command and control of 85% of the dental assets in the Iraq theater. Clinician education in the CDA and electronic record process refinement were immediate priorities. To ensure compliance with this policy and to maximize the reliability of collected dental data, it was decided to audit 100% of the CDA electronic patient encounters submitted. Clinician compliance with the electronic dental record policy, the quality of the data, and practical application of the data were readily apparent after the first month.

On September 1, 2009, the Multi-National Corps-Iraq (MNC-I) adopted the TF 1st MED policy. The Dental Services appendix to the Medical Services Annex of MNC-I Operations Order 09-09 *** stated that "Dental treatment documentation and accountability of all dental procedures provided for active duty service members and other beneficiaries will be recorded on the CDA ... website." This policy applied to all dental providers in theater. Army dental officers assigned to brigade combat teams, and USN and USAF dental officers working in Army facilities quickly complied with this new policy. To ensure compliance and maximize the reliability of collected dental data, it was decided to audit 100% of the CDA electronic patient encounters submitted in the Iraq theater of operations. These "audits" were conducted by the 502nd DCAS Commander, who also served as the Theater Dental Consultant (TDC).

An audit process was designed using the concepts taught by the US Army Medical Command Lean Six Sigma program. ([dagger]2) A senior dental noncommissioned officer (NCO) first reviewed each CDA encounter within 48 hours of the treatment submission. There were several areas of interest:

* Did the annotated DoD procedure codes, which captured the dental workload value, match the treatment narrative?

* Were all A0199 coded emergency visits accompanied by an electronic DNBI survey form?

* Were emergency dental exams, DoD procedure code D0140, written in SOAP format (symptoms, observations, assessment, prognosis)?

* Was there a treatment plan recorded for each nonemergency dental exam (DoD procedure code D0120)?

* Was the appropriate biographical data entered for each patient?

The number of daily patient encounters entered into the CDA ranged from 21 to 405, with a mean of 257 per day. The dental NCO required approximately 5 hours to review the daily encounters and record apparent discrepancies. The results of the preliminary audits were forward to the TDC. The TDC reviewed the audit results for each dental officer and then personally emailed each dental provider the results of the daily record audit. The number of patients treated and the value of the dental workload were also listed in the email. A member of the dental officer's chain of command was provided a copy of the email correspondence between the TDC and individual dental officer. The overwhelming majority of the audits, more than 91%, stated "zero negative findings." When discrepancies were noted, the dental provider was asked to make the appropriate correction. As part of the audit process, the dental record audit NCO would recheck the patient encounter to ensure the corrections were made. On the rare occasion when a correction was not submitted, the TDC would again email the provider. The TDC spent approximately 75 minutes supporting the dental audit process.

The daily record audit has several advantages:

* Maximizes the probability of uniformity in dental workload reporting.

* Maximizes the probability that all dental workload is captured by providers.

* Provides an opportunity to contact all theater dental providers daily and provide positive feedback.

* Enhances the reliability of collected data.

Over an 11-month period (July 1, 2009 to May 31, 2010), dental officers in Iraq recorded in the CDA more than 56,000 patient encounters (visits) and 190,000 procedure codes, with a value of $17.7 million. More than 19,000 of these encounters were defined as emergency visits and were accompanied by DNBI surveys. It is estimated that the CDA and DNBI data captured more than 97% of the dental patient encounters in Iraq during this period. The 97% calculation is based on patient encounters and workload recorded by 2 USAF dental clinics using the USAF version of the CDA. The USAF data did not include treatment notes or DNBI data. The USAF dental production data was incorporated into the monthly dental reports to the MNC-I Surgeon.

The validated dental data was used during the deployment by the TDC and TF MED 502nd to equitably distribute dental resources during the deployment. There were several reasons that a redistribution of dental assets was necessary. Military and other dental beneficiary populations on the various installations continually fluctuated due to troop restationing plans, as well as retrograde operations in support of the responsible drawdown of forces in Iraq. It was often necessary to backfill dental personnel. Dental personnel were redeployed early from theater for a variety of reasons and personnel replacement times ranged from one to 3 months. Dental personnel who used the rest and recuperation leave program were absent from their clinic for approximately 3 weeks. As the troop levels decreased, accompanying productivity and patient needs data justified eliminating several dental officer PROFIS requests generated by non-DCAS units.

