Personnel and Readiness Information Management (P&R IM), Office of the Under Secretary of Defense (Personnel and Readiness), led an in-depth analysis of the Health Treatment Record (HTR) life cycle management process. The HTR is the chronological documentation of medical, dental and mental health care received by a service member during the course of his or her military career. The Principal Deputy Under Secretary of Defense (PDUSD) for Personnel and Readiness chartered the project to improve the processes for the management and disposition of HTRs to ensure service members and veterans receive their benefits in a timely manner.

The analysis of DoD and Department of Veterans Affairs (VA) data proved critical to identifying inefficiencies associated with record processing time within and between the services and VA. Based on the findings, the analysis team developed recommendations for improvements in the management and handling of HTR information for both near-term and long-term implementation. This continuous process improvement analysis used Lean Six Sigma’s DMAIC methodology.

The Problem

In the past, DoD maintained ownership of HTRs but transferred them to VA to support pre- and post-discharge claims processing. Inefficient HTR life cycle processes presented records management challenges for both DoD and VA, and led to a delay in the delivery of healthcare-related benefits to service members and veterans. The HTR life cycle processes were error prone and inefficient because of over-processing, inconsistent practices, limited interoperability between DoD and VA’s multiple systems, and inadequate oversight and training. This resulted in systemic backlogs of HTRs at multiple DoD locations, including military treatment facilities. As a result, the VA received late and incomplete HTRs and loose and late-flowing documentation from the services. This had a significant impact on fit for duty and profile determinations, VA claims processing, and service members’ lives and well-being.

To understand the magnitude of the problem, P&R IM obtained data on more than 12,000 service members separated, discharged or retired between April 30 and May 30, 2008, including the service members’ corresponding separation/discharge/retirement dates. This data was cross-referenced with the VA’s database of all HTRs received for the time period of May 2 – September 15, 2008. The analysis revealed that only 54 percent of HTRs were received by the VA within 40 days (DoD’s target for delivery to VA) of a service member’s separation/discharge/retirement. Additionally, as of September 15, 2008, VA could not account for 2,397 HTRs (equivalent to approximately 20 percent of the total).

The analysis team also assessed the cost impact of processing loose and late-flowing HTR documents. The cost to transfer HTRs was accounted for in both departments’ budgets; however, the enormous volume of loose and late-flowing HTR documentation represented an additional cost that was not factored into the budgets. Therefore, the team examined the financial impact of the loose and late-flowing HTR documents based on the DoD inventory of 1,118 boxes of loose/late-flowing documents on September 5, 2008. The team used Army Human Resources Command labor rates to calculate the DoD labor costs. The team then combined the labor cost estimate with the cost of mailing the documents to VA to develop a total DoD cost estimate of $12.7 million for the 1,118 boxes. The VA then spends an additional $2.6 million to process them. This results in a total cost of $15.3 million to process the 1,118 boxes of loose and late-flowing documents. These figures do not take into account the personal cost and hardship service members and veterans incur – the team estimated that the 1,118 boxes of loose/late-flowing documents would affect more than 72,000 claims.

Improving the Process

As part of the Define phase, the joint DoD/VA-sponsored HTR Interagency Task Force and the Medical Records Working Group provided information and guidance to develop the HTR Analysis Lean Six Sigma Charter. The charter provided the project’s problem statement and objective; identified the functional team, suppliers, and inputs, processes, outputs and customers (SIPOC); and established a timeline with target completion dates for each DMAIC tollgate. The charter also established customer specifications that required DoD to assemble a complete HTR within 30 days of the date of a service member’s separation/ discharge/retirement, and provide VA access to complete HTR information for 95 percent of service members and veterans within 10 days of this 30-day window.

