key: cord-0989796-7zz2q7qc authors: Ramirez, Ariana; Owshalimpur, David; Mount, Cristin; Schofield, Christina title: Retrospective Review of a Novel Virtual Medical Soldier Readiness Processing Process in Response to the COVID-19 Pandemic date: 2021-01-15 journal: Mil Med DOI: 10.1093/milmed/usaa580 sha: 6d0f60a4278ccb78099299e1f0de5e7a76565de3 doc_id: 989796 cord_uid: 7zz2q7qc INTRODUCTION: Medical solider readiness processing (SRP) needed to continue during the COVID-19 pandemic. We developed a rapid practice improvement project to allow for a hybrid virtual medical SRP/in-person medical SRP to decrease exposure risk. A retrospective review comparing this virtual SRP to a historical in-person SRP cohort to the same combatant command was then performed. PROCEDURES: A virtual medical SRP was completed for 204 soldiers in preparation for deployment within 24 hours of receiving the deployment roster. Each soldier had their MEDPROS data sheet printed and reviewed for deficiencies. Soldiers were then divided into two groups. Group 1 required hybrid SRP with need for in-person labs or vaccinations. Group 2 had no deficiencies noted on MEDPROS review, and the entire medical SRP was done virtually. Pre-deployment health assessment (pre-DHA) was completed over the phone for both groups. The provider then determined whether the soldier was a GO or NO GO, and this information was passed to the unit’s medical staff. Comparative data analysis was performed using t-tests assuming unequal variances and chi-square tests. INFORMATION FOUND: A total of 204 soldiers were expected to complete the virtual SRP process. Of those 204, 191 MEDPROS records were reviewed (93%). Seventy-seven of the 191 soldiers (40%) required level one labs and immunizations, had not completed their pre-DHA, or had a combination of these factors. One hundred and fourteen soldiers (60%) had these items completed and were given virtual appointments in GENESIS. One hundred and six of the 114 (95%) soldiers were able to complete their medical SRP virtually. Eighty-six soldiers (80%) of this cohort were a GO for deployment at the end of their virtual SRP visit. The novel virtual SRP process was comparable to the historic in-person SRP as evidenced by no statistically significant difference in terms of the number of providers required and the number of soldiers that was seen by any one provider. The groups did show statistically significant differences based on age, gender, and GOs/NO GOs. CONCLUSION: This is the first proof of concept of a virtual medical SRP on literature review. A virtual SRP process that combines a pre-visit record review with a virtual pre-DHA is a viable process for SRP. The ability to utilize providers outside of a confined location or post may allow for optimized utilization of this scarce resource and result in cost savings to the Army. The recreation of this virtual medical SRP within other Army installations may allow for the improvement and standardization of the medical SRP process as a whole. During the COVID-19 pandemic, Madigan Army Medical Center (Madigan) was faced with a requirement to continue to provide soldier readiness processing (SRP) for I Corps whose real-world missions continued despite or because of the current global situation. We devised a rapid performance improvement project utilizing virtual health to meet medical SRP requirements and decrease face-to-face encounters, thereby decreasing COVID-19 exposure risk. We then compared this virtual SRP cohort to a historical cohort from a standard in-person SRP group, with comparable number of soldiers entering the same combatant command (COCOM) to look for similarities and differences. We tailored the virtual medical SRP to comply with Army Regulation 600-8-101 1 as able with a cohort of 204 soldiers who were on a short notice "Prepare to Deploy Order." It is important to note that Pacific Command waived theaterspecific immunizations, labs, pregnancy tests, and personnel functions (legal, SGLV, DD93, etc.) for this SRP to expedite the timeline given the low threat of the deployment area. Soldiers still must meet COCOM medical readiness standards in order to deploy to specific areas around the globe. Those not meeting these standards will require waiver for entry. For this deployment, the medical SRP site was ready to review soldiers within 12 hours of receiving the request for medical SRP; however, this was delayed as the unit required more time to assemble the deployment roster. Once the roster was received, the medical SRP staff reviewed each soldier's MEDPROS data sheets for level one medical readiness completion. This review is the same as an in-person medical SRP. Level one requirements included routine vaccinations, up-to-date labs, and deployment health assessments, which should be maintained by the soldier's individual units. For this deployment, the soldiers were divided into two groups. Group 1 consisted of soldiers who required either a routine immunization or lab draw requiring an in-person visit. Group 2 consisted of soldiers who did not require labs or immunizations and therefore did not require in-person visits. The staff then created appointments for each soldier in MHS GENESIS. Two different appointments were created. A partial virtual appointment (group 1) was created under the generic SRP_Provider in MHS GENESIS for those who required an immunization or lab. Soldiers who did not need an immunization or lab and could undergo a complete