The Gateway

We’ve been reviewing our policies in Afghanistan over the past few months looking for ways to improve our medical business practices. It has been challenging finding a way to ensure patient encounters are being properly closed so the information that has been obtained becomes part of the Soldier’s lifelong electronic medical record (EMR). As part of our solution, we recently created an open encounters report for Afghanistan.

We worked with MC4 and developed a report in Medical Situational Awareness in the Theater (MSAT) using Business Objects. Any open encounters that are more than three days old will show up in a query. We generate these reports once a week, which go to hospitals, regional medical commands and are consolidated and are briefed to commanders at all levels within our task force.

We initially identified more than 600 open encounters, but with this new business practice in place, we’re down to less than 10 open encounters a week. We’ve been doing this for about two months now and within the first month alone we saw a 72 percent decrease in the number of open encounters. The key is pushing requirements through operational channels and gaining command emphasis.

Medical personnel are now required to close the reports within 24 hours, but we’re exploring additional language to make the policy even more effective. Physicians don’t always close the encounters and then we run into a whole other challenge when they aren’t closed by the same person who created them. We hope that with new processes in place, we can eliminate the open encounters problem we’ve been experiencing for years. So far, the open encounters report is promising.

We’ve made a similar effort to overhaul the Afghanistan Health Information Systems (HIS) Policy. This time around with the Afghanistan HIS Policy we’ve made an effort to be prescriptive, not descriptive. We focused on the basics and made a conscious effort to spell out everything very clearly.

Folks will find that the HIS Policy is still very similar to what’s been done in the past, we’re not trying to reinvent the wheel, but we’ve eliminated a lot of the language that may leave folks with additional questions about best practices. For example, “could" and “can" are now “will" and “shall." It’s really been a group effort to identify changes to improve business processes here.

All these improvements really boil down to the patient. It’s all about the sick and the wounded. It’s about documenting care accurately and quickly with the EMR system. Time will tell just how effective these efforts are and help us medical leaders identify where we go from here.

Maj. Mark Mellott, Health Information Systems Administrator, Task Force Med A, Afghanistan

A new module in the Theater Medical Data Store (TMDS) has been released in January 2011 to assist with the tracking and monitoring of blood supply in theater. The blood module is a web-based database that manages all blood products in the operational environment outside of existing garrison programs. Blood products scanned into the system can be tracked throughout the inventory process to a final disposition of either transfused or destroyed.

This is a significant improvement to the process that was previously being used to track blood units in a spreadsheet, often referred to as the Mother of all Spreadsheets. The single report included over 1,000 hyperlinks and each individual blood product’s 13-digit unique ID number had to be manually entered into the spreadsheet with patient transfusion information. After five years of using this labor intensive process, the Armed Services Blood Program (ASBP) moved forward with a project to automate the data, affectionately called the electronic Mother of all Spreadsheets (eMOAS).

The automation of data made possible by the blood module in TMDS increases data integrity and directly contributes to the bottom line efficiency and productivity of blood product management. The eMOAS allows for searching and tracking both blood transfusions and blood donations within minutes, as compared to waiting for hours after putting in requests to the Joint blood program officers who managed the single report.

About 10 percent of TMDS active users are using the blood module. To date, more than 123,776 blood products have been entered into the module and 133,000 blood products have been processed via the module. The capability to scan blood products immediately gives valuable time back to blood program staff who can now focus on getting the products out to the medical units.

Through the automated reporting, the ASBP can determine who received which blood product, and in what amount with the click of a button. This access to blood product disposition data sharpens communication with military medical personnel and improves patient care both in the field and at medical treatment facilities.

Don Dahlheimer, Deputy Director for Information Management, Armed Services Blood Program

Navy Lt. Cmdr. Aaron Harding, Deputy Director for Policy, Armed Services Blood Program, contributed to this blog.

Telebehavioral health (TBH) has demonstrated to be a valuable tool in overcoming the terrain challenges in Afghanistan that severely limit in-person meetings between far-forward deployed Soldiers and behavioral health care providers. TBH is a low cost solution that increases a Soldier’s access to health care in the combat zone.

As of mid-September 2011, 47 far-forward sites in Afghanistan are operational with TBH, enabling health care providers to conduct more than 500 sessions with 200 patients.

The preliminary results of these sites are encouraging. Soldier satisfaction with the program is high and a majority of providers report that TBH encounters save them travel time and enhance their ability to provide timely care. Expansion of these sites is underway and will ultimately include a total of 81 sites.

