The Gateway

Where’s our MC4 equipment? Have you ever found yourself asking this question? If so, the answer may be as simple as thumbing through the Commander’s Guide to MC4. Annex E addresses a myriad of equipping, fielding and sustainment topics. Below are just two likely scenarios that demonstrate how the Commander’s Guide can transform a stressful situation into a more manageable position.

Imagine that a company commander has just received deployment orders. As part of their pre-deployment checklist, they notice a significant shortage of MC4 systems based on the current modified table of organization and equipment (MTOE) document. To ensure that the unit is properly equipped and trained prior to deployment, commanders should follow the step-by-step instructions on how to request the MC4 system outlined in Annex E.

Here’s another scenario. Imagine you’re the logistic staff officer (S4) with a deployed unit and the commander is pounding on your door asking for additional MC4 systems above the MTOE authorizations in order to support split-based mission requirements. Again, there is no need to worry as Annex E provides all the trouble-free steps you need to follow to request additional MC4 systems.

The two scenarios mentioned above only provide a requisition point of view. However, Annex E of the Commander’s Guide provides other series of knowledge appendices. In fact there are four general topic areas:

• Customer Request for Equipment (Appendix E-1)
• MC4 Equipment Fielding Process (Appendix E-2)
• Equipment Refresh Process (Appendix E-3)
• MC4 Equipment Repair and Disposal (Appendix E-4)

All of these appendices provide essential information to the commander and their supporting staff to ensure the unit is properly equipped, trained and prepared for their support mission.

I encourage all commanders to peruse these appendices prior to deployment or redeployment to ensure there is a basic understanding on how to request and maintain a high operational readiness of the MC4 system.

Medical treatment facility (MTF) commanders and clinical leaders closely monitor the number and types of patients evaluated, treated and evacuated from their facilities. This data is crucial in managing manpower and other resources which impact the mission, as well as the quality of patient care, and the completeness and accuracy of the electronic medical record (EMR). Annex G, Appendix G-3 of the Commander’s Guide to MC4 provides resources to help medical units proactively prevent problems that arise when a patient diagnosis is improperly documented or not accounted for at all.

The primary diagnosis for every patient encounter, as indicated by the ICD-9 code, must be appropriately assigned by the provider at the time of admission, or at least prior to discharge, transfer or evacuation. The ICD-9 code should reflect the patient’s condition or illness. The diagnosis then populates two databases: the Theater Medical Data Store (TMDS) and Medical Situational Awareness in Theater (MSAT). If a specific ICD-9 code is not entered, the databases will populate with “No Diagnosis.”

An incorrect or absent diagnosis code can rob the patient, the health care team, and the Veteran’s Administration of valuable information needed to provide care to the Soldier, plan for future treatment and rehabilitation, or submit disability claims.

Additionally, the absence of a specific diagnosis in TMDS and MSAT can deprive the command of the ability to accurately analyze illness and injury patterns, identify emerging health threats, and project future resource needs.

For example, the sudden appearance of multiple patient encounters for Salmonella Gastritis, which would appear in TMDS and MSAT as ICD-9 003.3, could alert the medical command to an outbreak of food-borne illness among Soldiers who ate at the same dining facility. The opportunity for intervention could be lost if the encounters were recorded as “no diagnosis.”

Similarly, a Soldier who is injured by a vehicle-borne improvised explosive device will likely need extensive treatment, rehabilitation and long-term care from the VA, in addition to screening for related injuries such as TBI and PTSD. The impact of the injuries on the Soldier, and the draw on resources to the command could be overlooked if the patient encounter is recorded as “no diagnosis.”

An outline of the sequence of events that support proper recording of patient diagnoses can be found in Annex G, Appendix G-3, of the Commander’s Guide. I encourage all deployable MTF commanders and clinical leaders to read this section of the guide to learn more about electronically admitting and dispositioning patients.

While operating as the MC4 Southwest Asia (SWA) operations manager, I’ve personally experienced a significant uptick in the use of MC4 to capture electronic medical records (EMRs), which until now was an uncommon practice in a theater of war. This has not been easy, especially during the early years in Iraq and Afghanistan. With each new command and unit rotation, MC4 support personnel have noticed a consistent trend: customers routinely faced the same issues, asked the same questions and generally lacked a clear understanding of their role in system usage and support.

We realized that a tool was needed to help capture lessons learned and solidify best business practices—hence the Commander's Guide to MC4 was born. From its infancy, I’ve personally seen this effort turn from a single page policy memo to what it is today—a comprehensive set of best practices and system usage materials.

In my experience one of the most critical phases and least discussed within the medical community is the implementation and sustainment of the MC4 system. After all, health care providers cannot use the system if it's not setup and maintained properly. The Commanders Guide is designed to provide a systematic approach to implementation, sustainment and redeployment procedures for unit level system administrators (ULSAs) to leverage and for commander's to enforce. For personnel technically supporting MC4 systems in Southwest Asia, they should administer and train by the following best practices found in Annex H, Annex K and Annex L.