virtual visit (group 2) had their appointment created under the specific name of the medical director for the SRP. For group 1, SRP requested the unit to schedule specific times to complete missing level 1 labs and/or immunizations for soldiers to maintain appropriate social distancing. In addition, medical SRP nursing staff would still ask the pre-deployment questions of Exceptional Family Member Program (EFMP) status, presence of allergy tags, and confirmation the soldiers had two pairs of glasses, hearing aid batteries if indicated, and gas mask inserts when the soldier came to the SRP site to rectify any level 1 deficiencies. These soldiers would still conduct their pre-deployment health assessments (pre-DHA) with a provider over the phone. For group 2, the provider would ask these questions during a telephone call for the soldier's pre-DHA. The contact phone numbers for soldiers were provided by the unit or found under demographics in MHS GENESIS and entered into the provider note using auto-text or typed into the note. At the beginning of the call, the soldier's identity was confirmed using two-point identification: name and date of birth. Their physical location and verbal consent allowing the virtual medical SRP to take place was documented into the note as required by Madigan telehealth guidelines. Although there was no emergent care required during the phone call during this SRP, the soldier's physical location was specified in the note allowing the provider to call emergency medical services if needed. The providers also had contact information of medical personnel from the unit to contact for non-emergent but concerning medical or behavioral issues. The provider determined whether the soldier was a GO or a NO GO for deployment during this virtual visit. The unit's medical staff were able to see GOs and NO GOs in real time in MHS GENESIS. This allowed them to review NO GOs to consider a waiver request for entrance into the COCOM area. A behavioral health specialist was also provided by the unit to review and help disposition soldiers with behavioral health issues. This virtual medical SRP was stopped after 1 day as the unit received new orders suspending their deployment. A historical cohort from a prior in-person SRP at the same facility was used for comparison. This cohort was chosen for similar numbers of soldiers processed entering the same COCOM. Comparison between the two groups was most notable for the different types of units compared (the virtual SRP was done on a medical unit; the in-person historic SRP cohort was done on a combat unit). Data were collected with each SRP for both internal and unit reviews. We de-identified and utilized these data for this retrospective review. The comparison between the virtual SRP and the historic in-person SRP cohort was done utilizing a t-test assuming unequal variances given two separate sized groups for age and number of providers used to see soldiers. Chi-square test (or Fisher's exact test) was used to compare gender and GO/NO GO rates. An initial roster of 180 soldiers was provided to the medical SRP staff at 7:30 am on the SRP day. An additional 24 soldiers were added throughout the day to give a total of 204 soldiers that required medical SRP. Of those 204 soldiers, 191 MEDPROS records (93%) were reviewed, and 13 (6%) were not reviewed as they were received late in the day. Of the 191 soldiers' charts that were scrubbed, 28 soldiers (15%) were found to have at least one level one deficiency. This list of 28 soldiers was provided to the unit to schedule an in-person visit to SRP to adhere to social distancing. Seventy soldiers (37%) had not completed the soldier portion of the pre-DHA within 30 days. This 30-day limit was imposed by the medical SRP staff to ensure an up-to-date pre-DHA. There were 21 soldiers who required level 1 lab or immunization and had not completed their pre-DHA. One hundred and fourteen of the 191 soldiers (59%) had both their level 1 and pre-DHA completed and were appointed in MHS GENESIS. One hundred and six of the 114 soldiers (93%) completed the virtual medical SRP process. Eight soldiers (7%) did not complete the virtual SRP for the following reasons: four soldiers were not completed because of time constraints, two soldiers were appointed into MHS GENESIS but had not completed their pre-DHA within 30 days, one soldier was awaiting unit behavioral health input prior to disposition, and one soldier's MHS GENESIS chart was unable to be completed for unclear reason. Of the 106 soldiers that completed the virtual medical SRP process, 86 (81%) were a GO for deployment, and 20 (19%) were a NO GO at the end of their virtual SRP visit. Fifteen total personnel were required to complete this virtual medical SRP. Five personnel reviewed the MEDPROS data sheets, appointed soldiers into GENESIS, and collected data that required 22.5 total hours. Ten total providers were needed to complete this virtual medical SRP. The seven providers intrinsic to the SRP provided 64.5 hours of total work. Three borrowed providers from elsewhere in the medical treatment facility provided more than 12.5 hours of work (one provider failed to turn in hours worked). These providers worked either from home or from their respective offices at the MTF because of difficulty with internet connection at home. None of the providers worked from the SRP site. An average of 12.7 soldiers were seen per provider. The unit provided one physician