While the audio and video quality is adequate for consultations, patient privacy remains a concern among Soldiers. The TBH program utilizes a hub and spoke concept, with a primary hub located at the behavioral health provider's area of operation and "spokes" located at far-forward sites. Presently, MC4 laptops with commercial software and a web-cam are being used on a secure Internet network for virtual face-to-face consultations.

By the end of November 2011, 81 sites throughout Afghanistan will be using MC4 hardware and COTS software to provide private, real-time audio and video via military networks. A recent pilot testing this new setup was well received by Soldiers, health care providers and commanders.

This has been an exciting year for telehealth and in particular telebehavioral health. TBH has become very successful in extending the clinical outreach of specialty providers to Soldiers in Afghanistan. Similar, smaller projects have been deployed to both Iraq and Kuwait, where they too have been well received by patients and medical staff.

Fielding the future telehealth suite could become part of every expeditionary medical experience. Deploying medical units with AHLTA-T will routinely provide safe, timely, early intervention from any geographic area.

Telehealth is a technology that stands ready to connect remote forward operating bases to deployed hospitals via military networks during future natural disasters or armed conflicts.

Col. Ron Poropatich, Deputy Director, Telemedicine and Advanced Technology Research Center, Fort Detrick, Md.

As the brigade psychologist for the 2nd Brigade Combat Team, 4th Infantry Division, using telebehavioral health (TBH) to conduct consultations has significantly increased my ability to provide services to a greater number of Soldiers in a more efficient and timely manner. Additionally, TBH has helped reduce some of the challenges that arise in connecting Soldiers with health providers downrange.

For commanders, determining when a Soldier may be in need of behavioral health services is not always readily ascertainable, particularly when a Soldier denies having problems or is not ready to ask for help. The thought of taking a Soldier out of the fight for several days would have considerable impact on the mission, not to mention the logistical challenge it would place on the platoon.

TBH provides for real-time video conferencing and grants an atmosphere similar to that of face-to-face interactions experienced in more traditional settings. As a result, the Soldier doesn't need to be moved or be held back from going on a mission to meet with an incoming provider, enabling units to maintain their combat strength.

In instances where the Soldier in need is not co-located with a TBH system, evaluations and follow-up services are easily coordinated around the unit's schedule; supporting both the unit and the Soldier.

While there have been a few minor growing pains in establishing the TBH systems, the benefits continue to be realized on a regular basis. I have found TBH greatly bridges the gap in accessibility and allows me to quickly assist commanders in constrained situations.

When I meet with a Soldier via TBH, at the outset of the interaction I make it a point to explain the nature of the TBH system, including the potential limitations in connectivity. I also make sure I obtain the Soldier’s consent to proceed with receiving behavioral health services via TBH during the first interaction.

Taking the time to do this helps the Soldier feel more comfortable and provides an opportunity to discuss any concerns they might have with using this system. This further engages the Soldier in the process and starts facilitating a therapeutic relationship.

The desert terrain coupled with the decentralized operations made it quite a challenge to move Soldiers or the health care providers to outlying locations, but TBH has proven to be a reliable and effective platform of increasing access to behavioral health providers despite these factors.

Capt. Cory Gerould, Brigade Psychologist, Regional Command – South, Afghanistan

As a late addition to the Task Force Medical in Afghanistan, I missed the scheduled MC4 training for the unit in garrison. However, upon arriving in Afghanistan, I spent two weeks with MC4 clinical operations (CLINOPS) personnel getting up to speed. That training was extremely valuable as I was able to get a clinical business process and practice perspective of MC4 versus my traditional S-6 angle that focused on communications, automation and network.

I used MC4 when I deployed to Iraq in 2006 and in my experience, it’s very important to know how and when to use MSAT and Business Objects to pull certain data. MSAT is more limited in the data it can retrieve, but the queries are very easy to put together. It’s great for answering command requests for information, for instance, an appropriately organized Business Objects query can provide the names of every Service member who has been electronically prescribed a psychotropic medication while in theater.

Business Objects shines when more in-depth detailed reports are required. While it requires knowledge of building the query, and then the report, the results can provide a much deeper look into the available data. Another advantage is the filtering that Business Objects is capable of performing. The filtering allows for much greater specificity in the results, like breaking down the outpatient data even further to determine how many are active duty Soldiers versus contractors. Business Objects is also much easier to use when changing search parameters or modifying report views.

