AD-A144 839 AMBUATAORY CARE DATA BAS PART B(U) ARMY HEALTH CARE 1/3STUDIES AND CLIRCAL INVETGATIONACTVY FORT SAM

HOUSON TXTR MI K ET AL 6MAR 84

ARCLASSFED HCSCA 83009 PT-B IDG 6/5 NI

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qt LTC T. R. MisenerMrs. P. M. Gilbert

FINAL REPORT #8.3-009

PART B

MARCH 1984

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uj US ARMYHEALTH SERVICES COMMAND A

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SFORT SAM HOUSTON, TEXAS 78234

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READ INSTRUCTIONSREPORT DOCUMENTATION PAGE BEFORE COMPLETING FORMI. REPORT NUMBER 2. GOVT ACCESSION NO. 3. RECIPIENT'S CATALOG NUMBER

83-009 Part B DAOG9528A

4. TITLE (and Subtitle) S TYPE OF REPORT & PERIOD COVERED

Final Report(U) AMBULATORY CARE DATA BASE Nov 82 - Mar 83

6. PERFORMING ORG. REPORT NUMBER

83-0097. AUTHOR(&) S. CONTRACT OR GRANT NUMBER(a)

LTC T. R. Misener, ANCP. M. Gilbert, DAC

9. PERFORMING ORGANIZATION NAME AND ADDRESS A0. PROGRAM ELEMENT. PROJECT TASK

Health Care Studies and Clinical InvestigationActivity, Health Services Command, Ft. Sam HHouston, Texas 78234

t. copT-RJLIlINtOFFIC NAIIE AND ADORE S 12. REPORT DATE.ea C n O Nare Nuaees and Cinical Investigation 16 Mar 1984Activity, Health Services Command, Ft. Sam ,3 NUMBER OF PAGESHouston, Texas 78234 190

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Unclassified

15. DECLASSIFICATION/DOWNGRADINGSCHEDULE

16. DISTRIBUTION STATEMENT (of this Report)

Approved for public release; unlimited distribution.

17. DISTRIBUTION STATEMENT (of the abstract entered In Block 20, If different from Report)

15. SUPPLEMENTARY NOTES

19. KEY WORDS (Continue an reveree side If neceeeary and Identify by block number)

Active Army, Medical, Management, Decision, Policy, Evaluation

20. FRcwrmetusa - vae hft flnecesy adIdeofify by block number)"XA partof the FY"83 AMEDD Study Program, the Surgeon General of The Army

tasked the Health Care Studies & Clinical Investigation Activity (HCSCIA) toinvestigate the need for an Ambulatory Care Data Base (ACDB). The studyproposed to answer two questions: 1) Is it possible to capture the necessaryinformation for an ambulatory data base (will health care providers completeencounter forms in addition to entries they are required to make in theoutpatient medical record) and 2) What types of reports can be generated fromthe data gathered. A six month project was conducted at Fox Army Hospital,

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Redstone Arsenal, Alabama (this MIF met the requirement of separateoccupationalhealth, troop, and outpatient clinics). The 10,000 - 13,000patients seen each month, clerical staff, and primary care providers assistedin completing a "Mark Sense" data capture form using the National ComputerSystems (NCS) Sentry 7001 Table-Top Optical Mark Sense Reader.(OMR). Afterconsultation with other health care providers, a two-sided, single sheet,multicolored form (purple and red) was designed to be different from anyexisting military forms. Major elements on the form were: demographic data(including occupational), provider identification, physical examinations,procedures performed, eligibility for care, referrals, disposition to includewhether the diagnosis was job related, and diagnostic data. The internationalclassification of health problems in primary care (ICHPPC-2) codes were used;the encounter form allowed space for only 250 of a possible 371 diagnoses.However, additional diagnoses could be found in a preprinted index and enteredin spaces provided. Actual data collection began on 1 Nov 82. Withapproximately 60,000 records in the database, it has been demonstrated thatpersonnel will complete the encounter forms. Three major categories ofreports can be generated: 1) provider profile reports, 2) reports useful tomanagement, e.g., MED 302, and 3) special reports not generated on a recurringbasis.

CONCLUSIONS: The overall objectives of the study have been met: 1) theelements to be collected for an ambulatory care database have been identified.A significant number could be standardized across MTFS, however, the need forsite specific variables is recognized, 2) the majority of care providers willcomplete their portion of the encounter form, 3) a single encounter form forall clinics is not acceptable, 4) data collected can be audited and provide anobjective and valid ambulatory peer review and quality assurance mechanism, 5)provider and clerical staff satisfaction was surveyed, 6) comparison ofencounters from the ACDB and the MED 302 was accomplished, 7) the number ofreports that can be developed from the data are limited only by the usersimagination. The MED 302 can be captured from the data elements, 8) the OMRmethod of data capture was shown to be efficient and cost effective, 9)problems needing resolution in future use of an ACDB were indentified, 10) theneed for command emphasis, at the highest levels, is obvious.

RECOMMENDATIONS: Recommend that this inexpensive and reliable datacollection methodology be tested at more sites for eventual implementation.Even if an ambulatory care database is not developed, it provides anefficient, reliable, and low labor intensive method to capture data which areneeded by the Army. The use of the discussed method is highly practicalbecause it will interface with any system or mainframe conceptualized orplanned at this time. It provides an excellent interim system until theComposite Health Care System (CHCS) is implemented. Finally, it cancontinue to be used in areas where a CHCS is not practical or planned, e.g., afield environment.

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Redstone Arsenal, Ala~ama (this MIF met the requirement of separateoccupationalhealth, troop, and outpatient clinics). The 10,000 - 13,000patients seen each month, clerical staff, and primary care providers assistedin completing a "Mark Sense" data capture form using the National ComputerSystems (NCS) Sentry 7001 Table-Top Optical Mark Sense Reader,(OMR). Afterconsultation with other health care providers, a two-sided, single sheet,multicolored form (purple and red) was designed to be different from anyexisting military forms. Major elements on the form were: demographic data(including occupational), provider identification, physical examinations,procedures performed, eligibility for care, referrals, disposition to includewhether the diagnosis was job related, and diagnostic data. The internationalclassification of health problems in primary care (ICHPPC-2) codes were used;the encounter form allowed space for only 250 of a possible 371 diagnoses.However, additional diagnoses could be found in a preprinted index and enteredin spaces provided. Actual data collection began on I Nov 82. Withapproximately 60,000 records in the database, it has been demonstrated thatpersonnel will complete the encounter forms. Three major categories ofreports can be generated: 1) provider profile reports, 2) reports useful tomanagement, e.g., MED 302, and 3) special reports not generated on a recurringbasis.

CONCLUSIONS: The overall objectives of the study have been met: 1) theelements to be collected for an ambulatory care database have been identified.A significant number could be standardized across MTFS, however, the need forsite specific variables is recognized, 2) the majority of care providers willcomplete their portion of the encounter form, 3) a single encounter form forall clinics is not acceptable, 4) data collected can be audited and provide anobjective and valid ambulatory peer review and quality assurance mechanism, 5)provider and clerical staff satisfaction was surveyed, 6) comparison ofencounters from the ACDB and the MED 302 was accomplished, 7) the number ofreports that can be developed from the data are limited only by the usersimagination. The MED 302 can be captured from the data elements, 8) the OMRmethod of data capture was shown to be efficient and cost effective, 9)problems needing resolution in future use of an ACDB were indentified, 10) theneed for command emphasis, at the highest levels, is obvious.

RECOMMENDATIONS: Recommend that this inexpensive and reliable datacollection methodology be tested at more sites for eventual implementation.Even if an ambulatory care database is not developed, it provides anefficient, reliable, and low labor intensive method to capture data which areneeded by the Army. The use of the discussed method is highly practicalbecause it will interface with any system or mainframe conceptualized orplanned at this time. It provides an excellent interim system until theComposite Health Care System (CHCS) is implemented. Finally, it cancontinue to be used in areas where a CHCS is not practical or planned, e.g., afield environment.

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TABLE OF CONTENTS

PAGE

REPORT DOCUMENTATION PAGE ......................................

TABLE OF CONTENTS.................................................. iii

LIST OF FIGURES .................................................... iv

LIST OF APPENDICES................................................. v

ACKNOWLEDGEMENTS................................................... vii

SUMMARY.......................................................... viii

INTRODUCTION ....................................................... 1I

Purpose ........................................................ 1I

Background..................................................... 1I

OBJECTIVES ......................................................... 3

LIMITATIONS OF STUDY............................................... 3

METHODOLOGY....................................................5

Overview........................................................ 5

Procedures...................................................... 8

FINDINGS........................................................... 11

DISCUSSION......................................................... 12

CONCLUSIONS........................................................ 21

RECOMMENDATIONS .................................................... 21ADDE DUM... ... ... .... ... ... ... ... ... .... ... ... ... ... .2ADDEENUM.......................................................... 22

REFEIRCES........................................................ 25

LIST OF FIGURES

FIGURES PAGE

1 Demographic Data (OEF) .................................. 6

2 Diagnoses (OEF) ......................................... 6

3 Additional Diagnoses (OEF) .............................. 7

4 Flow Chart (Redstone Operation) ......................... 10

5 Graphic Presentation-Provider Percentages forTotal Visits .......................................... 11

6 Graphic Presentation-Time Spent with Provider ........... 12

7 Flow Chart (Central Appointment System) ................. 18

8 Flow Chart (Manual System) .............................. 19

9 Conceptual Configuration (Central Appointment System)... 20

10 New Form Element (Complexity-Patient Problem) ........... 22

11 New Form Element (Additional Procedures) ................ 23

12 New Form Element (Time Spent With Provider) ............. 23

iv

APPENDIXES

PAGE

A Family Practice Center Encounter Form ....................... 29

B Methods of Data Entry--Advantages/Disadvantages ............. 32

C Outpatient Encounter Form (Test) ............................ 34

D ICHPPC-2 & ICD-9 CM Code Numbers ............................ 37

E Care Provider Codes ......................................... 48

F Clinic Codes ................................................ 50

G Family Member Prefix Codes .................................. 52

H Other Patient Category Codes ................................ 54

I Care Provider Instructions .................................. 57

J Patient Instructions ........................................ 59

K Clerical Staff Instructions ................................. 61

L Edit Code Sheet ............................................. 63

M Outpatient Encounter Form Test--Conversion Program .......... 65

N Memorandum to Care Providers ................................ 71

0 Provider Profile Report ..................................... 74

P Encounters per Clinic per Month ........................... ..89

Q Forms Completed per Care Provider (Jan/Fam Practice) ........ 95

R MED 302 Report .............................................. 97 *1

S MED 302 Svc Branch Total .................................... 118

T MED 302 Svc Branch Total (OH and TMC) ....................... 121

U Examinations Chaperoned per Clinic per Month ................ 124

v

APPENDIXES (Contd)

PAGE

V Students from Other Countries (Table V-i & V-2)

Table V-i Number of Encounters ....................... 127

Table V-2 Breakdown by clinic, date, & diagnosis ..... 128

W Management Reports (Table W-1 & W-2)

Table W-1 Profile Report (Fam Prac/Jan) .............. 132Table W-2 Peer Review (Otitis Media/Peds/Jan) ........ 147

X Number- of Procedures (Total Study) ...................... 152

Y Number of Referrals (Total Study) ....................... 156

Z Number of Examinations (Total Study) .................... 159

A-A Number of Dispositions (Total Study) .................... 161

B-B Primary Diagnoses (Total Study) ......................... 163

C-C Diagnostic Clusters ..................................... 170

D-D Comparison MCCU Count/Encounter Forms ................... 174

E-E Care Provider Questionnaire ............................. 176

F-F Clerical Staff Questionnaire ............................ 179

G-G Letter from MEDDAC Commander ............................ 181

H-H New Registration Form (Draft) ........................... 183

I-I New General Outpatient Form (Draft) ..................... 186

J-j New Preventive Medicine Form (Draft) .................... 189

vi

Acknowledgements

It is not possible to acknowledge all persons responsible for the successof this study, however, several played a vital role. COL James J. James, MC,and MG Quinn Becker, MC, were responsible for identifying the need for the studyand were instrumental in seeing that it was included in the AMEDD Study Program.COL Robert C. Todd, Study Director, Ambulatory Care Division, Health ServicesCommand, and his staff, provided ongoing encouragement and support especiallyduring the initial phase of the study when many others were less optimisticabout the possibility of such a study.

Because of the magnitude of the study the need for command emphasis wasimperative. Therefore, special recognition should be given to the twocommanders who were instrumental in allowing the study to be conducted at theirMEDDAC. COL John N. Bogart recognized the need for such a study and, during theconceptual phase, invited us into his facility. COL Graham E. Beard, upontaking command, followed through with the commitment and actively supported theendeavor taking the risk of exposing his MEDDAC for high level scrutiny. At thecompletion of the study COL Beard went one step further and implemented thesystem on an operational basis.

CPTs Keith Cuff, MSC, and Bruce McIntosh, MSC, the two Chiefs of ClinicalSupport at Fox Army Hospital were the day-to-day points of contact at theMEDDAC, supplying the detailed tracking of the data capture. Pauline Occomytook responsibility for the management of the data collection and the opticalmark reader became "her baby." Hubert Smith of the Missile Command ComputerCenter provided the necessary link between the MEDDAC and the mainframe computerfacility at HCSSA. Skip Cole and Warner Carlisle from HCSSA provided theprogramming support and preprocessing of the data so that the investigatorscould analyze the data. Mr. Harold Hill, the vendor's (National ComputerSystems) representative, went far beyond the requirements of the contract toassist the study staff so as to provide the best test possible.

But, most importantly, the entire staff of Fox Army MEDDAC accepted theadded burden of collecting the data required for the study. The AMEDD owes thema debt of gratitude.

vii kl k

SUMMARY

Providing outpatient health care for over twenty million outpatients peryear, the US Army is considered one of the largest Health MaintenanceOrganizations in the world. It has long been recognized that the Army'sInpatient Data System (IPDS) provides a wealth of data to carry out healthservice research and to assist in management decisions. Outpatient data havebeen less abundant. A six month study was undertake, to collect outpatientencounter information (including demographic data, workload, and diagnoses) atFox Army Hospital, Redstone Arsenal, Huntsville, Alabama, using the NationalComputer Systems (NCS) Sentry 7001 Table-Top Optical Mark Sense Reader (OMR).A multicolor form was designed and included a total of 371 possible diagnoses;the form allowed for the selection of one primary and five secondarydiagnoses for each encounter. This methods study proposed to answer twoquestions: 1) is it possible to capture the necessary information for a data-base? i.e., will health care providers complete encounter forms in addition toentries they are required to make in the outpatient medical record; and 2)what types of reports can be generated from the data gathered?

Data collection began on 1 November 1982; patients, clerical staff, andprimary care providers all assisted in completing the mark sense data captureform. Completed forms were processed locally (up to 900 forms per hour can beread by the particular table top reader being used for the test), and scannedto tape, which was then transferred to Fort Sam Houston, Texas. A compressionand edit program, creating a 220 character record, was written by personnel ofthe Health Care Systems Support Activity (HCSSA) and then merged with SPSS(Statistical Package for the Social Sciences) for data manipulation and reportgeneration. Profile reports were furnished (on a monthly basis) to each careprovider. The major reporting elements were: 1) primary diagnoses , 2)procedures, 3) demographic data, 4) beneficiary status of patient and, 5)number and types of physical examinations done. At the end of the study withapproximately 60,000 records in the database, it has been demonstrated that:1) personnel will complete the encounter form, 2) data can be audited,therefore, providing the basis for quality peer review, 3) the formeffectively fulfills current reporting requirements, e.g., the Med Summary302, and other administrative reports, 4) the optical mark reader is areliable data collection method. The number of reports and tables that can begenerated are limited only by the user's imagination.

In any future form design, a list of standard common procedures from amenu is recommended; this list should also provide space where less commonprocedures could be entered from tables. No single page form can meet thecomprehensive needs of every MTF, however, several forms could be developedfor different specialties (e.g., pediatrics, occupational health, etc.).Recommend that this inexpensive and reliable data collection method betested at more sites for possible Army-wide implementation.

vi

viii.

1. INTRODUCTION.

a. Purpose.

Recognizing the need for an Ambulatory Care Database (ACDB), The ArmySurgeon General tasked the Health Care Studies Division (HCSD), Health CareStudies & Clinical Investigation Activity (HCSCIA), to examine the feasibilityof implementing such a study. The study proposed to answer two questions:

(W) Is it possible to capture the necessary information for anambulatory database? (i.e., will health care providers complete encounterforms in addition to entries they are required to make in the outpatientmedical record).

(2) What types of reports can be generated from the data gathered?

b. Background.

Although reports, to document Army outpatient workload, are generat ona recurring basis the reliability of the data and their usefulness has fquestioned. The outpatient's individual health record contains routineinformation expected in any outpatient treatment setting. However, obtL naggregate data, auditing a random set of outpatient records, documentingindividual health care providers' practice profiles, or carrying outepidemiological research, has not been possible.

A literature search was conducted to include a review of the developmentof standardized diagnostic codes, data systems, methods of data collection, andmedical information management. Subsequent telephonic communications and sitevisits were made to explore available systems and to obtain guidance fromthose experienced in the field.

Several citations were found of ambulatory diagnostic coding schemes,their development, and use (Cote & Robboy, 1980; Schneider & Kilpatrick, 1974;Steinwachs & Mushlin, 1978; Anderson & Lees, 1978; and Tindall et al., 1981).The coding scheme discussed by Tindall et al. (1981) appeared to be the mostprevalent and acceptable in the primary care settings. It had been developedby The World Order of National Academies of Family Physicians/GeneralPractitioners as a truncation of the International Classification of Diseases(1977) and published as International Classification of Health Problems inPrimary Care (WHO, 1979), with an abbreviated title of ICHPPC-2.

A seven part series of articles appeared in The Journal of FamilyPractice (1977), which discussed the use of an integrated medical record anddata system for primary care using the ICHPPC-2 codes. Pack & Parrish(1974) published a thesis: Development of a Long-Term Process for Collectionof Doctor-Patient Encounter Data in an Ambu1atory Care Facility. This thesisdiscussed a pilot effort in development of a system to capture outpatientencounters in an Army facility. This method required key punching data andwas labor intensive.

A limited attempt to gather information in an automated mode has beencarried out at Family Practice Residency programs throughout the Army. Ananalysis of the system was described by Howard (undated paper) at MadiganArmy Medical Center. This appeared to be an excellent method meeting theneeds of users to document resident physician's experiential base while makingprogram management and research possible. The centralized database ismaintained at Fort Sam Houston, Texas. Again, the major disadvantage of theFamily Practice dataset has been the requirement to keypunch the data, whichnecessitated one to two full-time employees at each site, (Appendix A providesa sample of the Family Practice Center Encounter Form). This same disadvantagewas noted by Baker, Monson, & Jameson (1981), at Little Rock Veterans'Administration Hospital. The experience of the U.S. Public Health Service(MIDS, 1980) documents the management potential of a multi-site computerlinked database to monitor workload, assist in fiscal apportionment and trackprescriptions filled for beneficiaries within the PHS. Project officers forthe system were enthusiastic about its potential. However, this database waslost when the PHS ceased operating their health care system. Again the needto keypunch data entries was recognized labor intensive. The Bureau of IndianAffairs, (PHS) still uses a key entry method to aggregate workload data, (BIA,1982). Gelbach (1979), at the Duke-Watts Family Medicine Program, reportedthree methods of data collection including: write-in encounter form, checklistencounter form, and direct entry from the medical record. All methods requiredkeypunut or keyboard entry.

A site visit was made to the U.S. Army Family Practice Residency Programat Fort Ord, California, to examine their Computer Stored Ambulatory Record(COSTAR) system ("MITRE Corp.," 1978). The database and its managementpotential were impressive. The disadvantages of COSTAR included: i) require-ment's for terminals in each providers office in addition to those in theclerical area, 2) physicians need to key enter their own data, 3) backup hardcopy when the system was "down." COSTAR did not provide a feasible inexpensiveinterim system which could be used Army-wide prior to installation of theComposite Health Information System (CHIS).

The fiscal intermediary's data processing center for Medicare/Medicaidein the State of Texas was visited. Data are received from throughout the statewhere they are captured using optical character reading methods. The majordisadvantages included the need for on-line editing to correct errors andcentralized processing necessary due to the high cost of optical characterreaders. This method requires that those entering the original data writealphabetic letters and numbers in a standard manner. Errors are decreasedwhen physicians have adequate clerical staff to maintain data entry.

The least labor intensive method of data collection reviewed was theoutpatient medical treatment reporting system for shipboard use (Hermansen,Jones, & Butler, 1980). This system used an optically scannable summary ofthe treatment provided. A separate form was completed for each encounter andwas found to be a highly reliable, inexpensive and rapid form of data entry.The investigators were highly encouraged that this might someday provide thebasis for a Navy-wide system.

2I..

2. OBJECTIVES. During the six-month Redstone ACDB Test the objectives were:

a. Identify elements to be collected for an ambulatory care database.

b. Determine the effectiveness of using a single encounter form foroutpatient clinics, troop medical clinics, and occupational health clinics.

c. Determine if collected data can be audited, therefore, providing thebasis for peer review.

d. Measure satisfaction of both care provider and clinic staff with theform and output from collected information.

e. Determine ACDB effectiveness in fulfilling current reportingrequirements, e.g., the MED Summary 302, and other administrative reports.

f. Compare the number of visits reported by the MED Summary 302 and theACDB visit count.

g. Determine the effectiveness of the optical mark reader as a reliabledata collection method and identify any problems with the hardware.

h. Identify problems needing resolution if the ambulatory care databasesystem were expanded to other sites.

i. Identify personnel requirements and qualifications for an ongoingdecentralized database collection system.

3. LIMITATIONS OF THE STUDY.

The study was limited to Tri-service Medical Information Systems (TRIMIS)areas of non-interest. That is, although AR 5-5 allows much latitude in thetypes of studies that can be carried out, study efforts should not duplicateor interfere with TRIMIS plans. TRIMIS was not actively planning or imple-menting outpatient workload and epidemiology reporting systems as envisionedby this study; however, they were involved in laboratory, pharmacy, andradiology systems. Therefore, no plans were made to include definitive datacapture in these areas. However, it was recognized that the laboratory,pharmacy and radiology data captured under TRIMIS systems were not tied toindividual patients allowing for later merging of the data with the ACDB.Discussions with Army TRIMIS at the outset of the conceptual plan of this study,revealed no problems with the study objectives and methodology; the ACDBinvolved a method of data capture compatible with any mainframe system. Becausethe proposed method of data capture involved automation, it was necessary tofollow AR 18-1, "Management Information Systems: Policies, Objectives,Procedures, and Responsibilities."

3

Other limitations and caveats of the study were divided into threecategories:

Resource constraints (direct costs not to exceed $10,000).Amount of data gathered must be reasonable.Lessons learned from other studies regarding data entry used.

a. Resource constraints included both time and personnel. The datacollection phase of the study was to be completed by the end of the 3D QTR FY83. No full-time employees could be added for the study, i.e., personnelrequired were to be existent within the Health Care Studies Division, themedical activity where the study was to be carried out, and from shared dataprocessing staff.

b. Prior studies demonstrated that the data gathering tool needed to beprovider centered. Any table look-ups required by the provider should be keptto a minimum, and providers must feel the project to be symbiotic, i.e., theywould gain something in return for their efforts. To be most effective, thedata encounter form could not exceed one page (8J x 11).

c. Four alternative methods of data entry were examined. The advantagesand disadvantages of each are listed in Appendix B. The ACDB project was en-visioned as an interim system to be utilized in gathering data necessary beforethe "total hospital information system of the 1990's" was extant. With thisin mind, it was not plausible to consider use of terminals in each provider'soffice and in all administrative elements. Keypunching of data had been shownto be too expensive in the Family Practice Database. When extrapolated to theentire AMEDD the expense in using this method was believed unreasonable, tosay nothing of transcription errors. The remaining two methods, viewed asless labor intensive and allowing for use of leased equipment, were theoptical character reader (OCR) and the optical mark sense reader (OMR).Individuals possessing experience with OCR stressed three major disadvantages:

(1) hardware is extremely expensive

(2) centralized processing is required and therefore increases theturnaround time involved in error correction

(3) vendors of OCR equipment cite error rates of between 5-33% dependingupon the inputting individual's familiarity with the method, andtheir ability to write alpha numerics in standardized formats

Based on the experiences of the U.S. Air Force, several university testingfacilities, and the Academy of Health Sciences Correspondence Course Program,the OMR method was chosen. This method was deemed most reliable and providedmaximum decentralization of data processing, while being compatible with anymainframe for "uploading" as it produced a simple record of binary data.