Annex H provides guidelines for establishing the support roles and responsibilities between MC4 personnel and ULAs. It is critical for unit commanders and ULAs to read and understand the Tiered Support Structure by which MC4 support personnel reference while operating in SWA. The EMR Service Level Agreement (SLA) and Preventive Maintenance Check and Services (PMCS) document is accompanied by several must-have checklists, which cover in detail all the required tasks necessary to complete the implementation and PMCS process within a level I, III and III facility.

Annex K outlines the critical tasks to initializing the MC4 system. Several checklists help outline the processes for medical facilities to perform quality control checks, which ensure each step of the implementation process has been completed. Performing these checks will safeguard the system from potential business process pitfalls due to gaps in operations, like missing equipment or provider's not having the proper TMDS privileges.

For redeploying units, Annex L will provide a comprehensive list of the key steps to completing a proper transfer of authority (TOA) between an incoming and outgoing unit. Several configuration changes to the MC4 system need to occur during TOA. The Level I and II MC4 System RIP/TOA SOP and Level III MC4 System RIP/TOA SOP explain the particular requirements and steps on how to execute the changes.

Download the Commander’s Guide to learn more about effectively managing medical facilities in Southwest Asia.

For many years AHLTA-T has enabled providers to successfully document outpatient care. The app works well at all medical treatment facilities (MTFs) for documenting emergency room care and outpatient clinic care. At level 3/role 3 MTFs, such as combat support hospitals (CSHs), TC2 is used to provide deployed users with both ancillary services, including order entry and result capabilities, and inpatient documentation functionalities. A documentation gap has been observed, however, at level II/role II MTFs in Afghanistan, causing confusion among medical staff as to how to document patient care.

The conundrum for providers and nurses is determining how patient care should be documented if a patient is admitted to a holding cot or bed, and nursing/clinical care is provided at the level II MTF for up to 72 hours. Block 2 of AHLTA-T that was fielded in September of 2009 provided an inpatient solution for this problem. While not a perfect solution, it allows functional users to document patient care in a fashion that is more consistent with an inpatient setting, without needing the full functionality that is inherent to the TC2 application.

A Lean Six Sigma project was conducted to demonstrate that AHLTA-T is an ideal way to document care at level II/role II MTFs. A step-by-step process was developed by MC4 Trainer James Mitchell in conjunction with the commander and functional users of the 452nd CSH at Forward Operating Base Salerno. I traveled to Salerno to provide some clinical perspective on the solution they developed.

This collaboration resulted in the Level II+ Inpatient Electronic Medical Record (EMR) Standing Operating Procedures (SOP) that comprises Annex G, Appendix G-2 of the Commander’s Guide to MC4. I encourage anyone assigned to a level II MTF to review this appendix, and share it liberally with anyone who can possibly gain benefit from it as a reference. The process of using AHLTA-T for inpatient care is always evolving and I would appreciate hearing from anyone who has a new or better way of using this application.

A Service member’s electronic medical record (EMR) begins with the providers and medics at level I and level II medical treatment facilities (MTFs) who are responsible for documenting patient care. Every level I battalion aid station (BAS) and every level II medical company will probably have a different business process (BP) for performing this mission, but the most important thing to remember is that electronic patient care documentation is not done to benefit clinical providers or medics—it is done to create an enduring health care record for ill and wounded Soldiers who are treated on and off the battlefield. Annex G, Appendix G-1 of the Commander's Guide to MC4 provides end users with the information they need to properly accomplish the very important job of managing EMR documentation.

Although each MTF will have its own BP for setting up sick call flow like performing patient registration, obtaining and documenting vital signs, and establishing patient treatment areas, Appendix G-1 provides medical personnel with a streamlined process for accomplishing other tasks. This section of the Commander’s Guide contains the best practices for registering patients in AHLTA-T and/or TC2 with a CAC scanner, updating patient demographics, correcting duplicate patient records, and transferring a SOAP (Subjective, Objective, Assessment and Plan) note from a medic to a designated provider, to name a few. Medical personnel serving at level I or level II MTFs can download AHLTA-T sick call templates to assist with documenting common sick call complaints.

Caring for sick and wounded Soldiers starts at level I and level II MTFs. Therefore the Commander’s Guide should always be part of a BAS’s packing list for CONUS and OCONUS missions since it can guide medical personnel in the development of their clinical workflow. “Training as you fight” cannot be overstated and since training begins with the development of a training plan, I recommend that non-commissioned officers and officer leaders use the Commander’s Guide to develop their training plans for conducting level I and level II health care in garrison and in theater.