assistant to review NO GOs and one behavioral health specialist to help determine deployability of soldiers who were found to have mental health issues. The total man hours required to complete this task was over 120 hours, averaging approximately 8.5 hours per staff member. The historical cohort used for comparison was located at the same installation and deployed to the same COCOM area within the past 18 months. The cohort consisted of 87 soldiers from a combat unit. The average age for the virtual SRP group was 29.6 years with a range of 18-56 years. The historical in-person SRP group's average age was 27.1 years with a range of 19-47 years. Utilizing a t-test the age between the two groups was statistically significant with a P-value of .01. The virtual SRP group was composed of 81 males (70.4%) and 34 females (29.6%). The historical in-person cohort was composed of 81 males (93.1%) and 6 females (6.9%). Utilizing a chi-square test, there was a significant gender difference with a P-value of less than .001. The number of GOs for the virtual SRP was 88 soldiers (77.9%), with 25 soldiers being NO GOs (22.1%). There were two soldiers who did not have a GO/NO GO determination at the end of the virtual SRP. The number of GOs and NO GOs in the historical cohort was 77 (89.5%) and 9 (10.5%), respectively. There was one soldier who did not have a GO/NO GO determination at the end of the in-person SRP. A chi-square test did show statistically significant variation in the GO/NO GO groups with a P-value of .03. Ten providers were used to call the 114 soldiers in the virtual SRP group. All but three of the providers were intrinsic to the SRP. The average number of soldiers seen by provider during the virtual SRP was 11.5 soldiers. If we calculate the average by dropping the medical director who was managing all the providers and working with the unit's medical assets who only called one soldier, this average increased to 12.7. The historic in-person SRP cohort utilized six providers to see 87 soldiers. This averaged to 14.5 soldiers per provider. Utilizing a t-test comparing the number of soldiers seen by each provider does not show a statistically significant difference when the medical director was counted with a P-value of .47, or when the medical director was removed from the analysis with a P-value of .65. This is a retrospective data review of a novel virtual form of medical SRP that in the future may lead to improved standardization of the SRP process. Medical SRP occurs in all Army posts with deployable troop populations. Although the essence of medical SRP is the same at each installation, the process varies. At Joint Base Lewis-McChord, the medical SRP is staffed by the co-located medical treatment facility. At Schofield Barracks, the SRP is staffed by 25th Infantry Division. At Fort Bragg, the 82nd Airborne Division has their own separate SRP process, while the rest of 18th Airborne Corps use a different location and process. Other sites have a basic staff for SRP and will either request temporary duty travel (TDY) or contract personnel to increase staff for larger troop movements. Despite a single Army Regulation, there has been a lack of standardization of this fundamental deployment process. During the COVID-19 pandemic, a virtual process was required to continue I Corps mission requiring social distancing. This process was assembled rapidly because of a short deployment timeline. The concept of virtual or telemedicine and its potential benefits are not new to the military, and the shift toward virtual medicine in the military preceded the onset of the COVID-19 pandemic. In 2003, Surgeon General Richard Carmona stated that "telemedicine brings us the opportunity to help in a civilian and humanitarian capacity around the world as never before." 2 In 2004, the Army began utilizing telemedicine through the Telemedicine Teleconsultation Programs Project, which provided specialty care in austere locations. Army telemedicine has expanded over the years to include mobile application systems, tele-disease management, home health care monitoring, and virtual behavioral health. 3 An article published in Military Medicine in 2019 discussed the ways in which virtual medicine, specifically mobile health, could help overcome some of the unique challenges faced by the MHS, including the ability to provide specialty support to those in remote environments or resource-limited theatres and allowing for the continuity of care despite duty station changes and deployments. 4 As the COVID-19 pandemic rages on, however, the MHS has been forced to transition to virtual medicine in day-to-day practice at a speed and scale far greater than would have otherwise taken place. The data that continue to be drawn from this expedited transition to virtual medicine continue to underscore those benefits and challenge us to think about the utilization of virtual medicine beyond the landscape of the current pandemic. This novel virtual medical SRP is just one example of how virtual medicine can be applied within the MHS and provide a potentially more cost-effective and equally efficacious process. No prior virtual SRP was found through review of the literature, making this the initial published paper regarding medical SRP. This first attempt showed the feasibility of a virtual component to medical SRP operations. This virtual medical SRP had 12.7 soldiers seen by each provider, with providers working between 4 and 10.5 hours. This