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4. METHODOLOGY.

a. Overview.

(1) Site Selection. Several sites for the study were considered. Onecriterion for selection was that the MTF have separate occupational health,troop, and outpatient clinics. The site chosen was Redstone Army Arsenal,Huntsville, Alabama, as it met the criterion, and provided a MEDDAC of compara-ble size to another site which had been slated for an OCR study ("UnitedStates," 1981). Another significant factor in the selection of Redstone wasthe expressed desire on the part of the command staff to participate in thestudy.

(2) Participants. A six month project was undertaken to collectoutpatient encounter information (including demographic data, workload, anddiagnoses) at Fox Army Hospital, Redstone Arsenal. The 10,000 - 13,000 patientsseen each month, the clerical staff, and primary care providers all assisted incompleting a "mark sense" data capture form.

(3) Hardware. The hardware selected was the National Computer Systems(NCS) Sentry 7001 Table-Top Optical Mark Sense Reader, with tape drive andtransport printer attached. This equipment was compatible with hardwareexisting within HSC and a proposed Air Force study. NCS forms with an indivi-dual lithocode printed on each form facilitated merging/finding recordseasily. NCS was the only vendor known to provide this feature.

(4) Encounter form development. After site selection, it was necessaryto create the two-sided, single page encounter form (Appendix C). A multi-color form (purple and red) was designed to be different from any existingmilitary forms. The face validity of the form was assured by the investigatorsafter consultation with other health care providers, public healthprofessionals, and providers at Redstone. The major data elements collected onthe encounter form were:

demographic data (including occupational site for civilians)provider identificationphysical examinationsprocedures performedeligibility for carereferralsdisposition to include whether the diagnosis was job relateddiagnostic data

5

Ok

Sample demographic data are shown in Figure 1. Diagnostic codes included actuz]diagnoses, signs, symptoms, questionable laboratory findings, or a series ofwellness oriented reasons for care (see Figure 2).

I-C t Om DIAGNOSES

00AA NO S Ii~PIA I Ii'

*WUILNS PAY If ARMY DUTYI-nl

3 1 7 1 -.2 ) fil0.1 OA SW

43)43041 4*0f

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Figure 1 'kI'lllB-P I. WORI LAIl

'36 Dso F Ilifffr P4045SIic alS(ISFS Wfj_-

6111A 15511A 1 SYMPTOMS

ARp III'S.r I'PIFING '

f MA70.! A I 11TH IIII VI N II N' p

FF5 X IAI II ASIO I ISll Ii

VW' 1191 II AIIl - 11 l N 11 VIill S

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Figure 2

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rI(5) Diagnostic Codes. Overall Army needs mandated that diagnostic

intorination be a priority element in the database. After review of severaloutpatient diagnostic codes, the International Classification of HealthProblems in Primary Care (ICHPPC-2) was selected (truncations of the ICD-9classification ("Ninth Revision," 1977)). The codes were simple to use, andhad previously been used for the family practice database. The encounterform allowed space for only 250 of the possible 371 diagnoses. The remainingdiagnoses not on the menu could be found in a preprinted index and thenentered in spaces provided (see Figure 3):

0 50

Fiqure 3

Along with the demographics, the diagnostic information provides the core ofthe epidemiological data. These same data gave the MEDDAC the ability tocarry out peer review and retrospective chart audits in a reliable andobjective manner. Some demographic data elements such as race and ethnicitywere included as recommended by the National Center for Health Statistics("National Center," 1974) as part of a "minimum basic data set."

(6) Unique Element Rationale. Three groups of elements (federalemployee data, care providers, and students from other countries) needexplanation. The civilian occupational series numbers for federal employeescorrespond to standard job titles; building number refers to the employees'usual work site. These variables provided the basis for epidemiological studiesby the occupational health physicians. The fields "#1 and #2 care provider"allowed for documentation when more than one provider saw a patient. Forexample, if a patient were to be first seen by a physician's assistant, a nursepractitioner, or even a general medical officer, and then subsequently seen byanother provider (e.g., a specialty physician), both individuals would becredited for seeing the patient. The variable "Students from Other Countries"was requested by the treasurer to enable fiscal reimbursement from embassies forhealth care services provided to foreign nationals who are students at Redstone.

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I '-4.

(7) MTF Needs. Finally, it should be noted that several of the elementson the sample encounter form reflect unique needs of the medical treatmentstudied. An example is the field indicating whether an examination waschaperoned, requested by the Department of Nursing, for manpower documentation.The remaining elements on the form are self-explanatory.

b. Procedures.

(i) A pilot test of the instrument was carried out at Fort Hood, Texas.Twenty nurse practitioners used the encounter form to note any difficultyin flow or tracking. After the one day test a debriefing was held with thenurses and subsequently, minor form design and instruction sheet changes weremade. A major change, suggested and incorporated, was to request able patientsto complete their portion of the form.

(2) Staff training began two weeks prior to the collection of data.The Chief, Clinical Support, scheduled all clinic receptionists and primaryproviders to attend an orientation. Training was carried out by theinvestigators (a nurse experienced in primary care and a management analyst).Each trainee was informed about the data elements that required their attentionas well as the overall concept of the project. During the orientationproviders practiced using ICHPPC-2. Also, they were informed that regularpractice profiles would be furnished and they would have access to data forresearch and credentialling purposes. (Appendix D shows the ICHPPC-2 index.)

(3) Prior to the implementation of the study, care providers wereassigned a code number which was used in conjunction with the last four digitsof their social security number, i.e., physicians: 1 + last four = 12345;(see Appendix E); a two digit number was assigned to each clinic (seeAppendix F); family member prefix codes were defined (see Appendix G);and "other" patient category codes were taken from the beneficiarycodes already established for the Medical Summary 302 Report (see Appendix H).Three sets of instructions were prepared for each of the following:providers, patients, and the clerical staff. (See Appendixes I thru K.)

(4) Patients were instructed to complete their portion of the demographic-type data which was checked for completeness and accuracy by the clericalstaff; the clerical staff then entered the clinic identifier, family memberprefix (to identify household status of the patient), appointment status, andtime in. The remainder of the form was completed by the providers. Theclerical staff monitored completeness and entered the time out of the clinic.The encounter form allowed the provider to select one of 371 diagnostic codesas the primary reason for seeing a patient on a particular visit. One primarydiagnosis was required. Additionally, the providers were allowed to select upto five secondary diagnoses germane to a particular visit (a secondarydiagnosis was not required). Data collection began on 1 November 1982. Itwas expected that 80,000 forms would be consumed within six months.

8

-- ...... r -. mh, ..

dI

(5) The patient portion of the form could be completed in about twominutes; the provider data required about 30 seconds (after providers becamefamiliar with frequently used diagnoses). Clerical staff required about 30seconds to check and complete each form. After the encounter forms were com-pleted and checked for errors in the clinic, they were taken to a central pointin the Administrative Department of the MEDDAC, where one of three trainedpersons processed the records. Up to 900 forms per hour were read by theparticular table top reader used for the test. The first time records wereread, they were scanned only, i.e., errors are identified by an internal programin the readers edit routine (see Appendix L).

(6) Error fields are marked along timing marks (the short black rectanglesalong the left edge of the form). Forms containing errors were returned to theclinic for correction and re-editing. Error-free and corrected forms were readby the scanner and output onto seven inch magnetic tape. Data could have beentransferred on line to a host computer, however, processing by the tape methodwas chosen to be compatible with the goal of data decentralization andexportability.

(7) Tapes were transferred to the installation computer facility wherea backup copy was made before mailing to Fort Sam Houston, Texas. Attemptsusing telecommunications (AUTODIN) to Fort Sam were problematic and abandoned.The data would be handled locally in a completely decentralized fashion,however, for the six month study, it was not reasonable to request thefacility to increase its workload. Instead, it was decided that dataanalysis and report generation would take place at the investigators'facility.

(8) Data were received at the Fort Sam Houston computer facility as a 696column record. A data compression and editing program was written by personnelof the Health Care Systems Support Activity (HCSSA) to create a moreparsimonious 220 character record which was then merged with the StatisticalPackage for the Social Sciences (SPSS) for data analysis and report generation(the compression and editing program can be seen at Appendix M). SPSS was notthe ideal method for data handling; however, it was an "off-the-shelf" package.Ideally, a program would be written to run on the installation host computer,and data manipulation and report generation would be carried out on-site. (Aflow chart is shown at Figure 4).

9

U.S. ARMY AMBULATORY DATA BASE STUDY

=OUTPATIN

RISTRATIN---------------------OUTPATIENT61SKTIONENCOUNTERDESK FORM

PATIENT: PATIENT DATAWCOH PISSONEEL DATA SETION PRIOR TO TKA11ENI1

CLERK:A. IKON

1. APOITUNT STATUS2. CLIK3. FAMULY& NE POSITION

S. VEINY CONWUIN Of NOU81 PATIENT WOOD DATA SECTION

CARE----------------------------------OUTPATIENTPROVIDERENCOUNTER

FORM

PROVDER:PROVIDER DATA[WON THATENT All DM6N055 DATA S1KIN

OUTPATATINTREGISTRATION~~ini I-- - - - - - - - OTAINENCOUNTERDESK FORM

CLERKA. 11CO211 TIRE OUT

J. VINIY COMPUTIOI OF PROVER DATA SECTIONC. COSUCI SUD OUTPATIENT INCOUNTIS loans

iVALDATI USCODS DATAJOPTIONAL OUTPUT MEDIA 2.11CT mlots

3CIMAS OUTPUT KODj

COSSUNKAOCUONS fi-t DS

4MY9AIN -CRTlwDomm

Fiqure 4

10

5. FINDINGS.

a. The major study question was: will providers complete the encounterforms as requested? With approximately 60,000 records in the database, it hasbeen demonstrated that personnel will complete the encounter forms. Allprimary provider visits included in the Medical Sunmarv 302 Feeder Reportswere counted in the study. Visits to physicians accounted for 53% of thetotal encounters. The remaininq 47% of all encounters were credited to otherproviders (see Figure 5).

LEGEND:PHYSICIANSMURSES

,, PHYSICAL THERAPYa PAsE CORPSMEMI OTHER

NOIE

I F hysica -M 11Lue 31181.7 2. Nurses value 12153

3 Ph Therp vaiu* 3994I Ps value 37u35 Carps value 36

b 1% Other valup 4223

Entire Redstone Data Set

Fiqure 5

b. The second study question was: what reports can be generated from theacquired data? Reports can be partitioned into three major categories: 1)provider profiles, 2) reports useful to management; and 3) special reports notgenerated on a recurring basis. Samples of different reports possible arenumerous as can be examined at the appendices and are explained in thediscussion section.

11

- II

6. DISCUSSION.

a. Physician participation was highly important. Therefore, all primaryproviders were promised regular reports of their practice. The first providerprofile reports were mailed on 27 December 1982 (see letter, Appendix N);thereafter, on a monthly basis, reports were prepared for each provider toinclude physicians, social workers, nurses, and medics working in the variousclinics, i.e., all personnel generating outpatient Medical Care Composite Units(MCCUs). The report included the following information: (A sample careprovider report can be seen at Appendix 0):

a list and frequency of all primary diagnosesprocedures reportedpatient demographic databeneficiary status of patientsnumber and types of physical examinationsaverage time patients spent in the clinic

A graphic presentation of the distribution of patient time spent in clinics isshown at Figure 6.

LEGEND:Under 15 minutes15-30 minutes

1l1i 31-45 minutes6 46-68 minutes

S / lIU 61-98 minutesE Over 98 minutes

t Retf-- * Arsenal- Jaruary 193m4

I1..

Figure 6

12

As can be seen, 44% and 63% of all clinic visits were completed within 30minutes and 45 minutes, respectively. This variable was collected at therequest of individuals who had received complaints that patients had to "wait"too long in their clinic. In those clinics where providers filled out formsimmediately upon completion of the patient encounters, the values arereliable. Problems arose in clinics when providers did not complete formsimmediately following the patient visit (encounter), but held records andforms for completion during a slack time such as during an appointment "noshow" period. Subsequent time capture should be based on time spent with theprovider and not on time in the clinic. In addition to the already citedproblem, several patients tend to arrive early for appointments (for their ownpersonal reasons); if "time in clinic" is recorded, rather than "time spentwith provider" it skews the data making a clinic look inefficient when, infact, this may not be true.

Monthly aggregate reports, useful to management, were prepared andare shown at Appendixes P thru V. These reports include:

number of patients seen in each clinicnumber of forms completed by each providerinformation for the Medical Summary ReportMED 302 Service Branch TotalMED 302 Service Branch Total/OH and TMCnumber of exams chaperoned per clinicstudents from other countries

Appendix P provides information on the number of encounters per clinicper month. November, December, and January provide the most reliable counts.February and March data may show a decrease in visits captured as a function ofproviders' beliefs that the study was approaching a finish coupled with aperception that the command would not be continuing the method of data captureafter the study.

Appendix Q demonstrates a sample of encounter tracking by providers forone clinic for one month. Spurious provider codes were believed to be afunction of a provider marking an incorrect clinic and/or possible a miss-markof provider code.

Appendixes R thru T shows data needed to complete the Medical Summary 302Report. If a system such as that used in the study were operationalized, MedSummary feeder reports as well as clinic "sign in" sheets could be deleted asredundant. This would make the data capture more palatable to the clinicclerical staff.

Appendix U demonstrates the number of exams requiring a chaperone byclinic by month. This item requested by the MEDDAC for manpower documentationwill be deleted in subsequent form design, as it was a one-time data capture.

13

Redstone Arsenal hosts several students from other countries and theirfamilies. The MEDDAC, as mentioned earlier, must request reimbursement fromthe appropriate embassy for medical care provided these recipients. AppendixV, Table V-i, shows the number of encounters for foreign nationals; Table V-2is a further breakdown showing the clinic in which they were seen, the dayseen, and the diagnosis for each encounter. The treasurer could use thesedata to initiate fiscal reimbursement.

Appendix W, Table W-1, shows a management report for one clinic for onemonth; Table W-2 provides a sample of a report generated for one month in oneclinic on one diagnosis (otitis media). These data make an objective chartaudit and peer review process possible in the ambulatory care setting.Appendixes X thru A-A shows the number of procedures, referrals, examinations,and dispositions for the total study.

b. When data collection began, it was believed that providers would usea few select diagnoses regularly (likely to not exceed 20). This was not trueat Redstone; providers used a full range of diagnoses. This can be seen atAppendix B-B which is a report of cumulative primary diagnoses for the totalstudy. Because of the numerous definitive diagnoses used, to provide a moreparsimonious report, a set of 92 diagnostic clusters developed at the Universityof Washington, Department of Family Practice by Schneeweiss et al. (1983) wasu:,d as a further truncation of the 371 ICHPPC-2 diagnostic codes (seeAppendix C-C). As can be seen, twenty diagnostic clusters account for 77.9% ofthe diagnoses made during November, 75.4% in December, 76.6% in February, 78.9%in March, and 77.1% of the total diagnoses. These data have implications forthe kinds of physician staff mixes needed. For example, it would appear fromthe data that an orthopedist would be utilized whereas some internists mightpossibly be replaced by a general medical officer and/or family physicians,nurse practitioners, or physician's assistants.

c. To address reliability of data captured, the investigators randomlyselected 30 encounter forms and compared the entries against the outpatientcharts for the same encounter. The information on the encounter form comparedidentically in 100% of the cases.

d. Another major concern of the hospital staff was fear that the totalencounters reflected by the study would be fewer than the MCCU based on theMedical Summary 302 count. If the MEDDAC were to use the encounter system toreplace all Medical Summary 302 feeder reports, would the activity bepenalized? During the training phase this concern was alleviated, when oneclinic, which had counted 78 patient encounters on the MED 302 feeder reportthe previous day, ran their encounter forms and found 120 encountersdocumented, an increase of 54%. Appendix D-D demonstrates the month by monthcomparison of MCCU and encounter forms. The discrepancies are explained, inpart, as some providers did not participate in the study or stopped fillingout the forms after an initial participation. This will be discussed furtherin paragraph g of this section. A major strength of the encounter system isthat the counts or visits are completely auditable; i.e., charts can be pulledto compare encounter forms to actual patient visits. This information is moredifficult to extract from Medical Summary 302 feeder reports.

14

, -• I .. - - , .. ... . .. . . .. _ .... . , , :

e. During the study, individual requests for special reports were pro-cessed. Examples included: request by an occupational physician to identifyjob related accidental injuries occurring in a particular building to studypossible trends that might benefit from intervention; request by the communityhealth nurse for a list of all patients seen with a diagnosis of chronic lungdisorders to provide patients with information about a free educationalprogram available in the civilian community; request by a physician to listall patients seen with a diagnosis of migrane headaches to enable him to do astudy; and, a request by another physician to document peak workload times inhis clinic to enable documentation for staffing schedule changes. Theserequests demonstrated that the staff did recognize the potential research,service, administrative, and epidemiological uses for the database.

f. Near the end of the study period, care roviders and clerical personnelparticipated in a survey (see Appendix E-E and Appendix F-F) to measure theiropinions of the encounter form and suggestions (additions/deletions) toincrease its effectiveness. A synopsis of returned questionnaires follows:

Care Providers. Twenty percent of the care providers indicated theywould like to receive the practice profile report on a continuing basis.Others did not desire routine reports, but wanted to know that the informationwas available. Some providers felt that patient satisfaction with the formshould be addressed as additional feedback. Average time reported to completetheir portion of the form was 56 seconds with a range of 10 to 120 seconds,the high occurring when care providers had to look up additional diagnosticcodes. Diagnostic categories were indicated as sufficient by 53% of the careproviders and insufficient by 47%. Most of the comments regarding insufficientdiagnostic categories were generated by Occupational Health because of needspeculiar to that clinic, and by pediatricians who felt that many pediatricclinical conditions were inadequately addressed on the form. Use of secondarydiagnoses was indicated as: almost never 16%, rarely 42%, frequently 42%, andalmost always, 0%. When asked if use of the form should be adopted Army-wide, 21% said yes because they felt the form would give good estimates ofworkload; 68% said no, their reasons focused on additional time spent infilling out the form, which caused them to see two to four less patients perday; 11% had no opinion. Forty-seven percent felt information gained bycompleting the form was of value to them, while 53% felt it was of no value;58% felt it was of value to Fox Army Hospital and the Army while 26% felt itwas not; and 16% had no opinion. Comments regarding improvement of the formranged from elimination of patient involvement, as much as possible, todeletion of some elements such as ethnicity, race, and job related diagnosis,while Occupational Health and Community Mental Health felt the value of theform would increase if it contained elements more unique to their clinics.Only 10% said they preferred not to use the form at all.

15

Clerical Staff. Most receptionists responded that the form was easy touse and agreed that the elements were in the most logical sequence. All agreedthat the color coding made the form easier to use and 90% felt the form cap-tured all information required for report generation such as the MED SummaryReport 302. Average time to complete their portion of the form was 2.1 minutesreflecting that several clinic receptionists actually filled out the patient'sportion of the form. Most said patients were cooperative "if they understoodthe form." Retirees and higher ranking active duty members comprised thosemost vocal in their desire to not complete the patient portion of the form.

g. When the satisfaction survey was undertaken, a debriefing was held toprovide preliminary results to the staff. At this time several providersverbalized their desire that the project not be continued. A subjectiveappraisal revealed that objections seem to be loudest from providers appearingto be least productive vis-a-vis the number of encounter forms completed.Providers were assured that their concerns would be reflected in the finalreport. Their most verbalized concern was that the time required to fill outforms eroded into potential time to see patients. A check with the adminis-trative section revealed that the number of clinic visits had not decreased,clinic backlog of appointments had not increased, clinic hours had not neededexpansion, and overtime had not been necessary to meet clinic workload. Insum, it appeared that the providers found the information from the project tobe potentially useful, however, they would prefer not to expend the time tocollect data. A concern never verbalized by providers, but one which must beaddressed, is the fear of having their practice and "productivity" monitored.

h. Validation of the value of the data captured to management was pro-vided in a letter received from the MEDDAC Commander requesting that the studymethod be operationalized as an ongoing system at Redstone (see Appendix G-G).

i. Several lessons have been learned from the study:

(1) It was recognized at the outset that the procedures list was far fromcomplete, however, it contained those procedures which the medical staff atthe study site stated they wanted to capture. Having a prepared menu of pro-cedures did not require the provider to look up entries from a code table.Experience has shown that about 25% of the procedures were reported in the"other" category, which is not acceptable. Therefore, in any future formdesign, it would be considered advisable to include a list of standard proce-dures, and to also provide spaces where less common procedures could beentered from tables.

(2) It is further believed that no one page form can meet the needs ofevery clinic. It is suggested that further study be undertaken to developseveral forms for use by different specialties (e.g., pediatrics, obstetrics,occupational medicine, walk-in clinic, etc.).

16

(3) Several providers found the ICHPPC-2 diagnostic codes to be toogeneral for their needs. This may be a result of the physicians' experiencewith the ICD-9 codes for inpatient diagnoses. This area bears furtherexploration.

(4) The recording of significant telephone visits with patients may beunderreported as providers would have to initiate a form versus having onestarted by the patients and clerical staff.

(5) Time to fill out encounter forms would be greatly decreased if aregistration system were developed to hold the patients' basic demographicdata for call up.

(6) The need for trained and dedicated personnel to manage the projectand to process encounter forms is obvious. The number of personnel needed isa function of the number of forms processed, the number of forms with entryerrors, and the size of OMR used. It is not envisioned that added personnelwould be required, but that a realignment of duties may be necessary as thesystem would greatly decrease the MED Summary 302 clerk's workload.Additional personnel would possibly be required for the ADP activity.

j. In the future, it would be desirable that the system be connected toto a Central Appointment System. When a patient makes an appointment thesystem would:

create a chart pull list

create a problem list which would include the patient's listof current problems along with the first date they were seenfor the problem, how many times they had been seen for theproblem, and when they were seen last for the problem

an encounter form could be "preslugged" with data from theregistered patient's database precluding the regatheringof known information

Figure 7 shows an Outpatient Encounter Processing Centralized PatientAppointment Procedure.

17

ENTkALL-LL) IATIEN :P11 IN'LNT?PR- i kI

P Irt- ' !rrT.'p

nejett Lrror -umenL3atoMoo Ilo3 C Ii ac , Irma r Recor is

- P ~r .h~Jo otutt 0. -. nterface with; rfst

/ x otiS sd *'l s System

Patien Registratin *o

3. ~,I.I~ Printeroidr eno

1. Initial visit

2. JobRe~atd Patientsteamivatco~ ter 3Scsi

A. 'rocedure

I', ~ ~ ~ R- rdtpI lM~

Fiure

18.d O t

Enco.'tI

IIJNC RLC~rjO~%.

:

However, a completely manual system, such as that reported here, is needed forback-up when the system is "down" and for the walk-in patient as well aspatients who are seen outside the main treatment facility in a remote siteclinic or mobile health delivery unit (see Figure 8).

P..tLent Record: Pat Lent Pati Pet atient Re-r, rpnsrdata Registratiot tincoonte Only sponsor "N

joled fEr rtrm roorn FMP. Patirent :a 4,

V 1 <11<ti.A

Vet r PI IOIt Ie. PRVIE ENCUDESrr l:Vli

t~tO. J1 ob related diagnusir2Nn-regitranroI ~mP Cuels 3. Examination, if requiredP~t root Vcl trat ion and 4. ProceduresEncounter Forms 5 rmr igoi

II7001 0MP

1. Verification of Data Preparation2. Reject Error - Print Error Code .. rocess..d3. Edit and Format Records Drocese

4. Record Output Data on TapeDouet

Fpatilent records and changes tti~ r2. Extract detail trom Master nlsi

Regitintion File fot eachReot

Figure 8

19

I-ILL-

k. It is possible for the system to be connected to a word processingprogram whereby the provider's routine medical chart entry could be generatedfrom the encounter form. Additional narrative could be dictated and mergedwith the encounter data using the lithocode on each encounter form. Ifradiology, laboratory and pharmaceutical orders, and clinic reappointmentscould also be handled, the system would be even more acceptable (see Figure 9).