For the first time, reliable and auditable dental data on a valid, representative sample of the entire population is available to medical manpower analysts. The Army Medical Department (AMEDD) Strategic Studies Branch stated that the "dataset provided for the dental health project (through the use of electronic dental records and electronic DNBI surveys) is by far one of the cleanest, most complete datasets encountered in years." It is anticipated that medical planners at the AMEDD and Army Command levels can use this data to objectively establish dentist, dental ancillary, and dental equipment requirements for a deployed patient population based on patient needs and potential risk. The data clearly indicates that the dental treatment of nonmilitary beneficiaries must be considered by medical planners. The data reveals that deployed dental treatment facilities are significantly more efficient when the assistant to dental officer ration is greater than 1:1. Many 502nd DCAS and TF 1st MED DTFs had a 1:1 plus one staffing ratio. The "plus one" is an additional assistant available to perform reception, administrative, and instrument sterilization duties, as well as chairside assistance. These 1:1+1 clinics produced 38% more procedures per dentist than DTFs with a 1:1 ratio.

Dental data from any theater and time period should be normalized to account for difference in the assigned mission, theater policies, staffing ratios for dentists and their ancillaries, and theater infrastructure. Data collected by the TF MED providers during this period includes prophies (dental cleanings) comprising 14% of the nonexamination dental procedures. TF MED policy was that all dental providers spend 40 to 44 hours a week providing hands-on patient care. This policy increased the amount of routine dental care provided to Soldiers on a space available basis. This policy contributed to increased levels of Soldier dental wellness, enhanced patient morale, and enhanced unit morale as TF MED Soldiers stayed busy and productive in-theater.

In 32 various after-action reports, deployed dental officers made recommendations for changes to the current DoD definitions of Dental Fitness Category (DFC) 3. DFC3 is defined as a high risk for a dental emergency within 12 months. An examination of 19,000 DNBI surveys and 56,000 electronic dental records may provide the scientific justification for the proposed additions to DFC3 definitions:

1. Endodontically obturated posterior tooth without cuspal coverage. Currently, DoD Health Affairs (HA) Policy 02-011 (11) lists DFC2 for "teeth restored but for which protective cuspal coverage is indicated."

2. Partially erupted wisdom teeth which will not erupt into occlusion. Currently HA Policy 02011, lists DFC3 only if "historical, clinical, or radiographic signs of pathosis."

3. All interim restorations or prosthesis. Current DFC3 definition is "interim restorations or prosthesis that cannot be maintained for a twelve month period."

4. A Soldier with more than 6 DFC2 lesions.

5. A Soldier with orthodontic brackets and wire.

6. A high-caries-risk Soldier with interproximal posterior composite restorations.

The data from the DNBI surveys completed between July 1, 2009, and 30 June 30, 2010, are listed in Tables 1 through 8 and presented in the Figure (page 53). There were 16,084 military personnel DNBI encounters recorded, with a total of 19,084 recorded DNBI encounters in this period. Unfortunately, the MNC-I policy to collect dental emergency data and DNBI surveys applied only to military personnel. Some dental providers took it upon themselves to record nonmilitary DNBI data.

The gender and component of the military personnel who sought emergency dental treatment are shown in Tables 1 and 2 respectively. Emergency encounters were collected under the code "A0199 emergency visit-problem focused" found in the DoD Guidelines for Dental Procedure Codes and Dental Weighted Values. (12) According to this code, providers are to take credit only once per each unscheduled visit to a dental facility, regardless of the reason for which the patient sought expedited care. It is obvious that males were the predominate group that sought treatment of dental emergencies. However, without theater-wide personnel data on the component and gender composition of US forces in Iraq during this period, which component and gender was statistically more prone to seek treatment for a dental emergency cannot be determined. Gender, component, and age data should indicate which group of Soldiers should be the main target audience for preventive dental messages.

The DNBI survey also tracked the number of months that the Soldier had been deployed when the Soldier sought emergency dental care. Conventional wisdom is that dental emergency rates increased as the deployment dwell time increased. The data collected during this period does not support this conventional hypothesis. The number of months a patient had been deployed when he or she sought emergency dental treatment are shown in Table 3, and percentages for the deployment period are shown the Figure. There appears to be an initially high dental sick call rate in the first month of deployment and another peak at the 7-month mark. There are several potential explanations for the findings. One potential explanation is that Soldiers arrive with untreated dental emergencies. Another explanation is sequela from dental treatment just prior to deployment. Using CDA data, further investigation is warranted. Data on the average dwell time for these patients is needed. It is possible that in-theater dental sick-call rates are directly related to the amount of time since the Soldier's last dental exam. Soldiers who deployed in December 2008 may have had their last dental exams anytime between December 2007 and December 2008. Other potential factors influencing dental sick-call include, but are not limited to, the patient's, caries risk, oral hygiene, and the number of untreated DFC2 dental lesions.