was not statistically different when compared to an in-person cohort SRP as noted above. With time and practice, both the medical SRP staff and FORSCOM units can become accustomed to a virtual process and should increase the efficiency of a virtual SRP process. However, given the time it takes to chart review, interview the soldier, and document, it is unlikely that a virtual medical SRP will increase the number of soldiers each provider can see as compared to the in-person medical SRP. The benefits of a virtual SRP are that it allows the provider to work remotely outside the confines of a physical SRP structure and also allows the solider less time at the SRP to complete the myriad of other non-medical predeployment requirements. A virtual SRP process may be more scalable for larger deployment cohorts, particularly on short notice deployment orders, as multiple providers can complete the virtual process nearly anywhere with appropriate systems connection, without necessarily having to block or cancel large amounts of clinical time. Anecdotally, the soldiers who underwent the virtual SRP process seemed to prefer this process of a 20-minute phone conversation with a provider as opposed to a multi-hour-long visit to the SRP site. Further studies using validated surveys can be conducted to assess the response from soldiers, commands, and the SRP staff, which would be useful in determining the acceptance of a virtual SRP. For our virtual medical SRP trial, the 10 providers were sufficient to cover the 114 soldiers appointed in MHS GEN-ESIS. The time requirement per provider ranged from 4 to 12 hours. The 12 hours were completed by the medical director who was the medical deployment subject matter expert and was the point of contact for provider questions. The addition of at least one unit medical and one unit mental health specialist was imperative to review NO GO soldiers for both physical and behavioral health issues. Unit provider support relieved the SRP providers from placing waivers, which would decrease soldier throughput. Unit providers are requested for any large troop movement to decrease administrative burden on the medical SRP staff. For this specific deployment, the following items were waived by the gaining COCOM: hearing, vision, automated neuropsychological assessment metrics, labs (pregnancy and sickle cell), immunizations (Japanese Encephalitis Vaccine), continuous positive airway pressure waiver, and Adderall 30-day controlled substance waiver, which likely resulted in fewerNO GOs than would be typically seen. The personnel SRP functions were also waived for this deployment. With these waivers, 85% of the soldiers only required the completion of their pre-deployment health assessment. In a combat deployment, these waivers would not exist and would require a much larger proportion of soldiers who would need to complete theater-specific immunizations and labs at the SRP site. However, a large proportion of soldiers can complete the provider pre-DHA virtually. There are several areas of potential improvement identified that hindered efficiency. A finalized deployment roster was never received by the SRP site and continued to be adjusted until the deployment was canceled. This required multiple reviews of incomplete rosters to compare to each other, which delayed the MEDPROS data review. One way to improve efficiency would be to ensure the correct roster with Unit Identification Codes (UICs) is received at least 48 hours before SRP. Regarding staffing, the name and contact for information for all "guest" providers should be sent to the SRP team as early as possible to send them information before the SRP with ample time for preparation. A one-page instruction sheet was sent to the guest providers on SRP process and MHS GENESIS utilization that included use of auto-texts for appropriate documentation. A one-page quick reference sheet on most pertinent COCOM guidelines should also be included to decrease the time spent reviewing Army Regulations and COCOM medical guidelines. Our future goal is to continue to develop the virtual SRP process. The benefits of telemedicine for the medical portion of the SRP will improve both staff efficiency and clinical availability to the MTF and may provide needed standardization for the medical SRP process. Comparison with a historical cohort did show a nonsignificant difference between the number of soldiers seen per provider. However, the comparison did show that the virtual SRP group and the historic in-person SRP group did have statistical differences in age, gender, and GOs/NO GOs, which can be expected given the functions of each group (medical vs. combat units). Given the differences, it is unclear if this process can be generalized to a wider group of soldiers and further studies with larger groups would be required. A virtual SRP process that combines a pre-visit record review with a virtual pre-DHA is a viable process for SRP. Fifty-two percent of this cohort completed their medical SRP through virtual means within a 24-hour period of receiving an accurate deployment roster. The capability of a virtual medical SRP will allow resources across the Army to be utilized when needed and may allow for standardization of the medical SRP process across installations. Military health care and telemedicine US Army: US Army virtual health An editorial review of mobile health: implications for the US Military Health System None declared. None declared.