CONCEPTUAL CONFIGURATION

APPOfTMENT SYSTEM

CHART IPROLEM UST pUSU

WALK-AN DNTESPTIEN VERMSEENCOUNTER FOPRM C PRESLUG DATA

VOT- SPECIFI DATA

m. DATA SYSTEM

REPORTS 9F GOD MRE C DICTATION

Figure 9

1. The need for command emphasis is obvious. Less obvious is the needfor good public relations groundwork with the providers. For the system to befunctioning at its optimal level, it must be symbiotic. Providers mustbelieve it has something to offer them.

20

,ww* A

7. CONCLUSIONS.

The overall objectives of the study have been met. It has been demonstratedthat:

(1) The elements to be collected for an ambulatory care database wereidentified. A significant number could be standardized across MTF's, however,the need for site specific variables is recognized.

(2) The majority of care providers will complete their portion of the

encounter form.

(3) A single encounter form for all clinics is not acceptable.

(4) Data collected can be audited and provide an objective and validambulatory peer review and quality assurance mechanism.

(5) Provider and clerical staff satisfaction was surveyed.

(6) A comparison of encounters from the ACDB and the MED Summary 302was accomplished.

(7) The number of reports that can be developed from the data are limitedonly by the users' imagination. The MED Summary 302 can be captured from thedata elements.

(8) The OMR method of data capture was shown to be efficient and cost

effective.

(9) Problems needing resolution in future use of an ACDB were identified.

(10) The need for command emphasis, at the highest levels, is obvious.Failure to fill out the form properly must be viewed as negatively asfalsification of patient records.

8. RECOMMENDATION.

Recommend that this inexpensive and reliable data collection methodologybe tested at more sites for eventual implementation. Even if an Ambulatory CareDatabase is not developed, it provides an efficient, reliable, and minimallylabor intensive method to capture data which are needed by the Army. The use ofthe discussed method is highly practical because it will interface with anysystem or mainframe conceptualized or planned at this time. It provides anexcellent interim system until the Composite Health Care System (CHCS) isimplemented. Finally, it can continue to be used in areas where a CHCS is notpractical or planned, e.g., a field environment.

21

.. . . . . . . I-I I . - . . . . . .

ADDENDUM

At the completion of the study, approval was granted allowing the facilityto continue use of the system in an operational mode. This was based on theCommander's request cited in the text of the report. Because of the timerequired to obtain permission for continuation, to extend the contract, and toorder a new supply of encounter forms, the system went down for approximatelysix months; in November 1983, Redstone began to again capture data. Dataprocessing support was provided by the local computer facility. Localprograms have been written in IBM COBOL which is compatible with the VIABLEenvironment. This allows for rapid turnaround. Any data delivered to thecomputer facility at the close of business one day is batch processed andreports are available at the beginning of the next day. This furtherdemonstrates the benefit of local processing in addition to ease of editingerrors. This decentralized method allows for more "user friendly" reports.In order to begin data collection as rapidly as possible, the same forms usedin the study were ordered awaiting forms redesign. Subsequently, three formshave been developed for the facility in consultation with the studyinvestigators. The forms included one for registration and a generaloutpatient form in addition to a form specific for the preventive medicineactivity. Drafts of these forms are provided at Appendixes H-H, I-I, and J-J.

The diagnostic codes were augmented by surveying providers. Secondarydiagnoses were eliminated as the original study revealed that this variablewas not used extensively. Instead, an element was added to indicate theacuity and complexity of the patient problem (see Figure 10).

TYPE OF VISIT (mark only one)

o Acute problem, minoro Acute problem, complexo Chronic problem, routineo Multiple chronic problems, routineo Chronic problem, flare-upo Post surgery/injuryo Non-illness care

Figure 10

22

The qeneral outpatient procedures list was changed and spaces were provided to

add more procedures not listed on the menu (see Figure 11).

iD NIBIOI(CI) PRESCRIPTION RIFI1l W/O EX~AM0 AUDIOMETRV C, PROCIOSCOPY/SIGMOID0 BIOPSy CD SNOt RECORD REVIEWEDo CAST APPICAION 0 Soc WAX SVcs0 CAST REMOVAL 0 SPINAL TAP0 DIAPHRAGM FITTING CD SPIROMETRY0 DIETARY COUNSELLING CD SPLINTING0 DRESSING CHANGE 0 STRESS 1151C EAR IRRIGATION 0 SUTURE0 1KG C SUTURE REMOVAl0 EKG ORDER FORM 0 TELE CONSULT0 ENDOMEiRIAi BIOPSY C- THROAT CULTURE

) HEARING CONSY C) TONOMrIRY0 NMOCCU( T 0) TYMPANOMITRYo HOME VISIT 0 VASECTOMY

0 IMMUNIZA I IONS0 INJ[CIION/O8SERV ADDIIIO1A1L PROCEDURES

C)I U0 30) KOH PRE P1011I MUUN IC LErtERS FORMS0 1IDUID NITROGEN (. -1 X , .J (k I (ID C0 MANIPULATION I) r(. C1) a) C) LI C WD ,00 MINOR SURGERY () Ul) ID (1)O C D aL 0

CMYRINGOIDMY )")() LID (t)I) 'k (I

00of SIRVILLS cc 4I) C11 1' (ID I) ' -i C,0 PATIENT CONSULTATION (D D ) (I2)(IDX Cl) I?),

) PHYS HRAPY 4) 1J) (I) W , 1, T r,

C) PRIG DEIERMINAIION __)__.___ 6') I t'*

Figure 11

A major element change was in the time category. Instead of capturing the

time the patient spent in the clinic, the new form will only indicate the

amount of time the patient spent with each provider (see Figure 12).

TIME SPENT

+1 #2

o Less than 5 minutes oo 6-15 minutes oo 16-30 minutes 0o 31-40 minutes oo 46-60 minutes oo Greater than 60 minutes o

Figure 12

23

, j- , ' ° " "" l u

This element will capture data necessary to study Average Visit Groups (AVGs),which are outpatient correlaries to the inpatient Diagnoses Related Groups(DRGs).

With about one year of experience, the clinical support office was queriedabout clerical and patient reaction to the system. The Chief of the Activitystates that complaints from patients and clerks about having to complete formshave dropped to almost zero. He believes the system has been in existencelong enough so that personnel and patients now accept it as part of a visit.

The facility continues to develop new reports and conceptualize addi-tional uses for the data. For the providers, reports can be generated (if theyleave the Army) to help them document their experiences when they apply forclinical privileges and credentials at a civilian health care facility.

24

J- -A-

REFERENCES

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Baker, C., Monson, R., & Jameson, J. (1981, October). Ambulatory CareInformation System (HSR&D Project #269 Final Report).

Bureau of Indian Service. (Revised 1982, December). Health Manual. PHS,Washington, D.C.

Cote, R., & Robboy, S. (1980, February 22/29). Progress in medicalinformation management: Systemized nomenclature of medicine (SNOMED).Journal of the American Medical Association, 243(8): 756-762.

Farley, E.,Jr., Boisseau, V, & Froom, J. (1977). An integrated medicalrecord and data system for primary care, Part 5: Implications of filing familyfolders by area of residence. The Journal of Family Practice, 5(3): 427-432.

Froom, J. (1977). An integrated medical record and data system for primarycare, Part 1: The age-sex register: Definition of the patient population.The Journal of Family Practice, 4(5): 951-953.

(1977). An integrated medical record and data system for primarycare, Part 6: A decade of problem-oriented records: A reassessment.The Journal of Family Practice, 5(4): 627-630.

Froom, J., Culpepper, L., Kirkwood, C., & Boisseau, V. (1977). An integratedmedical record and data system for primary care, Part 4: Family information.The Journal of Family Practice, 5(2): 265-270.

Froom, J., Culpepper, L., & Boisseau, V. (1977). An integrated medicalrecord and data system for primary care, Part 3: The diagnostic index manualand computer methods and applications. The Journal of Family Practice, 5(l):113-120.

Froom, J., Kirkwood, C., Culpepper, L., & Boisseau, V. (1977). An integratedmedical record and data system for primary care. The Journal of FamilyPractice, 5(5): 845-849.

Gelbach, S. (1979, September). Comparing methods of data collection in anacademic ambulatory practice. Journal of Medical Education, Vol. 54, 730-732.

Hermansen, L., Jones, A., & Butler, M. (1980, January). Development of anoutpatient medical treatment reporting system for shipboard use. U.S. NavyMedicine, Vol 71, 16-21.

25

MERSHO

REFERENCES (Contd)

Howard, R. (Undated). Family practice service: A system analysis of aninformation system. Family Practice Clinic, Madigan Army Medical Center,Tacoma, Washington. (Unpublished).

ICHPPC-2: (1979). International classification of health problems in primarycare, 1979 revision. Report of the Classification Committee of the WorldOrganization of National Colleges, Academies and Academic Associations ofGeneral Practitioners/Family Physicians. Oxford University Press.

MIDS Management Information Decision System Documentation Manual. (1980,October). U.S. Department of Health and Human Services.

MITRE Corp. (1978). (Computer Stored Ambulatory Record-COSTAR). FunctionalSpecifications. A joint development of the National Center for Health ServicesResearch (HRA, PHA, DHEW), Laboratory of Computer Science (MassachusettsGeneral Hospital), and Digital Equipment Corporation.

National Center for Health Statistics. (1974). Ambulatory medical care records:Uniform minimum basic data set. Vital and Health statistics Publication (HRA)75-1453, U.S. Department of Health, Education, and Welfare, S,:ries 4, No. 16.

Nelson, E., Kirk, J., Bise, B., Chapman, R., Hale, F., Stamps, P., & Wasson,J. (1981). The cooperative information project: Part 2: Some initialclinical, quality assurrance, and practice management studies. The Journalof Family Practice, 13(6): 867-876.

Pack, S. & Parrish, M. (1974, September). Development of a long-termprocess for collection of doctor-patient encounter data in an ambulatory carefacility. Monterey, California, Naval Postgraduate School.

Schneider, D., & Kilpatrick. (1974, Fall). A medical classification systemfor ambulatory-care manpower planning. Health Services Research, 221-233.

Schneeweiss, et al. (1983). Diagnostic clusters: A new tool for analyzingthe content of ambulatory medical care. Medical Care, 21(105).

Steinwachs, D., & Mushlin, A. (1978, Spring). The Johns Hopkins ambulatory-care coding scheme. Health Services Research, 13(36).

Tindall, H., Culpepper, L., Froom, J., Henderson, R., Richards, A., Rosser,W., & Wiegert, H. (1981). The NAPCRG process classification for primarycare. The Journal of Family Practice, 12(2): 309-318.

United States Army Outpatient Reporting System Feasibility Study Statement of

Work. (1981, July). (Unpublished Document), Fort Sam Houston, Texas.

26

BIBLIOGRAPHY

Bise, B., Hale, F., Nelson, E., Wille, T., & Weaver, C. (1982, February).Use of a medical information network for practice management. The Journal ofAmbulatory Care Management.

Frisch, L. E. Word processing in ambulatory care. (1982, February). TheJournal of Ambulatory Care Management.

Froom, J. ICHPPC-2 (1980). An improved classification system for familypractice. The Journal of Family Practice, 10(5): 791-792.

Given, C., Browne, M., Sprafka, R., & Breck, E. (1981). Evaluating primaryambulatory care with a health information system. The Journal of FamilyPractice, 12(2): 293-302.

Meads, S., & McLemore, T. (1974). The national ambulatory medical caresurvey: Symptom classification. DHEW Pub. No. (HRA) 75-1337.

Nie, N., Hull, C., Jenkins, J., Steinbrenner, K., & Bent, D. (Eds). (1975).Statistical Package for the Social Sciences, (2nd ed.), New York, McGraw-Hill,

Perkoff, G. (1981). Research in family medicine: Classification, directions,and costs. The Journal of Family Practice, 13(4): 553-557.

Rice, C., Godkin, M., & Catlin, R. (1980). Methodlogical, technical, andethical issues of a computerized data system. The Journal of Family Practice,10(6): 1060-1067.

Schneider, D., Appleton, L., & McLemore, T. (1979, February). A reason forvisit system for ambulatory care. Vital and Health Statistics, Series 2, #78.DHEW Pub. No. (PHS) 79-1352. Washington, DC: U.S. Government PrintingOffice.

Stephens, B. (1978, November). A basic health information system for out-patient services. The Journal of Ambulatory Care Management, 83-97.

Systematized Nomenclature of Medcine (SNOMED). (1979). (ed. 2.), Skokie,Illinois, College of American Pathologists.

Tenney, J., White, K., & Williamson, J. (1974, April). National ambulatorymedical care survey: Background and methodology. OHEW Pub. No. (HR), 74-1335,

27

t ..

APPENDIX A

IL

4r

1

'- , ,._,,,L _ _ _... ... ... . .. . . ..

APPENDIX A

FAMILY PRACTICE CENTER ENCOUNTER FORM4 1IS4 IR HtI i 0(1 it 1 41

PATIENT IDEN71FICATION

CC 12 PRFIXCC 15-20 (KEY LAST 6 DIGITS)

CC 12 REFITPEOvIDER STAMP

CC 3-Il SSN

CC 12 14 INITIALS

ITHE AUTHORITY FOR COLLECTION OF ?HIS INFORMATION IS TITLE 5. U S CODE 301

I THI Pfl(NLIIeLf PURP1OSE IS TO COLL I LT SIATISTICAl DATA ON FAMILY PRALTILI, PATIENTS FOR THE FAMILY PRACTICERESIDENCY TRAINING PROGRAM

.1 ROUTINE USLS INCLUDE RETRIEVAL OF HILALTH RILCORDS FOR APPOINTMENTS THE COMPILATION OF STATISTICAL DATA FORREQUIRED MONTHLY REPORTSAND THE ASCERTAINMENT OF EACH FAMILY'S COMPLIANCE WTH THE POLICIES AND PROCEDURESUF THE FAMILY PRACTICE PROGRAM

4 DISCLOSURE OF INFORMATION IS MANDATORY FOR TREATMENT IN THE FAMILY PRACTICE CENTER FAILURE TO COMPLY COULDIICSULT IN ELIMINATION FROM THE FAMILY PRACTICE PROGRAM

CC 21-~6 CATE ~ I y j I j CC? 27R EATMENT NO DCC 28 APPOINTMLNI INIT F I I 2 WALKtjii] EMR j PHONEtIII OTHER

CC 29 APPI STATUS LATE NO SHOW -~NIGHT CAL73 INAFPROPRIATE 71

CC 30 ADMITTED TO HOSPITAL

cc I13 PRUCEDURIS DONE (LIMIT 41 CC 39 -. 0 REFERRALS LIMIT 1)

0 -1 -K -__ _I - ,-07 ARIUIIMINAL EXAM 17 LIOUIII NITROGEN 01 1 LLER.6V

IOil ASPIRATION 39 MAWFULATION 52 RY RE AL- IH NURE

0 CAST APPLICATCJN 40 MVRIN&JOT1YIYT CARDIYI.Ul_!T

-. ~j~TRMOAL ______On OWORSUP 04 COLNSELLIN- GCIIAII

06 -- I CEST EXjAM 34 ARTAL ITICA.L 15 _ 1

ETL____*01_ CI)I4PLETE#PHYS EXAM 20 PATEN COSLAIN VX lRAT' LOGy

oa_ -~DAHAM "ITTI NO 21 PE LVIC A DIOR P,.l -6 ~l TIAN I

I 6 RESIG HAGE 22 PROCTOSCOPY:S!IqlMOID 07 -LkFC

37 EAR EXAMINATION 23 SHOT RECORD REVIEWED 00 -- , GSNECioLOG F,

IS FR IRRIGATION 24 SNELEEN CFA R T_ INTERNAL MED _I I-E- 26 PIA T AP 19 NEUROL.OGY, _

3S EXO ORDER FORM 26 8 SPLINTING _____20 oerETRICS

41 F DEIME TRIAL BIOPSY 27 STES TST 11 11CC THERIAP

N T EXAMINATION 20 SUTURE _j ONCOLoGsY36 (SCEXAIAIN SUTURE REMOVAL _ _12 OPI.H AL M 0LDOY

HT EMOCULT 30 THROAT CULTURE 23 ORTHOPEDICS

Al-___3____ an31 -- IONOMET 4 - PDAIClJ l~ECIN/OISSERVATION 32 VASECTOMY 5 PY H A

14 ju D Be___5 VITAL SIONS 20 PUDIATEIy

76- ~GIPEPWEMOUNT 53 OTHEIRPftOCEDURFS IS - SCHIATRYTs RHEUMATOLOGY

20 -SOCIALWINRE

LL 43 50 1'ik7UIIYZAT IONS JLIM!T 41 2 SURGERY~

30 UIIIILOGY 6

r, u 13 FINE TEST00 A',,ILS a1N COiCI5 XINI lEST

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PT I Ml TI I

I NEn DIAlfNOSIS CODES ON RE R617SID OR FORM

RSC 1.-l 343A 0sIPAI I '.@I7

209

APPEIFND IX A (Caridt)

F AGN OS CO L'fs -MI S~lIS A TOTAL 1 ~ N 'A C ONSUL I

CC 5T-IS KEY A,. C L-iTES HE COHOIPL i LOW H IL&' H iNU A ADMIT11 ,1BOTH3JC,,AIiACTEI1I5LH1ARACTER AT- MANUOATO(iYONiSvtT

II-ARA '-SE ASY I tb I$U, r -MtE IU f Sj0, "18 $II , 5

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0 0ABE' SEASI tS EM N ' ,.' -

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111 1 11C IT 001 FS0 I 041, S I- U Au CYSTK M

[I1 1-0 0N ITA -11,1 L!C 124 11-f O A1,1A O-l O -

2 3al r I NES CI ,,iIH01S U- S MEU I 'ils 11.11C75N1to0E1'N iA, iSS

_24 3815 ENSTA 'N OR A1IAA,,6

ii) 1 139 0,841 48081SULSKEICO' lso

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2 80 S -64 . 7440 2YII41RIILSNII

3411 R-IE.C. NCIR 1SIO.SOYTSM~ '0 '273 CHETAAA INCSNRNI

29 I .EuSJTCHIN CACO(1 ,A A"I T 6.. 4 10 iA;P1MNWG RI ATNGIIMTIM

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77 -- 7--211 A, ASHMTM ILL OTHE N NEIFI SKINAICI

42 .6 ,II'S1R I HEAR1T DIS - .. NEC -19 14- 3 i INS 0 IDINS

J2 402 ^C 1 IIo- _TNSO INOVI0 7484 7 ORGAN(IOI--3 4_"___ _I________S E, IT PAIN I

,18 7298011 XV PINR TIE LeS AA E SYMPFETS

491 18- 4480HIIS CHOI OTHEROCHE A NOSSI CSI RP

Ell e42- --- -- ---------------- o±~J-- - --

C'4 i '- IIIE A uE O AR il60,lNI '9iA"_ 8 839 - LYACE IJT!NL(CPfLNCI INU M A IYEIT

US .-.- -IL s4- - S NiF ~ ~ ~ ~ ~ _L - - - - -_ .IO4EII.&4,N IIIIl ~'' 11

LAN 41 - SONOIETIB, CHM NI U E S -RONCI1E29AS- INJURIE, STAVERSE. CSIICTSi

4 _ 492 C AMP t88e U-a CRD I A, 642s Ll- ISRANTA IN WRSIST A ND IGR

4256 ASTHMAQdAN zQIIE ISiS43 68-f8TSWS 1UM1S 411 04 )9VI 83C 8400 MSRINSTRA A NKL

44 5190 IlYII HPIIIAII SYTM15 SS-L CRA ION PE.CuNt ROMICUT

...rN _ - _! y -- - -}- A1MISE T I ES E I

461 .! IIM01 NEC2 9 "01,585AL00 KMICIN POERDS.- - - ----- It

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YE "71" __ _O -,OV __S It

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SIR ~ ~ ~ ~ ~ ISII I ~ A I~ S .''I C C ..SU N C 20 8 1 E R L W E S M R I Y H I

3 02 INBTN RGAC

APPENDIX B

APPENDIX B

Methods of Data Entry Advantaqes/Disadantages

WHY OMR?

ALTERNATI[VES MODE PRO CON

Key Punch Centralized manual - Low Cost Hardware - Old Hardware-

Data preparation - Hard Copy-visual Low Reliabilty(Batch Mode) record - Slow Input

- Low salary range - Transcription erroroperator personnel rate

- Data recovery re- - Manual Key Entryread and Verification

- Centralized control cost

CRT Centralized or - On-line-elmination - Requirement forremote-on-line of Key Punch multiple devicesKey Entry - Edit/Validation in decentralized

- Visual Retrieval mode- "Real Time" input - Loss of Control for:

a-data validationb-Hard copy

"back-up"

c-Input datai ntegrety

- Training of non-DP personnel

- Manual Key Entry-requiring Trans-cription of datafrom original sourcedocument

OCR Centralized optical - Fast Input machine - Expensive Technologyscanning data entry readable documents High Cost(Decentralized data - Reads Alpha/Numeric - Reliability ofpreparation) Characters "reading" documents

- Eliminates Manual prepared in un-Key Entry controlled environ-

ment

- Hard copy-provides - Error correctionautomatic means of cycle long due toData Recovery centralized mode

of operation

OMR Centralized or - Low Cost - Cost of formsdecentralized Data - Machine "readable - Time consumingcollection documents" process to encode(decentralized data - Eliminates Manual data by originatorpreparation) Key entry -Requires forms

- Reliable to be available

-Originator encoded for data collectiondata-improved accuracy

- Hard copy providesautomatic means ofdata recovery

32

S.. .. ,

APPENDIX C

* m -APPENDIX C NUS I,,,u (1-1 3816 321

IBM OUTPATIENT ENCOUNTERIBMA FORM (TEST)

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-~ ~~~~~~~~~~ .3005 513333 IN__________________________________________________________

A: "il ' IIIIIIA l 111w~lVII34 A

APPENDIX C (Condt)

ICHPC- 2 MARK ONL PETNN OA NOF FO HSI If v

UIAGNOSES 9A 991 ',A '... lR .IN l~ I4A9 , " 111-11-.. ...999 ... 1-1--.

A, -1. % 994.9 .-A R I' * .S 'I99 . .. .. 4

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APPENDIX D

APPENDIX D

ICIIPPC and I(D-9-CM Code Numbers

I'05sit in I CI lOW

Number Code Condensed litle I(0-9-CM

1. Infective & Parasitic Diseases1 003- Proven Infectious Intestine Disease n?2 009- Presumed Infectious Intestine Uisease qijO

4 Oil- luberculosis 0116 033- Whooping Cough 9337 034- Strep Throat, Scarlet Fever, Erysipelas 034

8 045- Polio & CNS Enteroviral Diseases 0145

9 (J52- Chickenpox ni21(0 053- Herpes Zoster 05311 054- Herpes Simplex 05412 055- Measles 055

13 056- Rubella 0 614 057- Other Viral Exanthems (1715 ()/0- Infectious Hepatitis r) I)16 o72- Mumps 1721/ 075- Infectious Mononucleosis 071

8 077- Viral Conjunctivitis 07719 0781 Warts, All Sites 078.120 0799 Viral Infection NOS n/0.921 084- Malaria 0q422 090- Syphilis, All Sites & Stages 091

23 098- Gonorrhea, All Sites n2372 0994 Nonspecific Urethritis 099Q.24 110- Dermatophytosis & Dermatomycosis 11025 112- Moniliasis, Excluding Urogenitis26 1121 Moniliasis, Urogenital, Proven 112.1

27 1310 Trichomoniasis, Urogenital, Proven 131.028 127- Oxyuriasis, Pinworms, Helminth NEC 12729 132- Pediculosis & Other Infestations 13?