Maj. Robert Lang, Senior Health Information Systems Officer, Theater Health Information Program-Joint, Afghanistan

Setting up a hospital is no joke, especially working outside in temperatures ranging from 110 to 120 degree without shade. It makes for long, hot days. We completed the hospital infrastructure within one week after arriving at Camp Dwyer, Afghanistan. The process included 10 eight-section tempers, four two-section tempers, seven ISO containers and a lot of sweat. We also constructed living quarters, latrines and showers for more than 220 medical personnel.

The lab received two ISO containers, one for general lab services and one for blood. Both were incredibly dusty. There is no escaping the moon dust here. After we inventoried the equipment, we moved all of the equipment, furniture and expendable supplies into the lab. Everything was heavy. For the days that we didn’t have forklifts to move items from the connex to the lab, we had extra physical training in for the day. I started the deployment with three techs and they were awesome and very helpful. A lot of manpower went into connecting and organizing the two ISOs.

As a new lab officer, the deployment to Camp Dwyer was the ultimate on-the-job training experience. In school, all of the supplies were easily accessible. We didn’t have to worry about where or how we received supplies and reagents. When I stepped into my first lab, everything had standard operating procedures (SOPs), reagents were stocked or ordered, and everything had a place. Everyone knew what quality control items went with each test and everyone knew how to order the items with the proper national supply number (NSN).

Supply can be tricky if you don’t know what you are doing. In school, we conducted a method validation on the i-STAT, so I thought I was familiar with the instruments. When medical maintenance brought me four i-STATs, I didn’t think anything of it. I quickly learned that quality control on the i-STAT is more than just inserting the external simulator into the instrument. This process only verifies the electrical measurement of the i-STAT and there is wet quality control and calibration.

We were surprised to learn that the hospital ordered all of the controls and calibrators. The downside was that many of our reagents were either compromised from the heat or expired. When we tried to order replacements, we found that the SOPs and package inserts didn't clearly state the required controls needed and the NSNs.

As a new lab officer in the field, all of these things are a blur until you get your hands dirty. After my fellow lab officers and the senior lab techs arrived, quality control made perfect sense. Everything began to fall into place. The creation of SOPs, policies and procedures was a challenge due to our date given to be at full operational capability (FOC). For that, the FLIP Disk has been wonderful.

Sending out lab tests can be a challenge. Specimens have specific requirements and it can be challenging to arrange flights from Camp Dwyer to Landstuhl or to the states. There is no such thing as a direct flight from here to Landstuhl or the U.S. The use of any major overnight service from here is a pipedream.

During the early days of the CSH, the supply chain was problematic and the Internet was scarce. DCAM was not operational and it was difficult to look up product information without connectivity. I was very grateful when our Signal shop put MC4 systems online throughout the hospital. Sustaining the power supply for the hospital is a continuous challenge, especially when the outside air temperature rivals the inside of an oven.

Captain Amanda Luchinski, Laboratory Officer, 31st Combat Support Hospital, Camp Dwyer, Afghanistan

As a professional filler system (PROFIS) member of the 115th Combat Support Hospital (CSH), I understand some of the pains temporary members of a unit go through to support mission training requirements. Great communication with the 115th CSH commander, U.S. Army Col. Patricia Darnauer, helped me play an active role in the unit's pre-deployment planning process and focus on preparing the staff to use the clinical and operations systems in theater.

After returning from our three-week pre-deployment site survey in Afghanistan, I returned to my position as the deputy chief of the Sustainment Division at the U.S. Army Medical Information Technology Center (USAMITC) at Fort Sam Houston, Texas. The guidance and support from Lt. Col. Beverly Beavers, commander of USAMITC, was essential to allow me to prepare for the deployment from a distance. I collaborated with Staff Sgt. Jason Patitucci, the noncommissioned officer in charge of the Signal Office for the 115th CSH, to develop the exercise plan for the 115th CSH's certification training exercise. During this event, we created an operational order annex on the use of systems to digitally document electronic medical records (EMRs).

The site survey hammered home how important it is for PROFIS personnel to receive the proper systems training since everyone will have varying levels of experience with the MC4 system. Our goal was to train PROFIS personnel to be comfortable with the tactical systems and to understand the nuances of the automation equipment they would use in the deployed environment.

Two weeks before the unit deployed, more than 200 Soldiers attended three days of MC4 training. Approximately half of the attendees were PROFIS personnel. The timing of the training was perfect. When we arrived in theater, the information was fresh in everyone's minds and the medical staff quickly transitioned to the deployed environment.