Tables 4 through 8 reveal the etiology of the patient's chief complaint and the multiple etiology subsets. As part of the DNBI survey, more than one etiology could be applied to a visit. The most notable findings were that caries accounted for 22.5% of the dental emergency visits, pulpal disease requiring endodontic (root canal) therapy accounted for 20%, and visits associated with wisdom teeth (third molars) accounted for 4.2%. The data, in combination with the large numbers of single dental officer clinics, indicates that every dental officer must be proficient in endodontic and exodontia diagnosis and treatment. The complexity of many third molar extractions combined with the standard of care to provide sedation therapy for many of these patients confirms the theater need for a oral and maxillofacial surgeon to support third molar exodontias requirements. The alternative is the evacuation of military personnel from theater for complications from erupting third molars.

In a deployed environment, the CDA as an electronic dental record and electronic DNBI surveys proved a significant improvement over paper records and surveys. The low record audit error rate indicates that dental officers will use a clinician friendly electronic record, and that dental officers are aware of the Army Dental Care System requirement to collect accurate dental data. There is room for improvement. Dental record audits could be conducted from a location in the United States. A triservice electronic dental record should be adopted to ensure all dental data is collected and treatment notes are accessible to home duty station military DTFs and postdemobilization nonmilitary dental providers. Until a triservice solution is adopted, CDA as an electronic dental record should be the standard of care for deployed providers. DENCOM is studying potential modifications and improvements to the CDA. In October 2010, an electronic exam form or mass event module was added for use at first term dental readiness and Soldier readiness processing sites. The potential baseline data from an electronic dental exam for dental treatment needs could further refine dental manpower and equipment requirement justifications in both the deployed and fixed facility environments.

[GRAPHIC OMITTED]

Acknowledgement

The authors thank the US Army Dental Command and the Dental Staff at the Office of The Surgeon General for their superb level of support to the Soldiers of the 502nd DCAS during the deployment.

REFERENCES

(1.) Brewin, Bob. Army abruptly stops rollout of electronic dental record application. Government Executive.com [serial online]. November 3, 2009. Available at: http://www.govexec.com/dailyfed /1109/110309bb1.htm. Accessed November 15, 2010.

(2.) Brewin, Bob. Military Health to evaluate two electronic dental record systems. Government Executive.com [serial online]. November 25, 2009. Available at: http://www.nextgov.com/nextgov/ng_2009 1125_6460.php. Accessed November 15, 2010.

(3.) Eikenberg S, White K. Report of dental emergencies treated by the 257th Medical Company (Dental Service) in Haiti during Operation Uphold Democracy. Army Med Dept J. September-October 1995:17-21.

(4.) Tewles RB, King JE. Impact of troop dental health on combat readiness. Mil Med. 1987;152(5):233-235.

(5.) Chaffin J, King JE, Fretwell LD. U.S. Army dental emergency rates in Bosnia. Mil Med. 2001 (12);166:1074-1078.

(6.) Moss DL. Dental emergencies during SFOR 8 in Bosnia. Mil Med. 2002;167(11):904-906.

(7.) Deutsch WM, Simecek JW. Dental emergencies among Marines ashore in Operations Desert Shield/ Storm. Mil Med. 1996:161(10):620-623.

(8.) Army Regulation 40-66, Medical Record Administration and Health Care Documentation. Washington, DC: US Dept of the Army; June 17, 2008.

(9.) Technical Bulletin MED 250: Dental Record Administration, Recording, and Appointment Control. Washington DC: US Dept of the Army; April 28, 2006.

(10.) Medical Corps Professional Development Guide. Fort Sam Houston, TX: US Army Medical Department Center and School; March 2002:27.

(11.) Assistant Secretary of the Army for Health Affairs. Memorandum: Policy on Standardization of Oral Health and Readiness Classifications. Washington, DC: US Dept of the Army; June 4, 2002. Available at: http://www.ha.osd.mil/policies/2002/02-011.pdf. Accessed October 28, 2010.

(12.) Guidelines for Dental Procedure Codes and Dental Weighted Values. Falls Church, VA: Tricare Management Activity, US Dept of Defense; October 1, 2009.

COL Steven Eikenberg, DC, USA

MAJ Robert Keeler, DC, USA

SFC Thomas Green, USA

* AHLTA is the current US military electronic medical record.