To complete the Measure and Analyze phases and assess the “as-is” state of HTR life cycle management, the team facilitated four HTR Lean Six Sigma working group sessions, conducted 19 site visits, and gathered and analyzed information from the services, the Defense Manpower Data Center and VA. This information helped to determine the current record transfer time between DoD and VA, assess the impact of loose and late-flowing HTR documentation on claims processing, and estimate the total costs associated with processing loose and late-flowing documentation. The working group sessions and site visit interviews included discussions on the creation, receipt, maintenance, usage, transfer and disposition of the HTR. During the sessions, the services and VA validated their process models for each phase of the HTR life cycle. In total, the team developed 28 process models, depicting each phase of the HTR as-is life cycle for each service, their components and the VA. Input from the sessions and site visits revealed HTR process life cycle issues and related metrics.

The team assessed the data gathered in the Measure phase by analyzing the as-is state, and identifying non-value added activities, bottlenecks and waste, as well as their root causes. Some of the initial findings included:

• Inconsistent HTR practices between the services and between individual facilities
• Personnel and resource constraints
• Lack of interoperability between DoD and VA information systems
• Inability to gather complete HTR documentation from a single source
• Problems related to the existence of the hybrid record (a record consisting of both paper and electronic elements)

At the conclusion of the Analyze phase, the project team identified shortcomings in the current processes and policies for managing HTRs and categorized those shortcomings into nine major issues and 26 underlying issues.

The Results

To address the nine issue categories and 26 underlying issues, the team developed an Action Plan, inclusive of 55 recommendations. The Action Plan is the foundation for follow-up projects and efforts that could develop and/or implement Improve and Control activities.

The team developed the recommendations to improve the management of the HTR life cycle and ultimately meet the project’s goal of providing VA with complete HTR information within 40 days of a service member’s separation/discharge/retirement. P&R IM used Kaizen to prioritize the recommendations based on the level of effort to implement and the impact of the change. The specific recommendations coalesced around three major workstreams:

• Creating an electronic health record (EHR) maintained and owned by DoD. The EHR would be accessible by authorized DoD, VA and service members
• Establishing and updating DoD and services’ policies
• Establishing a military HTR records disposition schedule

The Action Plan recommended an EHR as the long-term solution, and a bridge solution until a complete EHR is available. The bridge solution would enable DoD to deliver a service member’s HTR to VA within 40 days of separation/discharge/retirement. As currently envisioned, the bridge solution would provide VA with electronic access to the service member’s medical and dental records via a one-stop DoD HTR portal. The portal would display information from HTR repositories upon query from authorized DoD and VA users. The EHR/HTR repository would store converted paper records in electronic format.

Additionally, the “to-be” processes would provide:

• Efficient records management practices through policy development and implementation
• An impetus for development of sound transition and implementation plans to promote enterprise-wide, full EHR implementation with interoperability
• Accountability for completeness through regular verification of the records with the service member and healthcare provider
• Verification at critical stages of the service member life cycle. (e.g., permanent change of station, deployment, mobilization, demobilization and separation/retirement)
• “On demand” records access to VA for benefits adjudication via the DoD portal

The to-be process would streamline the HTR life cycle management process by eliminating inefficient activities. For example, the process improvements would eliminate over-processing of the record during each life cycle phase. Scanning paper documentation, and combining it with electronic data, would convert the hybrid record into a fully electronic format. An EHR repository, providing authorized users access to information, would eliminate the need to transfer records and thereby significantly reduce the number of opportunities where HTR information may be lost. This, paired with the fact the VA would no longer have a need to dismantle the paper HTR, would preserve the integrity of the record.

Additionally, as DoD would develop and manage the portal, it would retain full ownership, physical control and oversight of the HTR. Finally, the processes would significantly reduce DoD and VA expenses by eliminating HTR and loose/late-flowing documentation storage and handling costs. This in turn would reduce VA’s labor costs associated with reworking service members’ benefits claims. Collectively, the efficiencies of the HTR life cycle management process would provide the most compete and accurate HTR information at any single point in time.

For the complete listing of the HTR Analysis Report Issues and Recommendations, please visit: https://www.mpm.osd.mil.