Since PROFIS personnel would continue to join the unit throughout the deployment and require systems training, we coordinated with MC4 personnel in Afghanistan to administer theater-specific training in accordance with our standard operating procedures as they pass through the reception, staging, onward movement and integration (RSOI) site. We arranged for a liaison from the CSH to provide the necessary training to the PROFIS personnel upon their arrival as part of their RSOI training. This arrangement has helped to ready the PROFIS members to be productive from the moment they hit the ground

Capt. Junjie Inocencio, Signal Officer and Health Information Systems Officer, 115th Combat Support Hospital, Camp Dwyer, Afghanistan

Today, we electronically capture patient data and fulfill medical logistics (MEDLOG) needs via the MC4 system. The brigade surgeon reviews the patient data to monitor the medical trends throughout RC North and the Afghanistan theater.

The clinical staff documents patient notes faster with MC4 than charting the same information on paper SF 600s. The staff is also more efficient with a paperless environment. The medics and providers pull up digital records throughout the facility and don't have to scramble to find paper files.

The use of DCAM made an immediate impact on our MEDLOG efforts. The same day DCAM went live in our facility, we established an account with the U.S. Army Medical Materiel Center – Southwest Asia and began placing orders electronically. By using DCAM, we now receive our class VIII supplies faster than when we faxed and emailed our orders. Today, we're able to better fulfill our patients' needs.

Although the unit received a familiarization class before we deployed, the additional training we received from the MC4 team was very beneficial and augmented the prior instruction. We received hands-on instruction to utilize DCAM and the outpatient program, AHLTA-T. MC4 personnel also showed our SASMO and signal personnel how to perform routine system maintenance.

We received a lot of information and great support from the MC4 team. We expect to continue to reap the many benefits offered by the MC4 systems throughout our deployment.

Sgt. 1st Class James Mentel, Noncommissioned Officer in Charge, Charlie Company, 10th Brigade Support Battalion, 10th Mountain Division (Light Infantry), Camp Spann, Mazar-e-Sharif, Afghanistan

I was the preventive medicine officer for Combined Joint Task Force-82 (CJTF-82) in Afghanistan with the 82nd Airborne Division. I was deployed from May 2009 to March 2010. One of my key missions was working with units throughout Regional Command East to utilize MC4 systems for patient documentation and to use the Joint Medical Workstation (JMeWS) for their reporting requirements.

When I first arrived in theater, a number of units were not recording or reporting patient data in MC4 systems. To complete disease and non-battle injury (DNBI) reporting requirements, units relied upon spreadsheets and not JMeWS. Two reasons repeatedly mentioned were network connectivity issues and dual reporting requirements for both DOD and the International Security Assistance Force in Afghanistan.

Level I and II facilities typically experienced the most issues with slow connection speeds. While many locations had SIPRNet access, the connections were very slow to pull DNBI data. To avoid the slow data transfer, units utilized spreadsheets.

Units hand-jammed data from their own spreadsheets to satisfy DNBI requirements, rather than pulling reports from electronic patient encounters. Then, they entered data into JMeWS, giving higher commands visibility of the local treatment facilities As a result, the numbers from electronic records did not match the numbers from the unit's own spreadsheets. Information from the spreadsheets was also used to populate a weekly DNBI report mandated by NATO.

After some effort, compliance improved to use of MC4 and JMeWS. Visits by MC4's deployed technical support teams (TSTs) were key. MC4 personnel helped users and commanders become more comfortable with the system. The TSTs also reminded medical unit leaders that when the clinical team charted patient care with MC4, DNBI data populated JMeWS and eliminated the manual process.

The DNBI data in JMeWS helped me and my team to respond to various trends and outbreaks throughout the region. We used JMEWS to monitor trends in respiratory illness and H1N1 influenza using both active and passive surveillance methods. We were able to monitor and document trends and potential cases, as well as assess the impact of our immunization campaign.

JMeWS also alerted us to another problem—malaria chemoprophylaxis. We saw additional cases of malaria during the cooler months when there is limited malaria transmission. We learned that many Soldiers had stopped taking their doxycycline or mefloquine, mistakenly thinking that they no longer needed it. These medicines don't actually prevent you from getting infected with malaria, but treat the stage of the disease that would normally make you symptomatic.