30 133- Scabies & Other Acariasis 13331 136- Other Intectious/Parasitic Diseases NEC 16

[I. NeoplasmsMal ignant Neoplasms

32 151- Malignant Neoplasm, Gastrointestinal Tract 15133 162- Malignant Neoplasm, Respiratory Tract 16?34 173- Malignant Neoplasm, Skin/Subcutaneous lissue 17335 '/4- Malignant Neoplasm, Breast 17d

36 180- Malignant Neoplasm, Female Genital Tract 1Rn37 188- Malignant Neoplasm, Urinary & Male Genital Tract I938 201- Hodgkin's Disease, Lymphoma, Leukemia ?l39 199- Other Malignant Neoplasms NEC 19I

NEC-nnt elsewhere classifiedNOS-not otherwise specifiedNYD-not yet diagnosed

37

imom

APPENDIX U (Contd)

Position ICHPPCNumber Code Condensed litle ICD-9-(M

Benign Neoplasms40 214- Lipoma, Any Site 21441 216- Benign Neoplasm, Skin 21642 217- Benign Neoplasm, Breast 21743 218- Benign Neoplasm, Uterus 2144 228- Hemangioma & lymphangioma 2P45 229- Other teniqn Neoplasms NEC 220

Unspecified Neoplasms46 239- Neoplasms NYD as Benign or Malignant ?Q

1l1. Endocrine, Nutritional, Metabolic Diseases47 240- Nontoxic Goiter & Nodule 2AO48 242- Thyrotoxicosis W/WO Goiter 24249 244- Hypothyroidism, Myxedema, Cretinism50 250- Diabetes Mellitus ?50

52 260- Vitamin & Nutritional Disorder NLC q54 274- Gout 27455 278- obesity 27856 272- Lipid Metabolism Disorders 27?57 279- Other Endocrine, Nutritional, Metabolic Disorders 277

IV. Blood Diseases58 280- Iron Deficiency Anemia 2,059 Z81- Pernicious & Uther Deficiency Anemias 28160 282- Hereditary Hemolytic Anemias ?8261 285- Anemia, Other/Unspecifed 2?8

62 287- Purpura, Hemorrhagic & Coagulation Defects 287b3 2891 Lymphadenitis, Chronic/Nonspecitic ?89.164 288- Abnormal White Cells 28865 2899 Blood/Blood Forming Organ Disorders, NEC 299.9

V. Mental DisordersPsychoses, Except Alcoholic

66 294- Organic Psychosis, Excluding Alcoholic67 295- Schizophrenia, All Types qq568 296- Aftective Psychoses '(f

69 298- Psychosis, Other/NOS, Excludinq Alcoholic 298

Neuroses70 3000 Anxiety Disorder 3fl.(I71 3001 Hysterical & Hypochrondriac Disorders 3(0.172 3004 Depressive Disorder 3on.a/3 3009 Neurosis, Other/Unspecified 300.9

Other Mental, Psychologic Disorders74 315- Specific Learning Disturbance 31575 30/4 Insomnia & Other Sleep Disorders 307.476 3078 Tension Headache 307.477 308- Transient Situational Disturbance, Adjustment

Reaction 308

38

L

APPENDIX D (Contd)

Position ICHP'CNumber Code Condensed Title ICD-9-CM

73 312- behavior Disorders NEC 31279 3027 Sexual Problems 302.780 3031 Alcohol Aouse & Alcoholic Psychosis 30.181 3050 Acute Alcoholic intoxication 30q.

82 3051 Tobacco Abuse 3035.183 3048 Other Drug Abuse, Habit, Addiction 30484 301- Personality & Character Disorders 3-ltR5 317- Mental Retardation i]a86 316- Other Mental & l'sychologic Disorders 316

VI. Nervous System, Sense Organ DiseasesNervous Svstem Diseases

87 340- Multiple Sclerosis 3n 088 332- Parkinsonism 33289 345- Epilepsy, All Types 34590 3,6- Migraine 34691 355- Other Nervous System Diseases NEC 349

Eye Diseases92 3720 Conjunctivitis & Ophthalmia 379.093 3730 Eyelid Infections/Chalazion 37394 367- Retractive Errors 36796 366- Cataract 366

97 365- Glaucoma 36598 3b9- Blindness 36(99 378- Other Eye Diseases 379

Ear Diseases100 3801 Utitis Externa 380.1

101 3820 Acute Otitis Media 3,1.0102 3811 Acute & Chronic Otitis Media 381.1103 3,15 Eustachian block or Catarrh '11.5

104 386- Vertiginous Syndromes 386105 387- Deafness, Partial or Complete 39q106 3804 Wax in Ear 180.410/ 388- Other Ear & Mastoid Diseases 388

VII. Circulatory System DiseasesHeart Disease

103 390- Rheumatic Fever/Heart Disease 3981(9 410- Acute Myocardial Infarction/Subacute Ischemia 410110 412- Chronic Ischemic Heart Disease 41411? 428- Heart Failure, Right/Left Sided 42R

Ili 4273 Atrial Fibrillation or Flutter 4?7.3114 4270 Paroxysmal Tachycardia 427.0115 4276 Ectopic Beats, All Types 427.6117 416- Pulmonary Heart Disease 416

]11 424- Diseases, Heart Valve, Nonrheumatic NOS, NYD 424

39

APPENDIX D (Contd)

Position ICiiPPC

Number Code Condensed Title ICD-9-CM

118 429- Other Heart Diseases NEC 429

Blood 'ressure Problems120 401- Hypertension, Uncomplicated an]121 402- Hypertension Involving Target Orqan 102

Vascular System Diseases123 435- Transient Cerebral Ischemia 435124 438- Other Cerebrovascular Disease 437125 440- Atherosclerosis, Excluding Heart & Brain 440126 443- Other Arterial Disease, Excluding Aneurysm 443

127 415- Pulmonary Embolisn & Infarction 415128 451- Phlebitis & Thromophlebitis 115I129 454- Varicose Veins of Legs 454130 455- Hemorrhoids 455

131 4580 Postural Hypotension 45R.0132 459- Other Peripheral Vessel Diseases 459

VIII. Respiratory System Diseases133 460- Acute Upper Respiratory Tract Infection 460134 461- Sinusitis, Acute & Chronic 461135 4b3- Acute Tonsillitis & Quinsy 463136 474- Hypertrophic Chronic Infected Tonsils/Adenoids 4711137 464- Laryngitis & Tracheitis, Acute 464

138 466- Bronchitis & Bronchiolitis, Acute 466139 487- Influenza 487140 486- Pneumonia 486141 5110 Pleurisy, All Types Excludinq luberculosis 511.05 5119 Pleural Effusion NOS 511.1

142 491- Bronchitis, Chronic & Bronchiectasis 491143 492- Emphysema & Chronic Obstructive Pulmonary Disease 492144 493- Asthma 493145 477- Hay Fever 477146 4781 Boil in Nose 478.1147 519- Other Respiratory System Diseases 519

IX. Digestive System Diseases148 520- Teeth & Support Structure Diseases 520149 528- Mouth, longue, Salivary Gland Disease 52R150 530- Esophageal Diseases 530151 532- Duodenal Ulcer W/WO Complications 532152 533- Other Peptic Ulcer 50

153 536- Other Stomach & Duodenal Diseases/Disorders 536154 540- Appendicitis, All Types 541155 550- Inguinal Hernia W/WO Obstruction 550156 551- Hiatus/Disphragmatic Hernia 551157 553- Other Hernias 5ii

40

Pu--I~

APPENDIX D (Contd)

Position ICHPPCNumber Code Condensed Title 1CK-9-CM

158 562- Diverticular Disease of Intestine 562159 558- trritable bowel Syndrome/Intestinal Disorder NEC 564160 555- Chronic Enteritis, Ulcerative Colitis 556161 5640 Constipation 564.()162 565- Anal Fissure/Fistula/Abscess %5

163 5646 Proctitis, Rectal & Anal Pain NOS 564.6164 5693 Bleeding per Rectum NOS 16q.3276 578- Hematemesis, Melena, GI Hemorrhage NO', 57R165 571- Cirrnosis & Other Liver Diseases 571166 574- Gallbladder & Biliary Iract Disease 574167 579- Other Digestive System Diseases NEC 577

X. Genitourinary System DiseasesUrinary System Diseases

168 580- Glomerulonephritis, Acute & Chronic 582169 5901 Pyelonephritls & Pyelitis, Acute 5q0.1170 595- Cystitis & Urinary Infection NOS 595171 592- Urinary System Calculus, All Types 502

172 597- Urethritis NOS, NEC 57173 5936 Orthostatic Albuminuria 593.6373 5997 Hematuria NOS 599.7

174 598- Other Urinary System Diseases NEC 599.9

Male Genital Organ Diseases

175 60U- Benign Prostatic Hypertrophy 60U176 601- Prostatitis & Seminal Vesiculitis 6011/7 603- Hydrocele 603173 604- Orchitis & Epididymitis 604

179 605- Redundant Prepuce, Phimosis & Balanitis 605180 607- Other Male Genital Organ Diseases 607

Breast Diseases181 610- Chronic Cystic Breast Disease 610182 611- Other Breast Diseases 611

Female Genital Organ Diseases183 614- Pelvic Inflammatory Disease 61,184 622- Cervicitis & Cervical Erosion 62?185 6161 Vaginitis NOS, Vulvitis 616.11.16 618- Uterovaginal Prolapse 61V

187 627- Menopausal Symptons & Postmenopausal Bleedinn 627188 6254 Premenstrual Tension Syndrome 625.4374 6250 Non-Psychogenic Vaginismus & Dyspareunia 625.0

Disorders ot Menstruation189 62b0 Absent, Scanty, Rare Menstruation 626.0190 6262 Excessive Menstruation 626.2191 621.3 Painful Menstruation 6?5.3

41

'I

APPENDIX D (Contd)

Position ICHPPLNumber Code Condensed Title ICD-9-CM

193 6269 Intermenstrual Bleeding 6/6.,l194 629 - O)ther Female Genital Orqd n [)i c e,

t ertil it.y l'rot)lems195 606- Sterility & Reduced lertility 606

XI. Pregnancy, Childbirth, Puerperium196 633- Ectopic Pregnancy 63197 640- Bleeding During Pregnancy 640198 6466 Urinary Infection, Pregnancy & Postpartum 6a6.6199 642- Toxemias of Pregnancy & Puerperium 642200 636- Induced Abortion 635

201 634- Abortion, Spontaneous & NOS 63a202 648- Other Complications of Pregnancy hA8

203 b50- Normal Delivery 650204 661- Complicated uelivery 661205 6/6- Mastitis & Lactation Disorders 6/62U6 670- Other Complications of Puerperium 670

XII. Skin, Subcutaneous Tissue Diseases207 68U- Boil & Cellulitis, Including finger & Toe 621209 683- Lymphadenitis, Acute 683Z10 684- Impetigo 684211 685- Other Infections Skin/Subcutaneous 686212 690- Seborrheic Dermatitis 690

213 6918 Eczema & Allergic Uermatitis 691.R214 692- Contact & Other Dermatitis NEC 692215 6910 Diaper Rash 691.0216 6963 Pityriasis Rosea 696.321/ 6961 Psoriasis W/WO Arthropathy 696.1

218 698- Pruritis & Related Conditions 698219 700- Corns & Callosities 700220 7062 Sebaceous Cyst 796.2221 703- Ingrown Toenail & Nail Disease NEC 703222 704- Alopecia & Other Hair Diseases 704

223 70b- Pompholyx & Sweat Gland Disorders NEC 705224 7061 Acne /06.1Z25 707- Chronic Skin Ulcer 707226 708- Urticaria 709227 709- other Skin & Subcutaneous Tissue Disease 7no

XIII. Musculoskeletal, Connective Tissue DiseaseArthritis & Arthrosis

228 114- Rheumatoid Arthritis & Allied Conditions 714229 715- Osteoarthritis & Allied Conditions 715Z30 7161 Traumatic Arthritis 716.1288 7194 Pain or Stiffness in Joint 719.4289 7190 Swelling or Effusion of Joint 719.0231 725- Arthritis NEC/Diffuse Connective Tissue Disorders 710

42

APPENDIX D (Contd)

Position ICHPrCNumber Code Londensed fitle I F)-Q-(Th

NonIrticular Rheumatism232 7260 Shoulder Syndromes /26.0233 7263 other Bursitis & Synovitis 726.3234 728- Other Nonarticular Rheumatism 7?2286 7295 Pain & Other, Limb Symptoms 721.

Vertebral Column Syndromes

235 723- Cervical Spine Syndromes 723237 721- 0steoarthritis ot Spine 721238 /242 Back Pain without Radiating Symptoms 724.2239 7244 Back Pain with Radiating Symptoms 724.4240 73/- Acquired Deformities of Spine 737

Other Musculoskeletal, Connective Tissue Disorders241 7274 Ganglion of Joint & lendon /27.4242 732- Osteochondrosis /32?43 7330 Osteoporosis /13.0244 717- Uhronic Internal Knee Deranqement /17Z45 736- Acquired ueformity of Limbs 73h246 739- Other Musculoskeletal Connective Diseases 73'A

XIV. Congenital Anomalies247 746- Congenital Anomaly, Heart & Circulation /16248 /54- Congenital Anomalies of Lower Limb 754249 7525 Undescended Testicle 752.52sl 7436 Blocked Tear Duct 743.A5Z52 758- Other Lonqenital Anomalies NEC 759

XV. Perinatal Morbidity & Mortality253 778- All Perinatal Conditions 779

XVI. Signs, Symptoms, lll-Uefinea ConditionsCentral & Peripheral Nervous System

254 7803 Convulsions 780.3255 7810 Abnormal Involuntary Movement 751.0256 7804 Dizziness & Giddiness 780.4257 7845 Disturbance ot Speech 784.c258 /84u Headache /2,4.0251) 7 20 Disturbance ot Sensation 7%1 . 0)

Lardiovascular & Lymphatic System

262 7865 Chest Pain 7q6.5263 7851 Palpitations /85.1264 780? Syncope, Faint, Blackout 7q0.2116 7:15? Ileart. Murmur NEC, NYD 7q5.2265 7823 Ldema 782. 3266 /956 Enlarged Lymph Nodes, Not Infected 791.6

Respiratory System267 7847 Epistaxis 744.7e68 7863 Hemoptysis 746.3269 7860 Dyspnea 796.0270 7862 Cough 7;6.?

43

APPENDIX D (Contd)

Position ICHPPCNumber Lode Condensed Title ICD-9-UM

bastrointestinal System & Abdomen273 7830 Anorexia /83.0214 7870 Nausea/Vomiting /97.n275 7871 Heartburn 787.1277 7891 Hepatomegaly/Splenomegaly 789.1278 7873 Flatulence, Bloating, Eructation 78/.3/79 7890 Abdominal Pain 799.0

Genitourinary System280 7881 Uysuria 7£g.1Z81 7883 Enuresis /88.3283 7884 Frequency of Urination 7q.9.4

General Signs & Symptoms29u 78u Excessive Sweating 780.8?91 /806 Fever of Undetermined Cause 780.6292 7821 Rash & Other Nonspecific Skin Eruptions 792.1293 7832 Weight Loss 783.2294 7834 Lack of Expected Physiologic Development /83.4

53 783" Feeding Problems, Baby or Elderly 783.3295 7S07 Malaise, Fatigue, Tiredness 78U.7Z96 7822 Mass & Localized Swelling NOS/NYD 792.2297 797- Senility without Psychosis 707

Unexplained Abnormal ResultsUrinalysis

298 791- Abnormal Urine Test NEC 791

Hematology37b 7900 Hematological Abnormality NEC 790.0

Blood Chemistry51 7902 Abnormal Unexplained Biochemical Test 790.2

Other Abnormal Results376 7950 Nonspecific Abnormal PAP Smear /95.0119 7962 Elevated Blood Pressure 796.2299 793- other Unexplained Abnormal Results 793

Sign, Symptom, Ill-Defined Condition NEC300 7889 Sign, Symptom, ll-Detined Condition NEC 700

XVII. Injuries & Adverse EffectsFractures

301 802- Fracture, Skull & Facial Bones 802302 805- Fracture, Vertebral Column 905303 807- Fracture, Ribs 807.0304 810- Fracture, Clavicle 810305 81z- Fracture, Humerus 812

306 813- Fracture, Radius/Ulna 813307 814- Fracture, (Meta) Carpal & (Meta) Tarsal 814

44

L L

APPFNDI X (Contd)

Position ICHPPCNumber Code Condensed Title 1CD-9-c"

308 R16- Iracture, Phalanges Foot/Hand 016309 820- Fracture, Femur 99(

310 223- Fracture, Tibia/Fibula P311 829- fracture, All Other Sites NEC 929

Dislocations & Subluxations312 836- Acute Damage Knee Meniscus 216.2313 839- Dislocation/Subluxation, Other Sites NFC 83

'lir,)i .oy ,< tra ins414 4 - Spra in/Strain, Shoulder & Arm 24n

.i15 '.?- Sprain/Strain, Wrist, Hand, Fingers 84216 '-,44- Sprain/Strain, Knee & Lower Leg 244

31/ Sabo Sprain/Strain, Ankle 845.0

iI1 '451 Spra in/Strain, Foot & Toes P45.1319 8470 Sprain/Strain, Neck 847.0320 8478 Sprain/Strain, Vertebral, Excluding Neck 947.9321 348- Sprain/Strain, All Other Sites NEC 242

Other Traumas322 85U- Concussion & Intracranial Injury P50823 889- Laceration/Open Wound/Trauma, Amputation 224325 910- Insect Bites & Stings qlq.l326 918- Abrasion, Scratch, Blister 919327 929- Bruise, Contusion, Crushing 924

328 949- Burns & Scalds, All Deqrees qa

329 912- Foreign Body in Tissues 015.r330 930- Foreign Body in Eye qJ'i331 939- Foreign Body Entering Through Orifice 931

332 9(0- Late Effect of Trauma 08o

3J3 959- Uther Injuries & Trauma q5q

Adverse Effects

334 977- Overdose, Medicine, Accidental or Deliberate 977377 9952 Adverse Etfect, Medicine Proper Dose 995.2335 989- Adverse Effects of Other Chemicals qin336 998- Surgery & Medical Care Complication 998337 994- Adverse Effects of physical Factor, 9q4378 9950 Other Adverse Effects NEC 995.8

Supplementary ClassificationPreventive Medicine

338 V70- Medical Examination V70339 VOl- Contact/Carrier, infectious Parasitic Disease VOl340 VU3- Prophylactic Immunization V06311 V14- Observation/Care Patient on High Risk Medication V67.514 2 VIO- Observation/Care Other High Risk Patient \'14i

API [NDI X I) (Contd)

Position ICHPPCNumber Lode Condensed Title ICD-9-CM

Family Planning343 V?52 Sterilization of Male or Female V25.2344 V255 Oral Contraceptives V25.02345 V251 Intrauterine Devices k1:1. I346 V253 Other Contraceptive Methods V25.0Z347 V256 General Contraceptive Guidance V?5.

Administrative Procedures348 V680 Letter, Forms, Prescription without Examination V6P349 V683 Referral without Examination or Interview vr.qI

Maternal & Child Health Care

350 VZ23 uiagnosing Pregnancy vI2.351 V220) Prenatal Care V22352 V24- Postnatal Care V?4

Miscellaneous353 V50- Medical/Surqical Procedure without Diaanosis V5r)354 V654 Advice & Health Instruction V65.11355 V6bl Problems External to Patient V65.1

Social, Marital, Family Problems356 V602 Economic Problem VAQ.2357 V600 Housing Problem V60.O358 V614 Medical Care Problem V61.43b9 V611 Marital Problem V61.136U V612 Parent & Child Problem V61.2

361 V613 Aged Parent or In-law Problem V61.3362 V61) Family Disruption W/WO Divorce V61.0363 V619 Other Family Problems V61.9364 V623 Educational Problem V62.3

J65 V61b Pregnancy Out of Wedlock VA1.r.366 V624 Social Maladjustment 162.4367 V620 Occupational Problem V62.0368 V627 Phase-of Life Problem NEC

370 V625 Legal Problem \'62.5369 V629 Other Social Problem V6?.0

Other Problems NEC371 V9Y9 Problems NEC in Codes 008- to Vb29 V82.9

46

. Il

APPENDIX E

APPENDIX E

CARE PROVIDER CODES

CODE

1 Physician

2 Nurse

3 Physicians' Assistant

4 Dietician

5 Physical Therapist

6 Corpsman

7 Social Worker/Psychologist

8 EKG Technician

9 Optometrist

4814

APPENDIX F

APPENDIX F

CLINIC CODE

CODE

I Family Practice

2 Pediatrics

3 OB/GYN

4 Internal Medicine

5 Surgery

6 Well Baby

* 7 Nutrition

8 Cardiac

9 Allergy

10 Hypertension

11 Neurology

12 Optometry

13 Physical Therapy

14 Audiogram

15 Minor Surgery

16 Stress Test

*17 EKG

*18 New OB

*19 Allergy (Bone)

20 CMHA

21 TMC

22 Immunization

23 Respiratory Therapy

24 Preventive Medicine (Occupational Health)

25 Emergency Room

26 AMIC

27 Cast Room

* not used 50

**1

APPENDIX G

Hii

4

A - --

APPENDIX G

FAMILY MEMBER PREFIX CODES

20 Sponsor

30 Spouse

01-19 First thru 19th child

40 Mother/Sponsor

45 Father/Sponsor

50 Mother-in-Law/Sponsor

55 Father-in-Law/Sponsor

60-69 First thru 10th other bonafide dependents

00 Other Category/Authorized Care

52

, I

APPENDIX H

APPENDIX H

Other Patient Category Codes

ARMY PUBLIC HEALTH SERVICE

1 Active Duty 37 Active Duty2 Reserve-Initial Entry Training 38 Reserve3 Reserve-IDT/AT/ADT 39 Retired4 Natl Guard-Initial Entry Tng 40 Depn Active Duty5 Natl Guard-IDT/AT/ADT 41 Depn Retired/Deceased6 Retired7 Depn Active Duty NATIONAL OCEANIC & ATMOSPHERIC ADMINISTRATION8 Depn Retired/Deceased9 West Point Cadets 42 Active Duty

10 ROTC Cadets 43 Reserve11 Designee Sec Army 44 Retired

45 Depn Active DutyNAVY 46 Depn Retired/Deceased

12 Active Duty CIVILIAN EMPLOYEES13 Reserve14 Retired 47 State Department Employee15 Depn Active Duty 48 Other Federal Department Employee16 Depn Retired/Deceased 49 Civilian Employee DOD Auth Occ Health17 Navy Academy Cadets 50 Other Federal Agency Employee18 ROTC Cadets 51 Civ Employee US Govt Disable Ret Exam

52 Nonmilitary Federal Beneficiary

MARINE 53 Other US Govt Empl Remote Areas

19 Active Duty DEPENDENT CIVILIAN EMPLOYEES20 Reserve 54 Depn Non DOD Federal Agency22 Depn Active Duty 55 Depn in Remote Areas23 Depn Retired/Deceased 56 Depn Other Federal Agency

AIR FORCE OTHER BENEFICIARIES

24 Active Duty 57 VA Beneficiary

25 Reserve/National Guard 58 OWCP Beneficiary

26 Retired 59 Soldier/Airmen Home

27 Depn Active Duty 60 Other Federal Agency Beneficiary

28 Depn Retired/Deceased 61 American Indian/Eskimo

29 Air Force Academy Cadets 62 Micronesian30 ROTC Cadets 63 Contract Employee

64 Seamen/Not MSTS/MSC

COAST GUARD 65 Prov Relief Act Beneficiary

66 Peace Corps/VISTA/Job Corps31 Active DutyPRSNS

32 Reserve PRISONERS33 Retired34 Depn Active Duty 67 War/Intern/Retain35 Depn Retired/Deceased 68 Other Prisoners36 Coast Guard Academy Cadets

54

I .- i

APPENDIX H (Contd)

Other Patient Category Codes

FOREIGN NATIONALS

69 IMET/Sales Trainee70 Other Foreign Military71 NATO EM72 NATO Officer73 Foreign Civilian74 Foreign Natl NATO Civilian Personnel, NEC75 Depn Foreign Military76 Depn Foreign Civilian77 Other Foreign Nationals

OTHERS

78 Applicant/Registrant79 Designee Secretary Defense80 Civilian Claimant81 Other Authorized Personnel82 Seaman, MSTS/MSC83 Former Female SM84 All Others, NEC

55

APPENDIX

[I

• I

APPENDIX

Care Provider Instructions

CARE PROVIDER:

The uppe t .wo-tkuAdL o6 the 6o'tm 6houtd be compteted wheni you 'Leceive it. You akeonig Apon64bte Sok the in6o~.mel.on with PURPLE HEADINGS at the Lowe# one-thikd andAeveAhe .6ide o6 the dokm -- the comnnet6 below L4JLU a6~.6it you:

lnZitiaL V6it go&t Th"Z Pxtobte: Set 6-exptoanatoAy.71I Case PkovieA - #2 ZaJe Povi~dA: You wiR be givuen a ca&e pkovideA numb eA.