** PROFIS predesignates qualified Active Duty health professionals serving in Table of Distribution and Allowance ([dagger]) units to fill Active Duty and early deploying and forward deployed units of Forces Command, Western Command, and the medical commands outside of the continental United States upon mobilization or upon the execution of a contingency operation. (10)

*** Internal military document not generally accessible by the general public.

([dagger]1) Prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to perform a specific mission for which there is no appropriate table of organization and equipment (the document which defines the structure and equipment for a military organization or unit).

([dagger]2) Information available at: http://www.armyobt.army.mil/cpi-kctools-lss.html.

COL Eikenberg is Commander, 502nd Dental Company (Area Support), Fort Hood, Texas.

MAJ Keeler is Deputy Commander for Clinical Services, 502nd Dental Company (Area Support), Fort Hood, Texas.

SFC Green is the Treatment Platoon Leader, 502nd Dental Company (Area Support), Fort Hood, Texas.
Table 1. Dental emergency encounters
by gender.

Gender    Encounters     Percentage

Male          13,572         84.38
Female         2,512         15.62

Table 2. Dental emergency encounters by
military service.

Component               Encounters   Percentage

Army Active Duty            9,036        56.18
Army National Guard         3,977        24.73
Army Reserve                1,912        11.89
Air Force                     720         4.48
Navy                          289         1.80
Marine Corps                  150         0.93

Table 3. Dental emergency encounters by number of months
deployed.

No. of Months   Emergency     Percentage of         Cumulative
 in Theater      visits      Emergency visits     Percentage of
                            per Deployed Month   Emergency visits

      1            2,377             14.8               14.8
      2              949              5.9               20.7
      3            1,090              6.8               27.5
      4            1,152              7.2               34.6
      5            1,322              8.2               42.8
      6            1,229              7.6               50.5
      7            1,627             10.1               60.6
      8            1,508              9.4               70.0
      9            1,265              7.9               77.8
     10            1,047              6.5               84.3
     11            1,070              6.7               91.0
     12              903              5.6               96.6
     13              299              1.9               98.5
    >13              246              1.5              100.0

Table 4. Etiology of dental chief complaint.

Etiology of Chief Complaint            Frequency
(Primary Classifications)             of Diagnosis   Percentage

Enamel, dentin, or restoration             11,947           48
Pulpal disease                              4,860           20
Dentoalveolar surgery or 3rd molar          3,249           13
Periodontal disease                         2,169            9
Other dental conditions                     1,008            4
Temporomandibular disorder                    805            3
External trauma                               603            2
Totals                                     24,641          100

Table 5. Subset of enamel dentin restoration
diagnosis.

 Etiology Subset 1 of 7     Frequency   Percentage
     Enamel Dentin
 Restoration Diagnosis

Fractured with caries          2,319        19.41
Hypersensitivity               2,262        18.93
Defective with caries          1,944        16.27
Caries                         1,475        12.35
Defective without caries       1,349        11.29
Other                          1,262        10.56
Hyperocclusion                   988         8.27
Fractured without caries         348         2.91
Totals                        11,947       100.00

Table 6. Subset of pulpal diagnosis.

   Etiology Subset 2 of 7        Frequency   Percentage
      Pulpal Diagnosis

Pulpitis                            1,629        33.52
Pulpless/previously treated           888        18.27
Necrotic pulp                         618        12.72
Periaradicular abscess                578        11.89
Anatomic space infection              558        11.48
Other                                 505        10.39
Periaradicular periodontitis           84         1.73
Totals                              4,860       100.00

Table 7. Subset of dental alveolar diagnosis.

          Etiology Subset 3 of 7             Frequency   Percentage
        Dental Alveolar Diagnosis

Alveolar osteitis (3-5 day postoperation)       1,104        33.98
Pericoronitis                                   1,003        30.87
Other                                             599        18.44
Sequestrum from previous extraction               190         5.85
Normal postoperation pain or swelling             184         5.66
Hemorrhage                                        109         3.35
Eruption pain                                      52         1.60
Anatomic space infection                            8         0.25
Totals                                          3,249       100.00

Table 8. Subset of periodontal diagnosis.

Etiology Subset 4 of 7               Frequency   Percentage
Periodontal Diagnosis

Gingivitis/Gingival Bleeding              931        42.92
Other                                     747        34.44
Necrotizing Ulcerative Gingivitis         420        19.36
Ailing/Failing Implant                     36         1.66
Periodontal Abscess                        25         1.15
Anatomic Space Infection                   10         0.46
Totals                                  2,169       100.00
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Author:Eikenberg, Steven; Keeler, Robert; Green, Thomas
Publication:U.S. Army Medical Department Journal
Geographic Code:7IRAQ
Date:Jan 1, 2011
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