We also saw periodic increases in the number of cases of gastrointestinal disease [in JMeWS], particularly during the summer months. Most of food borne illness is sporadic and not necessarily due to a large or sudden outbreak. When we observed higher rates than expected, preventive medicine teams responded and the reported rates would decrease.

Having the DNBI data from level I and II facilities helped us to ensure the proper resources and preventive medicine countermeasures were in place to prevent and treat non-battle injuries and illnesses.

Lt. Col. Robert Paris, Infectious Disease Fellow, Walter Reed Army Medical Center, Washington, D.C.

When I deployed to Iraq in 2005 with the 42nd Infantry Division (ID), our unit was the first Army National Guard division to be sent as a command element since the Korean War.

The 42nd ID headquarters was located at Forward Operating Base (FOB) Danger in Tikrit, Iraq. While in theater, we heard that the MC4 system was coming so that we could electronically document patient care. We returned home before we got to see the system.

Three years later, I deployed as the Task Force Surgeon of Task Force (TF) Phoenix in Kabul, Afghanistan, with the 27th Brigade Combat Team (BCT) as the lead element. Prior to deployment, our medical personnel received new equipment training at Fort Drum, N.Y., including exposure to MC4.

It was helpful for me to see the electronic medical record (EMR) system in use. Besides using the system to document patient care as a permanent part of the Soldier's medical record, I could use the system to monitor trends in illnesses and injuries.

When we arrived in theater, we back-filled providers from the 218th BCT. They had been using MC4 in theater prior to our arrival. As a result, we were already set up with the MC4 system. We had AHLTA-T and the Joint Patient Tracking Application (JPTA) [now part of TMDS]. We also had MC4 representatives in Afghanistan that helped us overcome systems issues. The 218th BCT providers also gave us their templates and workarounds, which was also very helpful.

I'm fortunate to have an EMR system in my private practice and I'm not intimated by electronics. Thus, the transition to MC4 was not as difficult for me as it was for some providers that had not used EMR systems. The system was valuable for patient care so we just used it. It's not rocket science and the basics are very easy to grasp. The harder part is trying to figure out everything that the system can do for you. If I didn't know how to make the system do what I needed it to do, such as generate specific reports, I called the MC4 representatives for help.

Many of the Soldiers we saw were either in processing or out processing through our base in Afghanistan and some required additional care when they got home. At the time, we weren't sure if the Veterans Affairs (VA) could see the EMRs generated while the Soldier was in theater. With MC4, we were able to hand Soldiers a copy of their records and their line of duty form, so they could follow up with the administrative portion of the process when they got home.

In other instances, it was helpful to see a patient's visit history and their medication use. We used the records to generate trends for the TF commander. We would see upswings in respiratory illnesses, dry eyes due to dust storms, etc. We could report the trends of our clinic and other troop medical clinics in the task force rolled up their data for us to report. The reports were easy to generate and interpret.

We also utilized telemedicine. We could take a picture of a rash and send it to Telederm, a consultative service that electronically connected us with specialists in garrison. We provided the patient's name and social security number so they could access the AHLTA record and see the entire patient history, as well as the picture we sent. Within 48 hours they would send us a list of differential diagnoses, the most and least likely conditions, as well as medical recommendations. Other than MC4 applications, we probably used Telederm more than anything else. We used MC4, as well as telemedicine techniques, during the 2009 Yama Sakura exercise in Japan.

In Japan, I knew how to use MC4 so there wasn't much of a learning curve and I knew what it could do. We had one Soldier that had a non-combat injury that required surgery. I was able to consult with providers at Tripler Army Medical Center in Honolulu, Hawaii. They provided input on the injury and treatment, so it made consultations with providers at distant sites much easier. We gave him a copy of his medical records and he brought them back to CONUS where he gave them to his providers at home.

During the exercise, we didn't have a lot of serious injuries. We used the MC4 systems to document everything—colds, sniffles and any treatment given at our clinic. We were able to provide each participating unit with statistics on the number of their Soldiers seen over the course of the exercise. Typically, we didn't print out the records, but told Soldiers that the information was in AHLTA and the VA could access the data if needed. We also told them that they could contact their state surgeon for copies of the records from local medical treatment facilities (MTFs).

The difference between my first and most recent deployment is that during the first deployment, we used paper records which had a greater risk of being lost. Today, we might not always be able to get into the EMRs, but someone can. I can call someone to research a particular injury or treatment if needed. Electronic files are also easier to retrieve and because we used templates, I think the care was more standardized.

Col. Joan Sullivan, State Surgeon, New York Army National Guard