Uip to tw'o caAe ptovideAu 'a be given EJtedi t '. £eeing the .6ame patiZent in anyj v~~uctinic -- be /.Amonabte, e.g., i6 a pediat~ic nu~ze ptuictitione/t wQAe to Aee a patientand then deterine that a pediattidian ol-Ao needed to .6ee the patient, both the nuuheand pediatcZan Am&..f iAe!eive ciiedit.

Exam6P'woceduAu I A6 many a6~ appticabte (ptea~e check i6d exam iA chape~oned ok not).

Job Retated Diagno6Z : VouA pAo6e66onoat opinion.VZ~po&Ztion: Choo~e the one beAt t'~apon6e. P~mWD

one 4 0,6,cA*The&e e37 igotcaeoke6 Select C )5howeveA, you may 6 etect up to 6Zve additZonat dignozAu. 16 ~ 1 1a diagno4". ". not piLepAinted, uAe the "Addit.Zonat DX" bMock 2 2 2 2at towe'r &Zgkt Aejemvig to the ICI{PPC-2 Index 6oir. covtect 3 3 3 3code (i6 the diagno~AiZ6 L 056 Rubella, 6LUt in the btock a.6 4 4 4 4shown in the exanpLe). 5 5 *

6 6 64

57

APPENDIX J

I1 I .

r,-,

APPENDIX J

Patient Instructions

MARKING INSTRUCTIONS FOR PATIENTS

o W~e 02 pencit (no pen o 6ett tip6).o Ma/k .6hou d 6iU the ci'cte comptetety.o Maze no &tOay nvLw o comment6 on the 6om.o EAe cteaxty any changa.o Feet f'ee to a.6k the ,sta66 60A

hetp i6 you have a que tZion.

On aide one on.y -F- tt in the keque~ted ,n6oa. .t.ion in aot btock4 with

Wirite you 'ttpone in the btock and 6it in the cozt6ponn .1_c.L'we. ALL co.tum, mu.ut be 6.Lted in; e.g., i6 youL bL'thdtZ5 Ma 1946, wte 46 nde "ye4" and 05 und e "month" IVthen 6U in c~etaahhown innexa e.. e 6o wnqbock4 I2 2aA.e AeLt-exptn.ato .u: BLilh, Spon6o SSAN, Patient Stu&, 2 3 2 2Sex, Ethnicity, Race, 16 Student From Other Cowitiwty, and Date. 3 3The otheA, btockA aae exptained betLow. 5 5 5

PATIENT'S INITIALS: 16 you have no rnZddte itiat 6 in 6 * 66the btan EL~cle above the mrddte "A."

STATUS: T6 you ate on active duty, a dependent o active duty, f.,t..ed, o aoieient 06 a ,teted o4 decea.6ed Aetvice membeA, ALSO indicae the Apon6o~ing

banch o6 hevice (tha wU kequiAe ,iting in two c.icte,6). "FedeAaLemp.oqea" Ahoutd be m'ked ONLY by DOP outhoi,'zed occupai..onat Te-Wcivuianenptoyeeh. .Civtgn cA 6et6-exptanatoy. 16 you aAe unabLe to Locateqou/t to am seg ho Lted, mak the "OTHER" categoi and a.6k the Ata66 6o4e4 a6te you have co'pteted the xet o6 the 6o,/rn.

FEDERAL EMPLOYEESt Setg-exptanatoozy.

C~uiZian Occ Se.ie.: YouA cuA ent occ AeA,6 nmbeA -- Exainte: 0343.Pay Gade: Exampete: 03, 05, 11, etc.W9dg NumbeA: 16 the numbeA hah a Lettet (T-634) di. 4eqgaAd the LetteA

and 6ilt in the c~i~.e "0." Examp.e: 0634.

AD ARMY: FOR ACTIVE DUTY MEMBERS ONLY -- DEPN, RETIREES: DO NOT FILL IN.

Pay Gutde: Exampte: 16 youA g'ade ia E-8 6iU in 08; i6 COL 0-6 6iUin 06; i6 W-7 64ll in 02.

16 AMAN-Vuty MOSISSI: Be 6ute. to Apeci6y DUTY MOS.nit: Set6-expLanatoAy.

CHECK TO SEE IF YOU HAVE: 1) WRITTEN YOUR RESPONSE IN THE BLOCK WHEN PROVIDEDand ALSO

2) FILLED IN THE MATCHING CIRCLE

THANK YOU!

59

I,

I

APPENDIX K

I

I -

APPENDIX K

Clerical Staff Instructions

Clerical Staff:

We appreciate your assistance in helping us with the OutpatientEncounter Test Form. Please fill in the blocks with PURPLE headings onthe upper two-thirds of the form (for your information the instructionsheets for patients and care providers are attached).

A numeric designation will be assigned to each clinic (first blockupper left corner) using the form. FM4 codes are listed on the backsideof the "Patient Category" sheet. Afti- you have filled in the "Ap Stt. 5"and "Time In" blocks, give the form and marking instructions to the patient.If a patient marks "Other" under the Status block, please refer to thePatient Category list-an fill in the appropriate code in the block titled"For Clerk's Use Only."

The bottom section of side one and the back of the form will be filledin by the care provider. When the form has been completed by both thepatient and care provider, fill in the "Time Out" block and scan the formfor any obvious omissions, such as birthda-te written in but circles notfilled in, etc., and correct accordingly.

LTC Misener and Ms. Gilbert will be available if you have anyquestions.

Thank you

61

APPENDIXL

APPENDIX L

i' 1kz Ufi ,li I~ 1.0 I' V. )J 3 I I I W (A. L.4 )

* CLIN IC ,,U 4 uE LA~iPLL~r A *

* £I~II* -U to C-.kiLL~rL U, A,~ . *

* i** iUL.'f BL C~PlkLLA

* *PA' ik3~i IN±. ii t~ bLu 'LL1L, L) U, A,,)-

* * * &dLL'L Jk uLAUi( L* I% *

lu ,AL *iUILi w tiiL~L CoJL(L'TiJ A,

* 1 /PlP'1..lU ~L iL C,.xdLL'iL *

*12 * LTL-LAY *Cx-W'LLTLh A98A Li I *.

113ALiT-~ C-ilLL'ik IO1111 V, LA,~.I j4 * U IL--MuNVii * CiPLL'±L *4090

*15 * %l,-L * CuJiPLL'iL IWMNM U* A,

*15 * 'i IML- IN *Ci[LLTE' JR BLN A) A

*17 * 'I I t-JuUI' A Cul&LLTEr uiN ii A,.

16 1.3 * a'iW US CCAIPLETE A 1) A,

I j A) CLLkK, UbL 2(vll'LbTL G1% jjLiM~2 U * )JUICIVE *C)OMPLLTh UR BLANK**

*21 .1' IULLL-k'Ui * u'iPL6TL UN lu4K A , i

* 2)2 * di) MiLITAI(Y * W-ijLi'L " 0 iiLANK*A* ) 3 * 04't 6kA)L N L. A C -A*LETL usi iBL\K -A U,A, *

A 24 * ,oj{,NiLIC C~1-.1L iCR Ok~4 * LAS K

2 UNIT *CdLiL uli 6"LAK *Ui,

A A7 r ED bvlLuYLL * CLuiPLLTL t- LdiPJK * U,,oA2. J CI V IL I /,d--CC. A) (JML'i NiLAjiK ~u\.S2) "' fr'' UQidA. CtV.* (A-i'LETL CRA t-, Li-Ao A LL.1. NUritLR A CaJPLt t bLLAU

A I Ii ilIAL VIb'IT A 1U.Ji iu &'LitA .A, A

A 32 AiNi ULIN e. A C(Av&PLLT6 4 . A R *

A j A pUVILL J; A u-IPLELL OR A Ai

A V Cik\PU(kUNLu CkA-,tLLT6 JR biLiNKA*A) AOD iRjyj t+I i t, jk bUJjj A) DA,, A

A A l~u. ':CNU)AI(+I* i-u-WiLE'f jl( bLANKAA

EL t i * i U E iL-.I, IUNoUDELLL 'uUii'Uf' iLUUR

63

APPENDIX M

APPENDIX M

Outpatient Encounter Form Test--Conversion Program

PIIRPOSE: Convert tape created by optical scarnr (9; character records,Ur YcTed) to co'des us d on inDUr t document 7 7't :P -':V , I ; T .

T

Output will be tape, 220 character records, blockeo 10.

DESCRIPTION OF INPUT:

P')S LENGTH DESCRIPTION AND CONVFPS,. .... IP'S

1-2 2 Clinic Code. No edit or conversion remi,red.

3-4 2 Family Member Prefix. No edit or conversion requirad.

5-6 2 Year of Birth. 2-diqits, no edit or conversion required.

--7-8 2 Month of Rith. 2-digits. If not 1 thru 12, fill with zeroes.

--17 9 SSAN. No edit or conversion required.

18-20 3 Initials. No edit or conversion reouired.

?I Sex. No edit or conversion renuired.

-22 1 Pace. No edit or conversion reeuired.

23 1 Ethnicity. No edit or conversion renuired.

-24 1 Apointment Status. No edit or conversion required.

45 1 Inpatient/Outpatient. No edit or conversion required.

-.26-27 ? Day of Visit. No edit or conversion required.

-28-29 2 Month of Visit. If not I thru 12, fill with zeroes.

1 Year of Vist. "I" = 82. "2" = 83. Convert on output.*

-31-34 4 Time Patient Arrived for Visit. No conversion for output.Time is recorded using 24-hour clock. This field will be used to

compute number of minutes patient was in the facility.

-35-38 4 Time Patient Departed Facility. No conversion for output. Timeis recorded using 24-hour clock. This field will be used to com-pute number of minutes patient was in the facility.

i4.

65

'I|

APPENDIX M (Contd)

Outpatient Encounter Form Test--Conversion Program

39 T -atient Status fode-1 I Active Duty2 = e'-rent Active "uty3 = Retired4 = Re.et Ret/Deceased5 Fec';ral Employee6 Civilian Emeroency7 Foreiqn Student8 =Other

If not one of alove (1 thru 8), fill with "I" (Force ActiveDuty).

40-41 2 Codo- for other. No edit. Move to outout record, if patientstatus code-1 (Pos 39) = "8."

42 1 Patient Status Code-2 1 = Army2 = USAF3 =Navy4 = Marine

This field is not used unless Patient Status Code-1 (Pos 39) is aa "I" thru "4." If Pos 39 = "I" thru "4" and Pos 42 is not "1"thru "4," fill Pos 39 with a "1." (Force Army)

43-44 2 Country Code for Foreign Students. No edit or conversion.

Move to outDut record, if Pos 39 = "7."

5 Off/WO/Enl Code. I = Officer2 = Warrant Officer3 = Enlisted

No edit or conversion reouired. Move to output record, if

Pos 39 = "1."

_,-46-47 2 Military Pay Grade. Move to output, if Pos 39 = "I."

---48-50 3 MOS. Move to output, if Pos 39 = "I" and Pos 42 : "1."

"-1 1 Unit. Move to output, if Pos 39 = "1" and Pos 42 = "1."

52 1 Fed Empi Code. Move to output, if Pos 39 - "5."

53-56 4 Civ Occupation Code. Move to output, if Pos 39 = "5."

57-58 2 Civ Grade. Move to output, if Pos 39 = "5."

59-62 4 Buildinq Number. Move to output, if Pos 39 "5."

66.4~ I

APPENDIX M (Contd)

Outpatient Encounter Form Test--Conversion Progrdm

--- 63 1 Initial/Pecurrina Problem. No edit or conversion renuired.

64-6P 5 #1 Provider. If = spaces, fill with zeroes.

6-60-73 5 #2 Provider. No edit or conversion required.

7±-124 5 PROCEDURES. This 51-caracter field represents the 51 proceduresprinted on the front side ol the crm. Procedures are assianed a2-digit code (01 for "Advice/Hpalth Instr," thru 51 for "otherprocedures." Procedures are nu-,ered consecutively starting withthe first column (01 for "Advice/Health Instr" thru 13 "EKG-orderForm"). Then second column (14 "Endometrial Biopsy" thru 26"Minor Surgery" etc. Input record will have a "1" or space incorresponding position for each procedure. A "1" indicates aprocedure was performed. Convert to 2-digit codes for output.Limit on output is 10 procedures. If more than 10 coded oninput, move first 10 to output record but list all that werecoded on the error report. This field is optional-may be allspaces.

125-152 28 REFERRALS. This 28-character field represents the 28 "Referredto" clinic/service on the front side of the form. Eachclinic/service is assigned a 2-diait code (01 for "Allergy" thru28 for "other." Clinics/Services are number consecutivelystarting with the first column (01 "Alleray" 09-ER; "10-FamilyPractice" 17-Othopedics), etc. Input record will have a "I" ora soace in the correspondina position for each Clinic/Service.A "1" indicates patient was referred to that Clinic/Service.Convert to the 2-digit codes for output. Allow for all 28 codeson output. This field is optional - May be all spaces.

-- 53 1 Job Related. No edit or conversion required.

__I.S4-160 7 Disposition Codes. If not, "1" thru "7," fill with "9."

,,461-171 11 Examinations. This 11-character field represents the 11 types ofexaminations printed on the front of the form. Each type of exa-mination is assigned a 2-digit code (01 for Abdominal thru 11 forVisual Acuity). Input record will have a "1" or a space in thecorresponding position for each examination. A "I" indicatesthat examination was performed. Some examinations are mutuallyexclusive.If Flight Physical (Code 06) accept no other types of exam.If not Flight but complete PE (Code 03) move 03 to output record.Accept no other types of exams.AIf not Flight or Complete PE and return to work (Code 10), moveCode 10 to output, if Fed Employee ("5" in Pos 39),else move "07" to output record and accept no other type of exam.

67

L.

APPENDIX M (Contd)

Outpatient Encounter Form Test--Conversion Program

If not Fliol' , , ca . .. ; ".r 1 03) or T,work (Code 10;, ',ut His+ory without PF i(ro '7), iove "07" tooutput reoord an. a-ce;,t no other- tvne (o -"

Other- i se, ct!v -t all ear-' cn# .',4 rnvr to output record.This field is ootional - may be all spaces.

.l172 1 Chaperoned. ,o edit or conversion reauired.

-- 73-425 253 Primary Diaqnosis. This 253-character field represents the 253diagnoses printed on the back side of the form. Input recordwill have a "1" or a space in corresoonding position for eachdiagnosis. A "1" indicates the diaanosis was recorded. Scannerreader each column from top to htztt.m starting with first columnon left side of form. Convert to 4-character diagnosis codesprinted on form, Hold for further edit.

426-678 253 Secondary Diagnosis (additional). This 253-character fieldrepresents the 253 diagnoses printed on the back side of theform. Input record will have a "1" or space in correspondingposition for each diagnosis. A "I" indicates the diagnosis wasrecorded. Scanner reads each column from top to bottom startingwith first column on left side of the form. Convert to4-character codes printed on form and hold for further edit.

-67-683 5 Free Form Primary Diagnosis. This field is used to record adiagnosis that is not oreprinted on the form. Diaqnosis codesused are 4-character. First nosition (Hi-order) has the letter"V" for some diagnosis. Otherwise, diaqnosis code is numeric.Input record will have a "I" or space in Position 679 to indicatediagnosis code starts with a "V." If Pos 679 = "1," move a "V"

to Pos 680. Positions 680-683 will have 4-position diaqnosiscode. This code oust match one of the codes on the attached list(may be one vreprinted on form also). If invalid reject and liston error list. There must be one primary diagnosis recorded.This field is checked with the conversion from Pos 173-425 todetermine if more than one or no diagnosis was recorded. If morethan one accept free form primary diagnosis, if any, else movefirst one recorded to output record. List all recorded on errorlist. If no primary diagnosis recorded, fill with 9999. List onerror list if filled with 9s.

68

APPENDIX M (Contd)

Outpatient Encounter Form Test--Conversion Program

P-CPP 5 Free Fo. nra 'cH-mics This f,-rl~to record an aildi tioral s<7 ,n,'>rv ) iaonosi s that is not T i 'fon the 'arr, 2iaanosls cr,,I-' u, a- t-.-'aracter. F st * -

tion (Hi order) has thE let*,er "V for scrie diacinosis. flthc'r#,SPDi agnosi s co'le i nir- '- -:.: v -or e 11il have a "I " or s,,ace,in Pos 684 to indicate di oi-os' s co)de starts with a "V." if Pos694 = I",~ move a "V to ;Pos £F . Positions 685-688 will have 4position diaonosis code. This code mist match one of the codeson the attached list (ray '-e one nreprinteO on the form also. Ifinvalid, reject and list on the error list. Recording additional(secondary) diagnosis is optional. This field may be all spaces.Output record is limited to five additional (secondary) diagno-ses. Diagnosis from Positions 684-689 must be concatenated withthose converted from Pocitions 426-678. If more than five,accept free form sec diaq, if any plus first four recorded inpreprinted position of form. List all recorded on error report.

-689-696 8 Document Serial Number. No edit or conversion required.

Additional Computed Output.

1. Patient's age in months at time of visit.

a. Assumptions: No patient is over 99 years old.

b. A baby less than one month old will be 000 months.

c. If date of birth is not recorded, move spaces to aqe in months field.

2. Time in Treatment Facility in Minutes.

a. Assumption: No patient will be in facility over 23 hours 59 minutes.If time in or time out not recorded, move space to time in facility in outputrecord.

3. Functional Point of Contact: LTC e "Health Care Studies221 -3331 /3116

4. Contractor for Optical Scanner: Jim ScullyNational ComputersFTS 612 830-7600 Ext. 8596 or(800) 328-6290 Ext. 8596

69

APPENDIX N

I1

APPENDIX NDEPARTMENT OF THE ARMY

US ARMY HEALTH CARE STUDIES AND CLINICAL INVESTIGATION ACTIVITY

FORT SAM HOUSTON, TEXAS 78234

HSHN-H 27 December 1982

MEMORANDUM TO: Primary Care Providers

USA MEDDACRedstone Arsenal, AL 35809

FROM: LTC Terry R. Misener, Principal InvestigatorAmbulatory Care Data Base

SUBJECT: First Ambulatory Data Report

1. We are pleased to provide you with the first report generated from yourpatient encounter data covering encounters through mid-November. For thisfirst report, we have chosen to provide information concerning primarydiagnosis. Early in January we will also provide data on procedures, dis-positions, exams, time in clinic, secondary diagnoses, and etc. We aremost encouraged by the potential data retrieval and the reports we will beable to provide to you on a regular basis.

2. On the encounter form, we continue to see two problem areas - Dispositionand Primary Diagnosis. These areas of the form cannot be edited by your"machine." Therefore, problems are not seen until the data tapes reach SanAntonio.

Possibly our explanation of these two areas were not clear. As vie canonly return to you data that you provide to us, we hope the following expla-nation stresses the importance of proper completion of the form:

" You may now choose multiple dispositions, however to avnid an errorcondition, you must select at least one of the seven provided choicesfor disposition.

" You may select up to five secondary diagnoses. But, you must chooseo ne and only one primary diagnosis. The computer logic reglardingprimary diagnosis is as follows: If you wake a diaqgio,.fic choicewhich you enter into the "Additional Dx," bluck helov 1. r. AlY .XThis is the one diagnnsis that the computer will designate as THEprimary diagnosis, no matter how many other diagnoses are erroneouslymarked. If you choose a primary diagnosis by bubbling in more thanone primary diagnoses, the first primary diaqnosis encountered by

t the scanner will be reported as THE primary diagnosis.

71

. .. -2

APPENDIX N (Contd)

HSHN-H 27 December 1982SUBJECT: First Ambulatory Data Report

3. I know that we did not promise to provide any output to you until January,but wanted to show you what is developing. We appreciate your patience inthese times of slow mail, personnel on leave, and overloaded computers.Encourage you to discuss problems or requests with CPT Cuff and to call meas needed (AUTOVON 471-3331/6028). Thanks again.

72

I '

APPENDIX C

APPENDIX 0PROFILE REPCRT - MODEL CARE PROVIDER 12235 RECORDS

(January)

PROX PRIMARY OX

VALUE LABEL FREQUENCY PERCENT

OBESITY 76 14.2ACT UP RES TR INF 31 5.0PRES INF INTES rIS 17 3.2PROB NEC IN OTH COS 17 3.2FX ALL 01H SITES NEC 15 2.8LAC OP WNC TRAU AMP 15 2.8PAIN OR SlIF IN JNT 35 2.8OTH BURSGSYNOV 15 2.8ABRA SCRATCH BLIS 13 2.4BRUISE CONTU CRLSHG 12 2.2BK PN WO RAD SYI4P 12 2.2NO DIAG PROVIDED 1? 2.2CYST EURIK INFEC 11 2.1MEDICL EXAM 9 1.1SPR STR ANKLE 9 1.7GONORRHEA ALL SITES 7 1.3HYPERTEN vLNCOMPL IC 7 1.3SINUS ACTECHRON 7 1.3BRONCHIEBRONCO ,AC 7 1.3PROS&SEMI VESCUL 7 1.3CERV SPINE SYNO 7 1.3CONTEOTH CERMA NEC b 1.1RH ARTHEALD CONC 6 1.1CHR INT K14EE DERANG 6 1.1DIITIS EXTERNA 6 1.1LIPOMA ANY SITE 5 .5TRAN SITUA DIST ADJ 5 .9MTHTONSALIV GL 1 5 .9 IMPETIGO 5 .507H INF SKIN SUBCUT 5 .5SPR SIR OTH SITES 5 .9ABS SCANT HENS 5 .5SHOULDER SYN 5PNLOIH LIMB SYMP 5 .19HERPES SIMPLEX 4 .7BENIGN NEEPLASM SKIN 4 .7

- AC TONSILI&QUINSY 4 .7HAY FEVER 4 .7PNEUMONIA 4 .7WARTSvALL SITES 4 .7MONILIASPLROGN PVN 4 .7ACT LCHR SER 07 ED 4 e7NONSP ABN PAP SMEAR 4 .7STRP ?HR SCR FV ERYS 3 .6OERMATOPHY&OERMAMYCO 3 .6MIGRAINE 3 .16HIATUS DIAPHRAG HERN 3 .6

74

A -+ I, A.. AL . _ _ ... .

APPFNI)TX 0 (Cnntd)PROFILE REPORT - MODEL CARE PROVIDER 12235 RECORDS

(January)

PRDX PRIMARY DX FREQUENCY PERCENT

ORCHITISEEPIDIDYMIT 3 .6ORAL CONTRAC 3 .6CONJUNCEOPHTHALM IA 3 .6PSOP WWO AR 3 .6ACNE 3 .6SEBACEOUS CYST 3 .6CHEST PAIN 3 .6NAUSEA VOPITING 3 .6REFRAC7IVE ERRORS 2 .4CHRN ISC HI DIS 2 .4PHLEBI TI SETHROMBOPHL 2 .4HEMORRHO I CS 2 .4BRCHI ,CHREBRCH ICTAS 2 .4EMPHYSEMA LCOPD 2 .4ASTHMA 2 .4DUOD ULC h WC COMPL 2 .40TH STOMOUOD DISOR 2 .4IRI BWL SYN INTS OSR 2 .4PELVIC INFLAM CIS 2 .4OTH FEM ORGAN DIS 2 .4BOILECEL INC FNGETOE 2 .4URTICARIA 2 .4FORGN BODY IN TIS 2 .4BRNSESCLJS ALL CEG 2 .4PRENATAL CARE 2 .4ACUTE OTITIS MEOIA 2 .4ECZ 6 ALG DERM 2 .4BK PN W RAD SYI"P 2 .4DISTUR OR SENSA 2 .4ADVS EF MED PRP DOSE 2 .4HODG IS LYMP LEUK 1 .2HYPOTHYR MYXEDE CRET 1 .2DIABETES MELLITUS 1 .2GOUT 1 .2OTH PEPTIC ULCER 1 .2OTHER HERNIAS 1 .2CIR LOTH LIVER CIS 1 .2OTH M GEN ORGAN IS 1 .2ECTOPIC PREG 1 .2ALECIAEOTH HAIR DIS 1 .2OTH SKNESUB TISU IS 1 .2ACQ DEFORM OF LIMBS 1 .2VIRAL INFECTION NOS 1 .2FORGN BODY IN EYE 1 .2OTH CONTRAC METH 1 .2TRICHO UROG PVN 1 .2ANXIETY DISORDER 1 .2SEXUAL PROBLEMS 1 .2EYLD INF CHALAZION 1 .2WAX IN EAR 1 .2BLEED PER RECTUM NOS 1 .2

75

• -; ' ' " , I" ...- " -. ,

4PPENDIX 0 (Contd)PROFILE REPORT - MODEL CARE PROVIDER 12235 RECORDS

(January)

PRDX PRIMARY DX FREQUENCY PERCENT

HEMATURIA NOS 1 .2SWIG OR EFUS Of JNT 1 .2GANGL OF .JNTETENWUN 1.2RSHEOTH NENSP SKN ER 1 .2HEADACHE 1 .2DYSPNEA 1 .2SIGN ILL CEF COIN0 1 .2

MOAL 534 100.0 100.0

VALID CASES 534 MISSING CASES 0

76

APPENDIX 0 (Contd)PROFILE REPORT - MODEL CARE PROVIDER 12235 RECORDS

(January)

JRDX JOB RELATED DX

VALUE LABEL FREQUENCY PERCENT

NO 523 97.97 1.3

YES 4 .7

TOTAL 534 100.0

VALID CASES 534 MISSING CASES 0

OPSCD OTH PAT STATUS COCES

VALUE LABEL FREQUENCY PERCENT

53* 100.0

TOTAL 534 100.0

VALID CASES 534 MISSING CASES 0

T IMEGRP

VALUE LABEL FREQUENCY PERCENT

161 30.130 TO 45 MIN 133 Z4960 TO 90 PIN 77 14.445 TO 60 MIN 72 13.515 TO 30 PIN 58 10.990 TO 180 NIN 14 2.f180* MIN 14 2.6LESS THAN 15 MFIN 5 .9

TOTAL 534 100.0

VALID CASES 534 MISSING CASES 0

77

I,, -

APPENDIX 0 (Contd)PRCFILE REPORT - MODEL CARE PROVIDER 12235 RECORDS

(January)

APSTA APMT STATUS

VALUE LABEL FREQUENCY PERCENT

UNSCHEDULED 438 82.CSCHEDULED 91 17.COTHER 5 .9

TOTAL 534 100.0

VALID CASES 534 MISSING CASES 0

IVYN INITIAL VISIT YES NO

VALUE LABEL FREQUENCY PERCENT

YES 321 60.1

NO 213 39.9

TOTAL 534 100.0

VALID CASES 534 MISSING CASES 0

CHAPYN CHAPERONED YES NO

VALUE LABEL FREQUENCY PERCENT

NOT CHAPERONED 470 88.0CHAPERONED 60 11.2NOT MARKEO 4 .7

TOTAL 534 100.0

VALID CASES 534 MISSING CASES 0

-7:-L 78

, ,

APPENDIX 0 (Contd)PROFILE REPORT - MODEL CARE PROVIDER IZZ35 RECORDS

(January)

FMP FA14 MEMBER PREFIX

VALUE LABEL FREQUENCY PERCENT

SPONSOR 432 80.9SPOUSE 76 14.2IST CHILD 12 2.23D CHILD 7 1.320 CHILD 6 1.10TH CAT AUTH CARE 1 .2

TOTAL 53* 100.0

VALID CASES 534 MISSING CASES 0

INPOUTP INPAT OUTPAT

VALUE LABEL FREQUENCY PERCEINT

OUTIPAT 532 99.6

INPATIENT 2 .4

TOTAL 534 100.0

VALID CASES 534 MISSING CASES 0

79

APPENDIX 0 (Contd)PROFILE REPORT - MODEL CARE PROVIDER 12235 RECORDS

(January)

C RO S S TA BUL A T I ON 0JFPMSCOI PAT MIL STATUS CODEI BY PMSCDZ PAT NIL STATUS CODEZ

PMSCD2COUNT I

ROW PCT INOT ACTI ARMY USAF NAVY MARINE RIWCCL PCT IVE DUTY TOTAL

I -11 11 ZI 31 41PMSCDI-4.- - 4. 4.--------------------------------------

1 1 I 358 1 2 1 1 1 10 I 371AD I 1 96.5 1 .5 1 .3 1 2.7 1 69.5

1 1 75.5 ! 8.7 1 4.3 1 90.9 141-------- 4 -------- ------------------

2 1 1 32 I 2 1 1 I 1 35DEPN AD i I 91.4 I 5.7 I 2.9 1 1 6.6

I 1 6.8 1 8.7 1 4.3 1 1---------- -------- 4- - ------------- 4.-----------

3 1 1 *01 8 1 13 1 1 1 b2RET I I 64.5 1 12.9 1 21.0 I 1.6 1 11.6

1 1 8.4 1 34.8 1 56.5 1 901 I4- --------.. - 4 ---. 4.-------------4.----------- .

* 1 1 441 11 1 81 1 63DEPN RET DECEA 1 1 69.8 1 17.5 1 12.7 1 1 11.8

1 I 9.3 1 47.8 1 34.8 1 1*------4--------4------------------4-------------

7 1 21 1 1 1 1 2FOREIGN STU 1 100.0 1 1 1 1 1 .4

I 66.7 1 1 1 I I4.4------------- ----------

81 1 II I I I iOTHER 1 100.0 1 1 1 1 1 .2

1 33.3 1 1 1 1 14- -------- 4-- --------- 4. -------- 4. -- - - - - ---

CCOLUMN 3 474 23 23 11 534TOTAL .6 88.8 4.3 4.3 2.1 100.0

NUMBER OF MISSING OBSERVATIONS s 0

80

a APPENDIX 0 (Contd)

*l jj 6~ ML2 140 *S Ms

r).. M1 p. #A 40* . 1'e I 0 ON C

z n 03- 1

4 , I e 00

D 1) 56 1~ 0 BI.Odo 1 0a~s OM 0 COs7

*lp a 0 N

os a

CLa of- 1 a 4

x a II- B S SM

ui CC - B

NC 49 0 4

C9 0 f jf- Lew

at u BI

La 0fo ~ oS a-u 44 B f

L U B

B .m-...ia

U 4~B81

APPENDIX 0 (Contd)PROFILE REPORT - MODEL CARE PROVIDER 12235 RECORDS

(January)

C R J S S T A BUL A T 1 ONPMSCDI PAT NIL STATUS CODE1 APMT STATUS

A PS TA

COUNT I

ROW PCT IUNS0HEDU SCHECULE OTHER ROWCCL PCT ILED D TOTAL

1 11 21 51PMSCDI -------.. - --- ---------------

1 1 292 1 74 1 5 I 371AD 1 78.7 1 19.9 1 1.3 1 69.5

I 66.7 1 81.3 1 100.0 1

2 1 32 1 3 1 1 35DEPN AD 1 91.4 I 8.6 1 1 6.6

1 7.3 1 3.3 1 1+ --- -4 - - 4------------

3 1 55 1 7 1 1 62RET I 88.7 1 11.3 1 1 11.6

1 12.6 I 7.7 1 1-- -------- -4 --------- 4.

4 1 56 1 1 1 I 63OEPN RE1 OECEA 1 88.9 1 11.1 I 1 11.8

1 12.8 1 7.7 1 1------------ 4-------------4.----------- 4

71 21 1 1 2FOREIGN STU 1 100.0 I 1 1 .4

I .5 1 1 i

811 1 I I! 1

OTHER 1 100.0 I 1 1 .2I .2 1 1 14---- ---.. 4----------- -4------------4

COLUMN 438 91 5 534TOTAL 82.0 17.0 .9 100.0

NUMBER OF MISSING OBSERVATICNS s 0

8 2

A.

APPENDIX 0 (Contd)

OROCEDURES REPORTED BY YOUPROFILE RPT-MCDEL CARE PROVIDER-12235 RECORDSIJAN)

GROUP PROC PROCEDURES

PCT OF PCT OF

CATEGORY LABEL COUNT RESPONSES CASES

ADVICE HLUH INSIR 522 32.7 97.8

ANTIBIOTIC 2 0.1 0.4

BIOPSY 2 0.1 0.4

BLOOD PRESS 59 3.7 II.

CAST APLIC 3 0.2 0.6

CAST REMOVAL 3 0.2 0.6

DRESSING CHANGE 20 1.3 3.7

EAR IRRIGATI 3 0.2 0.6

EKG 11 0.7 2.1

I AND D 3 0.2 0.6

IMMUNIZATION 1 0.1 0.

INJECT OBSERV 13 0.8 2.t

IUD 1 0.1 0.2

KOH PREP WET MOLNT 7 0.4 1.3

LTRS FORMS 94 5.9 17.6

MANIPULATION 5 0.3 0.9

MINOR SURG 4 0.3 0.7

PATIENT CONSULT a 0.5 1.5

PRES REFILL MO EXAM 39 2.4 7.3

SPLINTING 13 0 '. 24

STOOL GUIAC 5 0.3 0.9

SUTURE 2 0.1 0. 4

SUTURE REMOVAL 9 0.6 1.7

TELE CONS 1 0.1 0.2

83

APPENDIX 0 (Contd)

PROCEDURES REPORTED BY YOUPROFILE RPT-M(ODEL CARE PROVIOER-12235 RECORDS(JAN)

GROUP PROC PROCEDURES

PCT OF PCT OFCATEGORY LABEL COUNT RESPONSES CASES

THROAT CULTURE 22 1.4 4.1

VITAL SIGNS 531 33.3 99.4

07H PROCECURES 212 13.3 39.7

TOTAL RESPONSES 1595 100.0 298.7

0 MISSING CASES 534 VALID CASES

84

APPENDIX 0 (Contd)REFERRALS REPORTED BY YOUPROFILE RPT-MCDEL CARE PROVIDER-12235 RECORDSJAIN)

GROUP REFER REFERRED TO

PCT OF PCT OF

CATEGORY LABEL COUNT RESPONSES CASES

CARDIOLOGY 2 3.0 3.2

DENTAL 2 3.0 3.2

DERMATOLOGY 1 1.5 1.6

DIETICIAN 2 3.0 3.2

EENT 3 4.5 4.8

FAM PRAC 2 3.0 3.2

GYN 6 9.1 9.5

INT MED 4 6.1 6.3

NEUROLOGY 3 4.5 4.8

O, CHAMPU S 4 6.1 6.3

OPTHALMOLOGY 1 1.5 1.6

ORTHOPEDICS 9 13.6 14.3

PEDS 1 1.5 1.6

PHYS THERAPY 9 13.6 14.3

PODIATRY 3 4.5 4.8

PYCHIATRY 2 3.0 3.2

SURG 9 13.6 14.3

UROLOGY 2 3.0 3.2

OTHER 1 1.5 1.6

TOTAL RESPONSES 66 100.0 104.8

471 MISSING CASES 63 VALID CASES

85

V -

APPENDIX 0 (Contd)

EXAPINATIONS REPORTED BY YOUPROFILE RPT-MODEL CARE PROVIDER-12235 RECORDSWJAN)

GROUP EXAPS EXAMINATIONS

PCT OF PCT OFCATEGORY LABEL COUNT RESPONSES CASES

0ABDOM 2 0.4 0.4

CHEST 1 0.2 0.2

EAR 3 0.5 0.6

EYE 8 1.5 1.5

HISTORY WO PE 123 2Z.4 23.4

PARTIAL PE 379 69.0 72.1

PELVIC PAP 21 3.8 4.0

VISL ACU) 12 2.2 2.3

TOTAL RESPONSES 549 100 104.4

8 MISSING CASES 526 VALID CASES

86

,7A -A144 839 AMBULATORY CARE'DATA BASE PART B(U) ARMY HEALTH CARESTUDIES AND CLINICAL INVESTIGATIONMACTIVITY FORT SAM

IHOUS TON TX S R MISEN ER FT AL. 16 MAR R4

UNLSSFE HCCA8 -0 -TBFG65 N

2.0.

L-2 .4D 8

APPENDIX 0 (Contd)

EXAPINATIONS REPORTED BY YOUPROFILE RPT-MODEL CARE PROVIDER-12235 RECORDS(JAN)

GROUP EXAPS EXAMINATIONSPCT OF PCT OF

CATEGORY LABEL COUNT RESPONSES CASES

ABDOM 2 0.4 0.4

CHE ST 1 0.2 0.?

EAR 3 0.5 0.6

EYE 8 1.5 1.5

HISTORY WO PE 123 22.4 23.4

PARTIAL PE 379 69.0 72.1

PELVIC PAP 21 3.8 -4.0

V ,S ACUII ,2 2.2 2.3

TOIAL RESPONSES 5*9 100.0 104.4,

8 MISSING CASES 526 VALID CASES

86

APPENDIX 0 (Contd)

CISPOSITIONS REPORTED BY YOUPROFILE RPT-HODEL CARE PROVIDER-12235 RECORDS(JAN)

GROUP DISF DISPOSITION

PCI OF PCT OF

CATEGORY LABEL COUNT RESPONSES CASES

HOME DUTY 244 46.O 46.0

RETURN TO CLINIC 192 36.2 36.?

CONSULT 56 10.6 10.6

CHAMPUS REFERRAL 6 1.1 1.1

ADMIT 2 0.4 004

QUAR 28 5.3 5.3

OTH 2 004 0.4

TOTAL RESPONSES 530 100.0 100.0

4 MISSING CASES 530 VALID CASES

8

87 .

APPENDIX P

APPENDIX PEncounters per Clinic (November)

VeLUf t " t FREOUENCY PERCEN'T

ft4 L AC 1517 13.9

1 V( 1384 12.7E1 1299 11.9

pf 1047 9.6

PHiY TH :P y 903) F.2P L "IH! 877 8 .CIN .jn 849 7.eAf 1 _ 789 7.21 Mol l 568 5.2

LPl 7 !A-AT Y 395 3.fUPC Yp: 361 3.3CP0 , 345 3.2M F U PVL (C, Y 182 1.7Stjk ( 167 1.5HYP PT E t, 96 .qLASI L J (, 46 .4NELL P-Y 39 .4

NU T!T I UN 24 .2

AUU InGRAM 18 .2IFSP THERPY 17 .2ALLCY PEC I ,

TI AL 1'921 1 3. C

VAL!. CASIS 10921 MISSING CA5ES 0

89

-~ - 1 -

APPENDIX P (contd)Encounters per Clinic (December)

VALUE LABEL FREQUENCY PERCENT

Ek 1707 16.6f-AM PPAC 1 425 13.9PED 1 102 10.7PREV ME 885 P.6INT MED 72) 7.CTMC 717 7.CPHY5 TH~ktPy 709 6.9AMIC 564 5.5IMM5 556 5.4UBGYN 486 4.7OPTCME TR Y 36) 3.5CMHh 237 2.3HIYPERI EN 223 2.2SURG 195 1.9NEUROL(jGY 154 1.5WELL BABY 115 1 .ICASi F,.UUM 66 .6NUlfII IUN 15 ,1AUD lOGRAM 11 .1RESF THERIPY 11 .1ALLGY PEO 1 C

7CIAL 1 259 1001C

VALID CA.[S 10259 VISSING (ASES 0

mI

90

APPENDIX P (contd)Encounters per Clinic (January)

VPLUE L BLL FREQUENCY PERCEUT

I-AM P'<AC 1562 12.PTMC 1452 11.9E k 1441 11.eFFD 1 281) 1Z.5PREV ME[ 1007 82AM IC 977 Q.fPHYS THERAPY 94" 7.7

UPI LMt TkY 593 RINT MEO 564 4.eU1G YN 488 .CHYP -RTEN 481 3.9lM 475 4T 3.9CMHA 249 2.0NEUPOLICY 235 1.9SUP.G 203 1.7WELL BAeY 154 1.3LASI ',0CP 55 .4NUTPII ItjN 41 .3RESP THERtPY 14 .1AU0 ICGRAP 12 .1

ILT&L 1?229 100.C

VALID CASES 12228 VlSSING CASES 0

I

APPENDIX P (contd)Encounters per Clinic (February)

VmLUE LtBEt FREQUENCY PFPCENT

FAM PkAC 1263 12.9ER 1157 1l.ePED 1151 11.8TMC 1043 1V.7PREV MEU 822 8.4AMIC 802 8.2PHYS THERAPY 555 r.7INT MED 531 5.4UPTEMETRY 502 5.1IMMS 461 4.7U RGN 428 4.4HYPERIEN 397 4.1CMHA 283 2.9NEU(!LGY 181 1.9WELL RABY 95 1.CCAST P0Lr 52 .5NUTRI i IC' 25 .3SURC ID) .1AUD IOGRAA 13 01kFSF THE~tPY 9 .1ALLOY PEO I CCARCIAC 2 .CSTRESS TEST 1 .0

TOTAL 9781 10O0.C

VALIC CASES 9 7,3C ISSING CASES 0

92

APPENDIX P (contd)Encounters per Clinic (March)

VALU5 L;SEL FREOUENCY PERCE NT

PEI) 1282 13.3TMC 1161 12.1ER 1077 11.2FAM PRAC 1032 1 ).7AM I C 91) 9.5FREV MEC 872 9.1OPTEMETRY 519 9.4INT MED 511 5.3PHYS THERPY 481 5.0IMMS 454 4.7OBGYN 349 4.CHYPERTEN, 306 ?. 2LMHA 264 2.7NEUP."LOG Y 16) 1.7WELL BABY 94 I.CCASi R[JMf, ') .4NUTRIT ICN 34 .4kESP THER;PY 18 .2AUD ICGRA t 4 CMINCR SURC 2 OCSIRESS TEST 2 C

T]TAL 9611 ICJ.0

VALIO CA5ES 9611 t1SSI'S ASES U

93

~:' ."

APPENDIX 0

PPR-.

APPENDIX 0Forms Completed Per Care Provider

(January/Family Practice)

IROV 1, i)k X

r:1R0V II TR X

FU I 1)1: IT 111XC

FIR I.N1) III : X

F'ROV T DV F"j, X

F:.R(')V 1' Df.:I< X

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FR iONv: 1 4W F. X4

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* uNRiOE:u:. I:I::( X

* :1- l t.N3 FR :1: x .I '

*UNS. DVI:NT rr. : : 1)(F

FR( IV:, 1)1 X

TOTAL 1562

*Indicates code number not filled ir or inversion of digits

95

APPENDIX R

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APPENDIX S

I -.

APPENDIX SMED 302 Svc Branch Total

4

t ,

- 2 -=Z

118r

3 I- t - I " " " " I-

I ---

.1-Il-

] 118

APPENDIX S (Contd)MED 302 Svc Branch Total

t- - ( -- C - .IL

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IT

T

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II

APPENDIX T

III - .

APPENDIX TMED 302 Svc Branch i otal for OH/TMC

LA C A Z A C: IA D. (A z V

V 7 7 7 X w

m m 0

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b- 4P w %O Al OD W 0 w.& 0 L/4

121

APPENDIX T (Contd)MPED 30? Svc Branch Total for, OII/TMC

L X LA Z CA C LA is. L Z ' z

Z 7 7 7 M l1

4 n-b, U. b4 --- 4-4 Ili

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1224

b (

APPENDIX U

.4

I

APPENDIX U

Examinations Chaperoned per Clinic p er Month

,'l. I lt. [I II'-J I

, ,,(). .F ,' t- , '

Ir I

I F

* F F/.'F F.

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F +l 'tI '. .'.) F.',:

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I I I F

1). 1 . ' . ' .

124 '

APPENDIX U (Contd)

Exalinations Chaperoned per Clinic per Month

F F. I ' ; I I A I I I ' I

IFlF I' I '' ' I' ,'" I

IF I I I I I II

I i F

F F I

F I F.I,,

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I F.......F... .. . '. .

-', ' i ' I F''. I ',i .:F

'lIi' ,I ' lII F': . '1 , I !,

F FI 11 ' I F II l ' "- ' ' I ' ,/I " ' ' F

I I I. " I I F ' FI

125

-&Wk

APPENiDIX V

Tables V-1 and V-2

APPENDIX VStudents From Other Countries

Table V-i

I it. '',,'1, !!' ' I. ' ,

!,1

I ''I,'A") I ( '" ' / '

I, **'

( I I I

Ii.' ,;, , I, , , '

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I} I II i !', " *I, *': 1 I.': ; ' ' '

II;f 'i "':.r I , . ' ' I .' ~

'! , l I~ l ; ' , 1. I IlI..1,

127I I

* i I - i I *I . .

APPENDIX V (Cont)Students From Other Countries

Table V-2

'3E

7 7

7 b-

100

z '3

o0 M ' o M

3. z N, w b. LA 0A - 3w'3 ~ ~ ~ ~ C 7r LAA ' 3 A'3 '

D CD w - CD ' W .0 404 - 2

A 9" V ZZ

V1 r" W .4 % 4 M x p A A Ao kFA -4 '3 K'n r 0 0 M z 0 C.. r" A

4A 0

'A3

1281

-k-L

APPENDIX V (Contd)Students From Other Countries

Table V-2

77

ao -p

(Y'~. -4W -N W-M w a w M CD-4 - 0 0 -4 A-

LA 0 tA A I

jib ).J -4V -. AD)

M ja -4 .

C3 'a 10 -0 ;:N j-4 M~ $A x - -4 10 Ip r

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n- -X 3 a ~ a

A. U. -W tA

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M

z-

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NN

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5. .

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IPUD XO~d

APPENDIX W

Tables W-1 and N'- 2

APPENDIX WTable W-1

W H i I f.,

1 01,

i~ I I it~ 1: 1I

iVI I I A0 'I L

f I tI I I I I I I

.1 I

I

ii-' Ill I' fA II

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132

APPENDIX WTable W-1 (Contd)

I I'FREQUENCY PERCENT

I . i , 10 J

1 I .i I I ;

J- : f il I I .(i

o *I'1 I i IV 11) 1' . I I I 'll'i

FI. 1 It I I I I I

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,It I il .1. 1 W "

IRII1 . -I Ifj I.

133

APPENDIX WTable W-1 (Contd)

I it I1 I t iI i l I"! II

FREQUENCY PERCENT

-I j II ,I .

, il l I'l l I II '. I I I .z iI I I I II*'

110 1 III

.t I T I *ItYJ f~i. C : I-I* -'

(:1 ::. xI I VI )I I I

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1I.A Wt t llVi

iP tIIIr ,I I I I I i 1:" -* JI 1

1~ ~ 60 1I1JdI

' 1'

APPENDIX WTable W-1 (Contd)

IFREQUENCY PERCENT

.1 I O f 'A II I I

f 1..1 1! O ' III I I m .",

JI G [I I I t 1,.0

iI) *(1- t l l. hI' Ih'd I

F 1IJ VIkIff 101 111

fil k.1 JOI II'): I 111 1.1

135

Table W-1 (Contd)

-' I It I I~ I'

I ~I (A..N t I

r.::

14136

APPENDIX WTable W-1 (Contd)

L iII I I i I Iii i

CIi

I ,,) Ill iiIVI , I

V' I I ii I, .'~ iI " } i.I

.'1 I I I (8 ! 1 I 1 .l I'

I I1t. I

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lI, l8 rI. I 1 Ii kif" I \, I A .; '( I":'I'.

lI~~~~~dI ""iI..;,:' ,I.|. I: l II:,.' ~ l

diIh'l I(j,:24.i'!) I) ";i : 5

" .. Y

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'C0

APPENDIX WTable W-1 (Contd)

11 i

I~~ I I'J"

ItI

1.0 il I.(

138

APPENDIX WTable W-1 (Contd)

k* ,,ul II I I.1 ' i'A II: I

'" ' i'. n , I( I t. ' WIi'l I I II

I 1

S I '! I 'I1I ! (C) , I( I " I 1 1 :

S.. ...... . ..... ... ....$ ' i I II .~ .. I .. . I

.. ........ ..................... ,............. . .................... t.. ... ... ... ,

.:' 1 j 'I., 4! ' .1 ,.< ]I ,,z t ..

.1)1 I i ,(1 I I.I 'I. : . I. ' ] ., , , i : ' , .

€ ... ...... ... .. .. . ......... ........ . .............. .. I................ . . ...... . . ... .

.1I i . 1 ) ,I ' ', I, ," . ', I * , I

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r Il I I I~ i' S ": .'''. ' I , .:i'; M i. ':,'...

139

L'

APPENDIX WTable W-1 (Contd)

1401

APPENDIX WTable W-1 (Contd)

it i I' I I i ii I *I I I 1: I(1 0 ..- I I1 11-:A)

II 1 III\IJ.N.I:I If 0 1 1 1 ,' i t (1 .1 1 AI I CII I (I I If !1 1111 I

II. .......... ... .

If I i t

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I .141

APPENDIX WTable W-1 (Contd)

I~ it'll

oc I I i I i f)

O f- 11:1

II4

C ' c

APPENDIX WTable W-1 (Contd)

IIV I (i4l 'I Il 1. 1 3 1 .

Ii k' [IA 1.

1.143

APPENDIX WTable W-1 (Contd)

'lit It I~t I''1 1, 1,' I I) I

iiI f

' '; I

V 1.1 .,-

1441

APPENDIX WTable W-1 (Contd)

it II I (.. illiN .I

I t *lI l t '

145'

APPENDIX WTable W-1 (Contd)

I I~AL I

APPENDIX WTable W-2

:k ' 'IV I Wk i I t I t1I 20 I 1 MH

ItJ I 1 "

'2 '2 1, 22 til2 ) Ii

' " .4 ',H i. II I 1 ) I1l,

.'2 : ) I I' 1111) 14 f"

,22 1-2 2,22222) WG1).

.'D, ( ill ) ( ,

l.22., ,h 12 I~ ,' liE

'2' 2q. 221 2212 ) i',l'l-

* 2,.'211 1 2 22 22)11

I ' 1 I2II 1 2)'22. T

2222MI) 'I

I 2:: 2,1 2 1112I2 21.'"

22 22 ; 4 1'1 I 2222 I 22I 1,

WOM f','F I. I 1 D A I ;

22 l}.' 221 1,1111 1) I(

'2 ') '' 2, ' .22 2.II ) 222 .-

q '/,'i,' ' i llt 0 +I R.

147

t-~ 1IV

APPENDIX 14Table W-2 (Contd)

I i".( _:u L JILLD) LM l

'3 /4 tI) ll 1).

hIW IV 111DI I 11) 12 CHILD Il:

i.' 12 (;t4.LI) ecib

Y )4"1 .. A) I34jIL.U IA-

a a~aiv I)LjJ) (.I I2 t-LLD

'1 II ILD

:~~~l'.'~~M .1 -l . ) DA

I. I:.2 L1 LI L.0

1, 6 1.1 LIIILD USi-

40"1 .21) Ll I IL LQOJ-4f

148

APPENDIX WTable W-2 (Contd)

I HI l'ti, t), P I II II'~ f .1,1 ' I'., . IDI tI I~ l I I f1,i I'I rgeu I .! ':I L ',I II I I. I~ t f iii lfII '

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6 'I.. 1 L .I -I I.) H NI

'I) t M-111.

.A,', AD HI CIlli H A

1. L LI)I

41 L1 I I 1HI 1) CII.Si'.'" , I GIHl A JAW

1' .,'i,; ..1 81411 , KAWI

."I 1 1) F.1.F'

'"1o1.,4 ~ i.'lII ,111 MUI

2,l I H-I .l 1) .Jl.JS

, .'14 III I) L.W.

-i 21) L 4I.1) (IA w

Z14

d ',(,,' ;, D l;Hl D IW(

4 .' .3 11 1.( M I.; I.I i I 'l

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4L' tO N) 1 1.) AN

A, 1Li i: T A I LL .1..

i 42.4,.4 1.. 1 l t l. I1) bl-'

42!4 10 1 :,'1 C ,[L.D T G P.

-. .-- -_D ./,HILD _wId

149-

APPENDIX WTable W-2 (Contd)

4'4 -- 4U4- -).. -V-41-

30191 21 H11D EAS

30) CMI [LDF)

io)) I 1 1) IW

1.. ti lll I.) I ILK

1.) l 1 1) 1L(

-.4Iu .1D LHILD I.- J) M

Z.:O2 2 L1IILD LK

1320 1.4 ti-ILL D) JGF

II) I-I)LI)'Jul-

4) 1 1141 'A) LH) L1) N.H

(IN[I N1 LF CFO) C4F 196140 4114 11)411 D A;

150

APPENDIX X I

APPENDIX X

FOX ARMY HOSPITALPROCEDURES USINE MULl RESP34SE

GROUP PRJC PROCEDURES

PCT OF PCT OF

CATEGORY LABEL COUNT RESP0%ISES CASES

ADVICE HLIH INSTR 29251 24.0 55.1

ANT IBIOTIC 2772 2.3 5.2

AUDIOME TRY 2135 1.5 4.3

BiOPSY 77 0.1 0.1

BLOD PRESS 139b7 11.5 26.3

CAST APLIC 236 o.2 0.4

CtST REMOVAL 202 0.2 0.4

DIAPHkAGM FITTING 29 0.0 0.1

DIETARY COUNSEL 2743 2.3 5.?

DRESSING CHANGE 321 0.3 0.5

EAR ItRIGATI 162 0.1 0.3

E KG 983 OB 1.9

EKC OkIER FORM 197 0.2 0.

ENDOMETRIAL BIOPSY 49 0.0 0.1

HEARING CONSV 1024 0.8 1.9

HEMOCCULT 175 0.1 0.3

HOME VISIT 195 0.2 0.4

I AND 0 71 0.1 0.1

I MUt, I Z AT ION 1527 1.3 2.9

INJECT OBSERV 4529 3.7 -8.5

IUD 39 0.0 0.

KOH PREP WET MOUNT 187 0.2 0.4

LTRS FORMS 6774 5.6 12.3

LIQUID NITROGEN 20b 0.2 O0%

- 152

APPENDIX X (Contd)

FOX ARMY HOSPITALPRCCE2uRES USING PtV I RFSP04SE

GROUP PROC PROCEDURESPCT OF PCT OF

CATEGORY LABEL COU/T RESP(14S-S CASES

MANIPUL-t lION 173 0.1 0.3

MINOR SURG 323 0.3 0.5

NASAL SFEAR 12 0.0 0.3

GB WGRKUP 38 0.0 0.1

01 SERVICES 3 0.0 0.3

PATIENT CCNSULT 138? 1.1 Z.6

PHYS THERAPY 3169 2.6 6.0

PREG DEFR 157 0.1 0.3

PRES qEFILL WO FxAM 1B05 1.5 3.t

PROC S1GMCI 115 0.1 0.?

SHOT PEC REVIEW 2793 2.3 5.3

SOC WK SERVICES 402 0.3 O.3

SPINAL TAP 13 0.0 0.3

SPIg A4ET Y 238 O.Z 0.5

SPL INT ING 189 0.2 0.

STOOL GUJAC 88 0.1 0.2

STRESS TEST 7 0.0 0.2

SUTURE 163 0.1 0.3 41

SUTURE R EMOVAL 294 0.2 0.5

TELE CCNS 838 0.7 1.5

THROAT CULTURE 1581 1.3 3.0

TONOME TR Y 921 0.8 1.7

TYMPANOPE TRY 22? 0.2 0.%

VASECT 167 0.1 0.3

APPENDIX X (Contd)

FOX AR4Y HOSPI'ALPROCEDURES USI Ir MVLT RESP31SE

GROUP PkOC PROCEDURES

PCT OF PCT OF

CATEGORY LABEL COUNT RESPO4SES CASES

VITAL VJGNS 25932 21.3 ,8.9

OTH PROCEDURES 12862 10.6 24.?

TOTAL RESPONSES 121780 100.0 229o4

5805 MISSING CASES 03081 VALID CASES

154

APPENDIX Y

APPENDIX Y

FOX ARMY HOSPITALREFERRALS USING MULT RESPONSE TOTAL STUDY 58890 REC

GROUP REFER REFERRED TO

PCT OF PCT OF

CATEGORY LABEL COUNT RESPONSES CASES

ALERGY 152 3.6 3.8

COMM HEALTH NURS 22 0.5 005

AUDIOLOGY 30 0.7 0.7

CARDIOLOGY 66 1.6 1.6

DENTAL 80 1.9 z.o

DER4ATOLOGY 73 1.7 1.8

DIETICIAN 230 5.5 5.7

EENT 158 3.8 3.9

ER 50 1.2 1.2

FAM PRAC 289 6.9 7.2

GYN 194 4.6 4.8

INT MED 520 12.4 12.9

NEUROLOGY 170 4.1 4.2

00 CHAMPUS 36 0.9 0.9

OCC THER 2 0.0 0.0

ONCCLOGY 13 0.3 0.3

OPTHALMOLOGY 149 3.6 3.7

ORTHOPEDICS 243 5.8 6.0

PEDS 200 4.8 5.0

PHYS THERAPY 285 6.8 7.1

PODIATRY 54 1.3 1.3

PRIVATE PHYSICIAN 80 1.9 2.0

PYCHIATRY 104 2.5 2.6

4 RHEUMATOLOGY 9 0.2 0.2

156

~e-V

APPENDIX Y (Contd)

FOX ARMY HOSPITALREFERRALS USING MULT RESPONSE TOTAL STUDY 58890 REC

GROUP REFER REFERRED TO

PCT .lF PCT OFCATEGORY LABEL COUNT RESPONSES CASES

SOCIAL 6IORK 51 1.2 1.3

SURG 342 8.2 8.5

UROLOGY 84 2.0 2.1

OTHER 496 11.9 12.3

TOTAL RESPONSES 4182 100.0 103.6

54855 MISSING CASES 4035 VALID CASES

157

APPENDIX Z

IC

APPENDIX Z

FOX ARMY HOSPITALEXAMS USING MULT RESPONSE TMTAL STUDY 58890 REC

GROUP EXAPS EXAMINATIONS

PCT OF PCT OFCATEGORY LABEL COUNT RESPONSES CASES

ASD0M 629 1.5 1.6

CHE ST 1211 2.9 3.1

COMPLETE PE 3865 9.2 9.8

EAR 856 2.0 2.2

LYE 2523 6.0 6.4

FLIGHT 73 0.2 0.2

HISTORY W(J PE 5884 14.0 14.9

PARTIAL PE 23296 55.4 58.9

PELVIC PAP 2151 5.1 5.4

RTN TO WCPK 305 0.7 0.8

VISL ACUIT 1259 3.0 3.2

TOTAL RESPONSES 42052 100.0 106.3

19329 MISSING CASES 39561 VALID CASES

159

APPENDIX A-A

ot-- 7

APPFNDIX A-A

FOX ARMY HOSPITALDISP USING MULT RESPONSE TOTAL STUDY 58890 REC

GROUP DISP DISPOS ITIONP

PCT OF PCT OF

CATEGORY LABEL COUNT RESPONSES CASES

HOME DUTY 34735 78.4 78.

RETURN TO CLINIC 7575 17.1 17.1

CONSULT 651 1.5 1.5

CHAMPUS REFERRAL 112 0.3 0.3

ADo, I T 370 0.8 0.8

QUAR 568 1.3 1.3

OTH 267 0.6 0.6

TOTAL RESPONSES 44278 100.0 100.0

14612 MISSING CASES 4*278 VALID CASES

161

I

r- -- -- - -

APPENDIX B-B

I.

C.

-3- I -- C-

APPENDIX B-B

F L :UiLNCIF I': !IIA NIt- F -, I ITAL S IUODY ("PSc "

F ILt

PREX HkIMARY DX

VAL IP C t'"

VALUE L ;.( L VALJUE F Pf QFINCY P! kCF N. T PERU r'1 Pf CU 'IT

NU DIAG F'Kf. VIDEn 999q 5 2 3 . ..MEPICL f- A 4'.0 1070 -3 1I2 ti. 7 F .7 17.

REF kACTIV t'RURS 367 2 p Fj 4.9 4.9 22.'

ACT UP kFS TR IFI- 460 ?94 4.P 4.( 31.

HYPERTEN,CLNCOMPLIC 401 2789 4.7 4.7 "42 .HAY FFVEk 477 ?41 ? 4.1 4.1 A(I.!PIROB NEC IN (il- C:)S 1999 1549 2.6 2.6 Th."

PROPIlYLAC IMMUNIZ 1003 1417 2.4 2.4 41..'

ACUTE uIlllS MErIA 3A20 1303 .2 2.2 43.4

SHOULDEk SYN 7260 1042 ]. m 1.8 4,.]OBE SITY 278 935 1 .6 1.6 40.7SPR SIR 1,1H SITFS 90A 1 .5 1.5

BK PN W ;AP SYMP 7244 8()5 1.5 . 4.

BK FN Wfl A( jYrMP 724? R73 1.5 ., ' .

LAC IIP WN! TRAL' AHP b%89 731 1.2 1.2 rLIR FMS PkiS WC LXA4 16AO 703 1.2 1.? .1PAIN JR 1IF It, JNI 7194 6601 . 1.1 L4

SINUS ACTLCHRON 461 64 1. I I. I '.

BRUISE CNIU CRUSHG 1 9?9 623 1.1 1 .1bRONCi I L ikPfNCO t AC 466 601 1 .0 1 . ) 0f.

AC TONSILILQUINSY 463 59) 1.0 1.0 9SPk SIR Ar..KLE 84r,0 521 .9 .QCER/ SPINf SYrjC 723 513 .9 .9 60.7

NAUSEA V,I. ITINC 7F70 4 .E .&Cl4F INT KNIIE DFRAN 717 473 . ..

CYST rUNI'. IIJFEC L%95 464 . ..FX ALL 1Ill4 Sil S NtC 1?9 4 34 .7 .7 ,

VIkAL If',l (- TIIM.' NiIS 799 431 ,1 ,7 f .,

ACT L(HI t ( k il MlD 3 ll 425 .7 .1(IAhE rIF, , L! t 7US 250 41. . 7 .7 6,.'

SIRP TH- '+,(P FV 1'YS 34 40 , 1 .7 '1.7EPILtPSY t.L TYPES 345 40? .7 .7 '7.4APS SCANT lotNS 6260 39? .7 .7 1H.iHtAoACMI 7f440 3 7", .6 .t F .7CHRN I c( k- I PI S 412 3f) 9 , ci. AA ST HM 4Q3 363 .6 .6 (q. )

SOSiA TIAt.i i C( Nf 719 3 6 T5."VAGIN[IPI 'i .S, VULV 6161 133 .6 .6 71.l

CONTCiTH J L"A f C 6 2 33? .6 .6 71.7DEFPRISSIV[ 1lSI:fl 3004 315 ., .c 71'.2W ARTS,I tl LI t S 7H1 311 ., .5 7,.7

IRT 1hiL ',YN INT) ")S- ",i, 301 .5 7 1 .IPNL(!f'f ( IP'' SYMI' 1?, , ," .' . 71.7114AN ')IT!JA ISl I A)J kqp 2 1 . 7r1 .

b U I 1 1.1 I I 14 ( I t(,. I I? " +0 ,7" . .1 (. .IPkI I'II I',I' , ' ' 25- .No .' N',.1 N

CO0NJJUN( .f I'll AI "' IA 120 ?f'S .'. ,,, 7.,.

163

-Mal

APPENDIX B-B (Contd)

F IL I

PRDX PK IMAPY [A

OTH BURS&SYNV 7263 26 A .4 .4 7t,PNEUMONIA 4.86 259 .4 .4 7t-ANXIETY Dl]SlIF;' 3000 251 .4 .4 7hE MP HYSF F A t.CtiP 4 (92 2 4, .4 .4 77.ORAL CONTC 1255 234 .4 .4 77.71NF LUEN , '4-7 22 .4 .It 7hIOTH SI]M ( Lt) 0 IS) K ) 36, 2,)7 .4 .4 7.4MARl I 0"I I ? 0 . 3 .3 7 .ECZ f 4IG L IRM f)4 lR . " 1.OTH INF 'KI1 N SU.C T?-II ,) 19) * 7'0.OTH MALOiG N rfPI N( 1')9 193 * . 3 74)I.C HE ST PAI, 7D'S5 I,' .I N '('. IMIGRAINE 446 IF. .4 .RH ARIHLAL, CON 714 I ,. .+ .3 0. I

ACNE 7061 179 .3 .3SEBACEUUS CYST 7062 171 .3 .3ABRA SCRATCH BLIS 41P 175 .3 ..OTITIS EXTERNA SO 1 17 , .3 .3 F 1.

PRENATAL CAR[ 1220 173 .3 .3 2

DTH BENIGN NEDPL '4EC 229 171 .3 .3 2.OTH FEM Uf.GAN {IS 62? 157 .3 .3 ,2.'SIGN ILL LEF C{ND 78p9 163 . 3 .3 P3.10TH INJ E TRAUMA Q99 162 .3 .3 '3.3

BRCHI,CHRFhRCHICTAS 49] 15 3 .3 .3 . bPAR CHILD PRrJB 1612 14 2 ? .2

0TH MEN FPSY DISOR 31) 139 .2 .2 P4.1

URT ICAR IA 708 135 .2 .2 4.ADVEHILTH INS!TUC I b 5'. 135 .2 .? F 4BRNSESCLOS ALL OFG 9 4 9 113 .2 .2 '4

AC U[AM KNI- MENISC -36 13? .2 .2 5"',.:

DUUD ULC 6 Wl CUIMPL '32 131 .2 .2INGN 1NL C NAIL DIS 701 131 .2 .2 PS.' _NONSP APN PAP SPLA.6 7950 11 .2 .27

DERMATPHV1JERMAMY1.) I 12 .2 .2PEIVICL INVLAM ()IS 614 121 .2 .2 Th.,OTH NURV SYS DIS NEC 315 11 1 .2 .2 "6.3

GEN CONTRAC GUID 1256 11 1 .2 .2 9 .0TH EN,(f NIU META DI 279 11b .2 .2 h6CHRN CYST nRST )S 610 115 .2 .2 Ph."

CRVCTS 1. CVC ERflS (22 115 .2 .2 r7.1HYPGTHYR P'YXF)F CRET 244 112 .2 .2 1-7.-1MNPS SYMS.F5T ,iNn *L3 627 113 .2 .? r7.4CHkON SKIN ULCER 7n7 109 .2 .2 r7.f,HRT MURM NEC NYI! 7'2 105 .2 .? r7.0TH NFNA1IIC RHFU' 72P 105 .2 .2 P tA

ECTP PIATS ALL TYPF 4276 1r0 .2 .2 of'

I(Jk N 1 I I AN[ M1 2I'o 101 .2 .2 ..tEE TfIf.'T STkU [01 '20 '9 .2 .2 .AITH NEC LIF CON TiS 72" .2 .2GONfJR611F t ALL SIT, 9, .2 .D E A f N o A P t g CA IM PL " 7 164

;i 164

+" +' +': +:" - - . . . . . .. . I I I I II . . . F I II . . .

APPENDIX 13-1 (Contd)

F RE U NC I S ('f D] GNE'l 'f F-t T A L CIIJDY 88t.9C k-C

F ILE

PkDX FkIMARY CX

IMP T I ff 684. .2 .?

NON SPE C I UkE TH RITI IS 994. '4.S E BORC () k 1A I II IS 690 .?2 .29LATE E FFC If TR AUMA gnp 91 .2 .2

I H M GCF N ; k GA N D IS fto?,- .2 ?2ESO0P 1,A 6 F AL 1) 1 S r"

DISTUR 1.k INSA 7P?0 1.

WAX IN I A04 .1 04

0FC H I ITI S l. PI11) YM I 1 0' (1 F- IH~mt'RkH I I'S 495 *i) I I 1 l 0. 7FDG Pk3 ;'AhY [LftLY 7)- 3 9.)1 .1 oVERT lIIMM)S YNfl 386 74 1.CURNS&CALL 700 71. ~ .0 TH CJN I W 1C M. L I ?q'3 79. '1.SWIG OR 1--US OF JNJt 1190 1- 91 1AVVS I-F F-1-1 PRP D.JSP 9 9) 2 7- 1.DYSURIA 7FA1 77 . 1 CIBEHAVICF, FASOR NEC 312 751 .1 91 7HIA TUS D] APHRAC tlER"J 551 75 .1 n.I

0 1Z ZIN S G Ibr INE S 7F04 74.11INCUIN tIEK W WO 0tBST 155j 73 *BLEED PL[.k FCTUM NPS 95693 7 ? .I. p.0TH INFCT PAR ST DI S251 71 .10TH bkEAST rJISEA5t-S f"l 1 1 7)01H FAM PIk~r 16119 7J 1CONtI IrPAT I I f 9~-. 1, .1 7)t US IAL H r I K (1k C A IAq I~1 k' .1 .

PUS IN ( k 10?4 e. L4

E YLb INV- LA#ALA Ih 71P 730 6*1 .ALEI C I Af, I iII HA IR' 1) 1' 704 '- 1.0THk (I ki e-tiVAS PIS 4 IR 6 '4 1.M AL A I1, qf A TIb .11 14 1) 0176 *I*II*TUB[ RCUL(!IS 11 6') 1.

GOUT 274. 63 .1.ABN UN E XP V-IflC H T S 790? 51 131 .LRYNGITS. ] CHITS, AC 46'4. .HEMATUk I A N(;S 5997 5- .1 310TH VIIWAL 1XA141'S5 97 s7 .94.ALC A E'U S P.ALC PSY 3031 97.1.

GAL!Li0 L ~L 6Y TR 1) IS '974 11 S1 94F OkUN FI1:;Py IN f11 I1 .1 C42

OJCCUJP PKI11[ 162 '4 1 A

CGUCH 7F62 I9 ..4*Nil) P;YcD Ilk M(, 1 2 19 9 4 .1 .1"

D IV TI c (i 1( 14 N 11 S ,2 r'. 4 1OHP 1VILGI S 4.1 5

[A PL F '- .(, rni 0I 4 r.?LO9 I I*1

M IN. ,1Jt I\ I V 14 ' 131 (4 1 '.

165

APPENDIX B-B (Contd)

F IL f

PRL P1.. 1 PAA-Y OX.

FLAT t3L[,A],G FkdJCTAI 7F,73 4.~ .1.

YNAUHAT A 1HP I TIS -1161 4 .11AC MYC INFAim SLU I S A 10 45. 41.URN SYS CLCUS tAt IYP 45 .4 .1DIS LO SUF LU~X 1TH SIT .q .1)FORLCN BODiY IN EYE ~ 30 4s . .HERPE~S ShIPLE A 5 4 4 1 . 97Sl[kEROCLD FlizTIll f 06 45 1.SCAbIFSL'!lh ACAR2IAt 1.33 4 A .1.L YMPIIADI N I II S, ACU T t tA '43 . .T R ICHoU kUHG PVFJ 1"310 q43 .1.

0TH SIJC "11F 16,10 4 ? .1.FEVER OF tLNflT CAJSI 71406 q4? .1. T.SCH I ZUPH AtLL T YPF ,, 41 * 96*RHEUM FV 1- 15 I 90 41 .1.OlAF' HASH 6910 41 .1 1 9*ELEV Bi(iL PRESSUN E 7 96? 41 .1 Qt,.NONTOXIC 6':C.L[ThtJ 240 43 .1 Of.1FAM 015 W", FIV 1610 4'1 Oh..

NEUR(JS Cilli UNSPEC '3009 '43) .1INFECTIUIIS) MPfNI 79 3 1.

PBR(SCSEIM1 VESCLL (101 30 .1 .1 LP YL PHR FP YL T IS, AC 1 9o 1 37 .1 I.It1R SH UT H N N SP 5 KN t ~ 7821 37 . 1 96 0.9HEARTc3UkN 7F.71 37 .1 7.1CHRN ENTRS,ULCk CLIS 1 9 )31 .1 7.1'CIR LUTH LIVir DIS 5>71 3o .1 Q7.CANGL OF JNTI2TENDON 7?74 36 .9 71 C.

SYNCO FAITNT PIKr-UT 7 23S n1 .1.L IP 10 METIAcULI SM D 1S 272 35 .1 .17PARfXYSIA1 TACHYCAc0 4270 35 .1 0 7.?AFFECTIV f'sycI$Isi~S 2905 33 .1 Q7.1ANAL FIS I IS? AE'CtSS 1 1 33 .1 I ).1

PFOC ,Id CF.ArAL V'AIN ',6'46 'A3 .1 0..1t P I S A X I 7t. 47 3? .1 .1 q7.AIHkSCL I AC HRT bqN 4.40 -A I . .)1 !I IFA LlT (10 V 1251 31 .1 7. C7A 1P. JAl i- OF4I FLWI 4273 1*I 11PS(JtP WI~i %~ 696 f, *)f I '.P ALP ITI A T 11,1S 7 Q) 1 31 * .7' .PERSONECIltAFA D1SUI.R -A01 3,1 11 7.1HPR CHRN INF TONh ADE '474 3 ) .. 1ABN URINF TEST IJEC 79 1 3.) 1 .1INS BTESrINGS 910 24 . .0 %*fl

FREIQ OF UKINATWN 798H4 2-1 .0 . r 0)0 DIH MSK ELC NCTI D IS 739 2 1 .0 .0 9fISENIGN NEIP)LASMA SK IN 216 2/1 .0PHL E 8 1L Hk0M SlPHL '451 27 .0 .0PRUk f. L. Mr cCInP 69p 21 .0 .0 ni,3

166

APPENDIX B-B (Contd)

F . LF ' U NCI ' f I1AGN- C FLV I JIAL_ IJY ( 4 G-4 i. K )

F IL E

PROX I kIMAY [X

0TH SKNFSU- TIS J LIS 709 21 .0 .o GADVS EF 'ITH CH[F 9,9 ?7 .0 ton 00 4

PREMS TS SYN i2t 4 27 " 4 P 7I .

0S IkUARII [ .F S P IJt 721 09 . .0

OIHLR P k.l AS "593 21) to . r.

HYSTERE.HYF'[CH D'IS,3 3O01 25 .0 .0 ,.

OVDOS ME I1 AC OR DLIiH 977 24 .0 *0 ,PARK INSEN ISM a37 ? .0 .0 0$4 toOTH UNEXP' AHN R FSJLI 793 23 .0 . 0ABN INV'L PhVEMENT 7I(; 3 .o .)APENICII ALL TYPS 40 2? .0 .. 7SOC MALA ,AISTMI N T 1,24 2 .FOR B1D 1NI-Fk TI - !]-H.I1F 939 ?I .0 ..CONT CA. INF PR S LS 1001 21 .to . 0 .U

OBS Ck ,I0 0 HI R S PAT 1010 21 .0 .0 o..

DYSPNEA Th60 ? 1 .0 .0 aLIPCMA ANY SITE 214 2) .0 OF o .HEART FAIL , < L SIDl- 42 2 .23 .0 0c).

CONL INTkA CR AN I ' J S50 2) 0 .0 0( ,)

INSOM SFT S cISUq 3074 29 .o .0 0

HEMA AFNf4 NEC 79nO) 2T) . .0 00.]TRANS (FRI-SAL ISCH 435 I .0 .0 00.1ENURESIS 7P E3 l1 .0 . 0",OXY PNWV'1S HFLU' NEC 127 14. . o.

PITYRIA ;<:,SE 6963 1 0 .0 ".9?

WEIGHT LrIJ1,S 7032 1 7 ,0 0 toBENIGN PfilSTAT FHYPE. 600 1$ .S . ,+,+. ,

OBSEk HI IS i 1., 1014 1 5 .0 .0 c(. ,VRCS VI IN' (t S I' .O .1"0,.OSI tiC t it I - 4? I *. (' .0 ,

MASSLL lCAL SwEL N:)S 7822 15 0 .0ENL LYM NI;DF NrOT IN[ 7H96 .0 .n to 4MENIAL k F TAK I 7 1'. .1 .0 Q9 4

PL[UR At L I C IUOl q 9110 1 ' .0 ton 4,.'MAL 16 N! fiL PRf ASr 1 74 1 , .0 o,

HEREGIT HI m[lLYTIC AN 2.0? . .0CATARACT 366 1 3, .oHEMAT, 8L%,A, GI tiFm ",79 1 .o .0LACK OF .X PHY DVL 7,434 ? .0 t,9.o-,

MULTIPLE CrLrS RU0 11 .0 .0 to0TH EYE 01 78 .37 .0

OTH CUNGF N ANI'ALIf S 75,9 t 0 .o . tINFECT IGUS HEPATITIS 70 9 .o .0HOUG 0IS LYMP LFUK 201 .0 .0

DISTURP 'iF SPEECH 7k 4 ., . C-0. ,0 TH F A WCm 1.') T I( 0 1 S .0 .0 94.1HYDk{cI I ! ,'A " . ,r) V9 tSFX t Al F -I fL F H , 3('p7 -,t . .0 ) C.

.Tff I ;t , Af IiAF AIIL) -04 R i ,. C( q ,7A CU AL ((H I JT'1X I 3090 L ., .C , .

C(JNVULr I toS I'9 . .0 qq ,

167

APPENDIX B-B (Contd)

F It f:

PkUX )kl I I;' m t.

I: LI 1 .A I ? q.O. ),

SYPH AL L ISLS1 , . .S T0./ 7

0TH HkT 'IIStASF NtC 429 7 .0 .f,A( G Off1,-" IF LIM S 73!, 7 a (10

IFNS IUN HF, A-ACIhF 3j7A 1 .0 ' .

BNG% NELi- rRt AST 217 5 .0 .Of

GL AUCI 'A 3 65 .0 .qDIS HI VA.L N[, I H - U .2_ S 42 .0 .0.GLM [I N , A( i. CHUN .0 .0 0 .U1E k0VAGl FhkL t SE f-/ IN ,r.' q !]

CHICKtNPX 5? 5 .0 .0 5. .0MAL IG Nil! ,A F T l 5 ., .0P SY ['IH ,.I g E X( AL( ?9 0 n ,

UTH R- SF "< 1,14 .IS bl, .0 .0

F X I Ek f I "LA -, .0 .0Sit kIL Ptlk F I ALt- 12 ? . C .0 0O.

EXLESSIV < AT I NG 7 OF .0 .0w- .)

PUMPES,, AI C;LNO DIS 705 4 .9 .1 .,kMECSUkC P,,',rC iL ) IA& 1050 4 .0 .0 c) .'

HEM6PTYI S 7863 4 .0 0 .ORGNC PSY f X . ALC3IH ?9 4 3 .0 ..AC Q D tO (F( " QF SP1'IL 737 3 .0 ) C*,-.3

CON G AN(J'AL L UW LIMf 754 3 .0 .0 ", .

T BACC' ArUSF 30'I 3 .0 .0 -9.9ANORE AIA 7P3 0 10 .

PVN IYF CC 1 TI S (T iS .0 .0HERPES f'' lF-k 2 .0 .0MAL IG NE '4 S N SUlHC . 173 2 .0 .0 ,-e .()

THFkIXC(SI w o G, ?4? 2 .0 .0 1( .,BL I NUNE S69 .0 . 10.ECTLIPIC -'il G t-3 ? .0 .0 1l00.')CONG ANIM;,l Y OTC C - 746 ? .0 .0 1 P0.FX VEkT C' 40 9 2 . .( 10O.9

EDUC P'- I16?3 ? .0 00.,)LYPHAD 0lI-. ",ONSPEC ?R(l 4 .0 .C 100.)PA 1NFUL mf rS /62 3 2 .0 .0 10O. DHPATUMGLY SPf[ N'MEG 7T1 2 .0 .0 1e0.0 jSPR S1k NiC, F470 2. .0 1(0.,MALIG NF CP PF St' I 162 1 .0 .r ]no.9

PURP HLtNPf.C1IiG [JEF ?,Q7 i .0 .0 1Po0.',BLOG DLI IG P,<FC 640 1 .0 .0 100.ALL PF~INATAL C fNL) 77P, 1 .0 .0 100.1FX HULME U- F12 1 .0 .0 1oO.,FX META CAPTARSAL P14 1 .0 .n 100.')RF WU E XAM-INTFkV IhR3 1 .0 .0 100.1NON-PSY VuNS L [YSP 1,250 I 0 . 100.9UNkY INI l% F. PSPAk[ If 466 0 .O .0 1 P0.)

IST I UPOK (', I1S 130 .0 .0 1".4'

11Apt >,40p: 100.0 100.0

VALID CAStS "I'0 "SSING CASES 0168

APPENDIX C-C

APPENDIX C-C

Diagnostic Clusters

November (10932 Records)

VAL If) c IVALUE L'BEt FRECUENCY PfRCE NT PEFCF!47 PEPCE V7

NCI IAG PPfIVISCE 129) 1 3 P 13. 1 .F,C E NJ M E V E YA M 1 0 ? ? 1,. 0 1 0. ,? ?4 . p 1ACUTE UkI -'4 9 r,.9 5.9 30. (HYPEPIENS Iqr 530 7 r.7 36.3PEFRACTIVE Ekq0 S 46 , .1 5.3 41.4L8KPN E SYNEROM E5 441 4 .7 4 .7 4o.CHRENIC RHINITIS 411 4.4 4.4 , D. 4LACP CEINT! APRAS 319 3.4 3.4 5 3.ACUTE SPkINS STPANS 286 3.1 3.1 I,6.PBUR! SYNC' TENPSYN 263 2.E 2.P q,.7(IT M.ED ACI CHRON 256 2.7 2.7 62.4NONPSY UEP ANX-.EURO 238 2. 2.5 64.9FIBPOTS MYLG ARTHG 227 2.4 2.4 67.4DEGEJ JNI DISEASE 179 1. . .-UBE SIY 149 1.6 1 .5 7C.qACUTE LUW[I; RESPI 145 1.f 1.f 72.4ALL FX 0ISLCATIONS 13? 1.4 1.4 7?.PN[NFG INF 'KKESPQ TS 129 1.4 1.4 7 ,?DFRMATITIE C EC? 128 1.4 1.4 76.6FAUACHL S 124 I. 1.1 77.c:

December (10266 Records)

VALIC CUMVALUE LABEL FREQUENCY PERCENT PERCENT PEPCENT

GEN MED EXAP 1161 13.5 13.5 13.5N] GIAG PRFVIOED 829 9.6 9.6 23.1ACUTE URI 616 7.1 7.1 30.2(.HRENIC RI-INITIS 476 5.5 5.5 35.7HYPERTENS IOvN 467 5.4 5.4 4e2REFRACIVE ERRORS 396 4.t 4.6 45,8LBKPN E SYNCROMES 354 4.1 4.1 49.9UTf PEO ACT CHRON 319 3.7 3.1 53.6LACR CENTS ABRAS 243 2.e 2.q 56.4BURS SYNCV TENOSYN 235 2.7 2.7 59.1ACUTE SPRANS STRANS 206 2.4 2.4 61.5%"NPSV tEr ANX-NEURO 177 2.1 2.1 63.6FIBROTS PYLG ARTHG 158 I.e 1.9 65.4ACUTE LUWFR RESPI 154 l.P 1.8 67.2VAGNTS ULVIS CRVCTS 133 1.5 1.5 68.7DEGEN JN1 DISEASE 122 1.4 1.4 70.11ICNFG INF SKNLSBQ TS 122 1.4 1.4 71.5ALL FX DISLCCATIONS 114 1.3 1.3 72.9DERPATII! E ECZ 113 1.3 1.3 74.2SINUSITIS AC CHRON 107 1.2 1.2 75o4

170

" I.

APPENDIX C-C (Contd)Diagnostic Clusters

January (12235 Records)

VAL I C CJMVALUE LABEL FPFQUENCY PC RCFNT PERCFNT PFFC[NT

LEN MED EXAM 1367 13. 4 13.4 13.4KF. F.IAG P r-jVIDEO 1 '2 10.4' 10.2 23.1,ACUIE UV.I 6,? '.' .r 3').'FEFP9AC1IV ERR PRS 602 1r, . .

HYPEPIEKS I 161. r C. C 41.4

CHRCNIC RFINITIS 423 4.1 4.1 45.5LBKPN E SYNDRCMES 40b 4.C 4.( 49.S

UT WED AC1 CHRON 364 3. 3.6 3.LACR CENTE APRAS 32q 2 3.2 .6.ACUTE SPRNS SWPANS 313 3.1 3.1 59.4PUPS SYCV TFNfJSYN 299 2.9 2.9 62.3FIBRCTS MYLG ARTHG 250 2.. 2.4 64.7UBESITY 216 2.1 2.1 66.8NONPSY DEP ANX-NEURO 177 1.7 1.7 68..

ACUTE LUWER RESPI 163 1.6 1.6 70.1SINUSITIS AC CHRON 144 1.4 1.4 71.'r[CERPATITI! G ECZ 14) 1.4 1.4 72.9EEGE' JNI DISEASE 133 1.3 1.3 74.2ALL FX DISLOCATICNS 130 1.3 1.3 75.5NONFC INF SKNESnO TS 119 1.2 1.2 76.6 0

February (9784 Records)VALIC CUm

VALUE LABEL FREQUENCY PERCENT PERCENT PERCENT

GEN MED ElAt 1073 12.9 12.q 12.0NO CIAG PFOVIDED 844 10.1 10.1 23.,)ACUTE URI 697 B. 8.4 31.4HYPERTENS ION 534 6.4. 6.4 37.8REFRACTIVE ERRCRS 519 6.2 6.2 44.)OT MED ACT CHRON 393 4.7 4.7 49.PCHkRfNIC kVINITIS 379 4.66 .6 F,3.3LACR CENTS ABRAS 234 2.A 2.8 56.1LBKPN E SYNDROMES 217 2.6 2.6 58.7UBESITY 206 2.5 2.r fl.?ACUTE SPiANS STRANS 204 2.4 2.4 63.6PURS SYNLV IENOSYN 199 ?.4 2.4 66.,ACUIF L['WIR WESPI 175 2.1 2.1 fR.INr]NPSY LH ANX-NCURO 164 2.C 2.C 70.1DEGEN JNT DISEASE 151 1.8 1.9 71.9FIBROTS MYLG ARTHG 142 1.7 1.7 73.hSINLSIIS AC CHRCN 135 1. 1.6 75.2DER mATITl! C ECZ 103 1.2 1.2 76.'ALL FX UISLCCATICNS 100 1.2 1.2 77.7HEADACHES 98 1.2 1.? 78.9 S

171

I.

APPENDIX C-C (Contd)Diagnostic Clusters

March (9617 Records)VALID UM

VALUF LABEL FREQUFNCY PERCFT T PF RCENI PF PCENT

GEN ME', EXAM 107' " 13.4 13.4 13.4NO DIAG PROVIDED 701 8.7 8.7 ?2.1ACUTE URI 667 8.3 8.3 '0.4REFRACTIVE ERRORS 56A 7.1 7.1 -, 7. FHYPERTF.%S ION 457 5. j 5.7 43.2CHRONIC RHINITIS 432 5.4 .4 .9OT MED ACT CHRON 3 1 3,5 3.9 fi?LACR CENTS ARRAS 262 3.3 3.3 5.7ACUTE SPRANS STRANS 762 3.3 3.3 ',9.0BURS SYThfV TPNO1SYN IPtd 2.3 2.3 ,3LBKPN f SYNDROMES IP4 2.3 2.3 .3,6JBESI TY 175 2.2 2.2 65.8

ACUTE L[WER RESPI 161 2.C 2.0 (7.RDEGEN JNT DISEASE 160 2.C ?.0 69.PNONPSY PEP ANX-NEURF 152 1.S 1.9 71,7

FIBROlTS MYLG ARTHG 192 1.5 1.q 73.6DERMATITIS & ECZ 130 1.C 1.6 75.2

SINUSITIS AC CHRON 113 1.4 1.4 76.64ONFG INF SKNCSrQ TS 951 1.2 1.2 77.8HEADACHES BH 1.1 1.1 79,9 0

Total Study (58890 Records)VALIC CUM

VALUE LtBEL FREQUENCY PERCEPT PERCENI PERCENT

GEN MED EXAM 6550 13.2 13.2 13.2NO CIAG PROVIDED 5234 10.6 10.6 23.8

ACUTE URI 3536 7.1 7.1 31.9REFRACTIV. ERRORS 2886 5.e 5 . 36,7HYPERTENS ION 2784 5.6 5.6 42.3CHRONIC RFINITIS 2412 4.9 4fi 47.2LBKPN C SYNDROMES 1799 3.6 3.6 r'0.8OT MED ACI CHRON 1763 3.6 3. 54.4LACR CENT! ABRAS 1555 3.1 3.1 r7.5ACUTE SPRANS STRANS 1426 2.9 2.9 60.4BURS SYPIL TENOSYN 1305 2.f 2.6 63.1FIBROTS MILG ARTHG 1046 2.1 2.1 65.1NONPSY DEF ANX-NEURO 996 2.C 2.: 67.2OBESITY 935 1.9 1.9 69.0ACUTE LOWER RESPI 860 1.7 1.7 70.8

DERMAT]TI! E ECZ 662 1.3 1.3 72.1SINUSITIS AC CHRON 649 1.3 1.3 73.4ALL FX OILOCATIONS 621 1.3 1.3 74.7NONFG INF SKNESBQ 15 609 1.2 1.2 75.9VAGNTS ULVIS CRVCTS 576 1.2 1.2 77.10

172

L-

APPENDIX D-D

APPENDIX D-DMCCU Count vs. Outpatient Encounter Form

Month MCCU OEFa

November 12,509 10,932 .13

December 10,542 10,266 .03

January 12,879 12,235 .05

February 13,045 9,784 .24

March 13,138 9,617 .26

174

A -

APPENDIX E-E

4.

APPENDIX E-E

Care Provider Questionnaire

TO: Fox Army Hospital Providers

FROM: LTC Misener and Ms GilbertHealth Care Studies andClinical Investigation Activity

During the past few months, you have been participating in an ambulatorycare data base project which has gained much interest among military andcivilian health care professionals. Thtre seems to be agreement that themark-sense format you have been using is the most efficient method.

Your participation is greatly appreciated. It is hoped that the practice-profile reports have been informative/valuable. As we prepare to make ourfinal report for The Army Surgeon General, we would like to have feedbackfrom you.

We are interested in your individual comments, however, we ask that youapproach the evaluation realizing that in the future some method of capturingthese data will surely be required. Our goal is to help you design a formthat is most responsive to your needs for "recertification," research," etc.

The overall question is how can we meet the requirements to provideinformation efficiently, economically and as easily as possible, whilemeeting your needs.

1. Have you received any computer reports? a. es no

b. If yes, how many?_

2. Would you like to continue receiving practice profile reports on aregular basis? yes no

3. What additional feedback would you like?

{J4. What is the first digit of your care provider number? _1

5. How many seconds would you estimate it takes you to complete your portionof the encounter form?

6. Are the diagnostic categories sufficient for your use? yes no(If no) What changes do you recommend?

over please

176

WPPENDIX E-E (Contd)Care Provider Questionnaire

7. How frequently do you use the secondary (additional) diagnostic categories?(Please circle your choice)

Almost never I93rely 2Frequently 3Almost always 4

8. Do you believe the encounter form such as the one you have been usingshould be adopted Army-wide? yes no.

Why?

9. Do you believe the value of the information gained by completing the formis potentially worthwhile to:

You yes noFox AH yes noThe Army yes no

10. Which portions of the encounter form do you believe could be eliminated?

11. What recommendations would you make to improve or simplify the encounterform?

I177

~7j -

APPENDIX F-F

- .1

: 4

• V'

APPENDIX F-F

Clerical Staff Questionnaire

TO: Clinic Clerical/Administrative Staff

FROM: Ms Giloert/LTC Misener

Your assistance during the test phase of the outpatient encounter formproject is greatly appreciated. We believe that in the future the Army willrequire some method of gathering these data on a world-wide basis. As treend of the "Study" approaches and before the final report is written, wewould appreciate your ideas on how to make any future encounter form easierand more efficient.

1. On the average, how many minutes did it take you to complete your portionof the form? minutes.

2. How cooperative are most patients in filling out the forms? (please circlethe number of your response).

Very uncooperative 1Uncooperative 2Cooperative 3Very cooperative 4

3. Did the color coding on the form make it easier for you to use ?yes no

4. Would you prefer other colors for the form?yes no

5. Does this form capture all of the information for any reports you arerequired to generate such as the Medical Summary 302?

yes no

If no, wha' needs to be added?

6. Overall, have you been satisfied with the form? yes no

7. Has the form been easy to use? yes no

8. Are the elements in the most logical sequence? yes no

If no, how would you prefer to have them changed?

9. If the Army decides to continue using a form such as this on an ongoing basis,what changes do you recommend. Please be specific - this is your chance topossibly make the task easier.

179

= s '= , . . .... L ..

APPENDIX G-G

DEPARTMENT 6F THE ARMYUNITED STATZS ARMY MEDICAL DEPARTMENT ACTIVITY

REDSTONE ARSENAL, ALABAMA 21OS

"Eft v TO

HSXW-CO 18 March 1983

SUBJECT: Extension of Funding for Anbulatory Care Data Base

CommanderUS Army Health Services Command

ATTN: HSAM (Mr. Hime)Ft. Sam Houston, Texas 78234

1. We are aware that the Ambulatory Care Data Base Study will end presentfunding on or about 30 April 1983. Based upon positive results for patientmanagement and personnel and data retrieval it would be imperative tocontinue this on an on-going basis to further monitor trends and to providestatisticians the opportunity to view this system in operation.

2. We will be submitting a more formal request to the Automation GuidanceCouncil for funding of the extension. Please take this to be a statement ofintent.

M E. BEARD, M.D.COL, MCCommanding

181

ADA144839 AMBUATOR CARE 'DATABAS PART BAU ARMY RALTHCARESUDIE AND CLINICAL INV G ON A ORT SAM

HOUSTON NXI MISEN N E AL N MAN N4F NC A AH N AP ANN M

li1.0-

11111.2 .

V:P0H ki'2 I'~ 7 .N 6

APPENDIX H-H

I4

i i

-I

- - -- -APPE;4JDIX H-H NSTIOt,10 391i

een

Gele UNITED STATES ARMY MEDICAL DEPARTMENT ACTIVITY= REDSTONE ARSENAL. AL 35809aies

m

B ear Registrant:

- It you are not presently assigned here. welcome to Redstone Arsenal. We at Fox Army Hospital are prepared to support yourmedical needs in the most efficient and effective manner possible.

retel4111111 An integral factor insuring the continued improvement of medical services is our ability to project and identify health care411111 requirements through statistical analysis. In Order to accomplish this Fox Army Hospital. in conjunction with the U.S. Army

OdrHealth Service Command, has initiated an automated medical data collection system for gathering this vital information.

emYour participation and contribution to this program is accurately filling out this form which will register you as a health care- recipient. This information will be recorded and placed on the Automated Patient Master File for reference each time you are- provided medical treatment. When treatment is provided, a "Patient Encounter form" will be prepared at the hospital by the

rele administrative personnel and attending physician. In this manner your complete medical history of treatment will be maintained- and specific medical detail collected for administrative and medical statistical studies. The end result will be better health careem through improved service to you.

Meet= Thank you for your cooperation. Sincerely,em MEDOAC COMMANDER

IMPORTANT. All INFORMATION FOR BOTH SPONSOR AND DEPENDENTS IS TO BE FILLED OUT ON A SEPARATE FORM FORrele EACH FAMILY MEMBER REGISTERING FOR TREATMENT.

411111111,u~ec A1III$ AN r O SERVICE4111111 0 0(J) Mj~ a' oLD , 0 LbO(0'(6' )Active Duly ARMY 0 0 (0,

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183

APPENDIX H-H (Contd)

DO NOT WRITE IN THIS AREA

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IFYUARE A FEDERAL EMPLOYEE. IN ADDITION I.. . .ssrgn l 1 cdr ilsnr and d.te.in boer ohrImIasan odwludi

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rol EMPLOYMENT, YOU MAY RECEIVE CARE AS A 1lli811 dulta,

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vaorrlbOR S Nor persnrrl h Mr~a estr q ounvted rnlnmetr nrsoltr Ifr 1, e~llci resl roJ r ~~is no luroihed nmeoipeh-,v.s healthr-crne oaynt be possible but CARE Will NOT RI 01N1ED

Thi .I I I P... s s ec. .T ov1 1

a? 2'. II (Y) 2 Your synetorrr Otolt acknwedqvs that Vou basr beeo advsed oflrho, loteloill I iirquo.ted.1 3 (I 3 cl'

3 0 (h" In ccpnlrrsort il he I frcleirt ia

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184

~ U m

APPENDIX I-I

APPENDIX I-Im m -NCS To.% Opi.c'E601 13199 321

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APPENDIX J-J

I I

-- N.

APPENDIX J-JIIIIIII Mill CS Trans OftiC 101101 13798 321

CNN-OHSSSA rNIP PTIENT NITIAL OUTPATIENT

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191