The Gateway

In July, MC4 participated in an exercise where medical providers were able to create and remotely transfer electronic medical data to the MC4 system. This is the first time a point-of-injury (POI) encounter has been captured with a TC3 app and transmitted over the cellular network to the MC4 system using a smartphone.

At the Command, Control, Communications, Computers, Intelligence, Surveillance and Reconnaissance (C4ISR) Network Modernization (NetMod) Exercise 12 (E-12) at Fort Dix, N.J., Soldiers used an Android-based Tactical Combat Casualty Care (TC3) card prototype developed in collaboration between MC4 and the Army Signal Center, Fort Gordon, Ga.

The TC3 cards were completed on smartphones that have the capability of transferring the encounters over a fourth generation long term evolution (4G LTE) network to the MC4 system. From the MC4 laptop, the TC3 encounters were successfully uploaded into the AHLTA-T application. The 4G LTE is the latest and greatest cellular network that allows for faster upload and download speeds.

MC4 is committed to the Army Chief Information Officer Lt. Gen. Susan Lawrence’s vision for Network 2020 that is always on and always connected to the Soldier. The 4G LTE is an experimental network for the Army and has not yet been deployed for Soldier use. In the meantime, proofs of concepts such as this will provide the way ahead for future development of applications for the next contingency.

Providing relevant clinical information to the command is one of the most important tasks for the clinical operations (CLINOPS) staff. The Business Objects application can provide medical staff with detailed medical situational awareness, and it can assist the mission command of direct reporting units.

Business Objects is an excellent tool for analyzing data that has been captured via the Army’s deployed electronic medical record (EMR) system. It is a commercial off-the-shelf (COTS) product that can be used on MC4 systems to extract medical encounter details for analysis, assessments and decision making. Business Objects allows clinical leaders and providers to drill down into aggregated EMR data that can be used for briefings and to create accurate, meaningful medical surveillance reports.

It is simple to log on to the Medical Situational Awareness in the Theater (MSAT) application and download data into an informative Excel spreadsheet. This data can then be analyzed to build a useful operating picture of the medical situation in a particular area of operations.

• Detailed clinical information on medical encounters that have occurred in an area of responsibility. It is easy to search and find individual diseases, diagnoses, clinical findings or medications.
• Customized standard surveillance reports from Joint Medical Workstation (JMeWS) by searching inside the content of the EMR for any word or character string within the following encounter areas: Chief Complaint, Hx of Present Illness, Past Medical Hx, Physical Examination, Assessment, ICD9 codes and Procedure Codes. However, laboratory and radiology results are not available at this time.
• Customized complex searches for special queries that identify conditions that have overlapping descriptors. For example, searching for “extremity” and “leg” while excluding encounters that mention “arm.”
• Syndromic surveillance customization that allows the user to separately search the differing sections of EMR encounters.

Business Objects is an important tool because it allows providers, clinical leaders and CLINOPS staff to obtain meaningful, objective, actionable information that can be used for conducting mission analyses and for command decision making. For example, the number of Soldiers prescribed sedative hypnotic drugs, the types of injuries observed from IED blasts in different regions of the theater, the number and types of surgical cases being performed in role 2 medical treatment facilities (MTFs), etc.

Business Objects reports are powerful, and they provide a robust data-mining tool that searches the entire MSAT medical encounter database. The MSAT Business Objects tool already has many standard report templates that are invaluable to users, but the ability to customize reports is even more important. MSAT users will find that the personal effort needed to learn MSAT’s Business Objects application is well worth the time spent.

While on a recent visit to Afghanistan to assist incoming medical units, I encountered a significant number of medical personnel asking about rabies documentation. To help meet this documentation requirement, I worked with Maj. Jason Bennett, theater Infectious Disease consultant with the 782nd Brigade Support Battalion, 82nd Airborne Division, to create a new Rabies AIM Form that focuses on the data elements necessary to document the evaluation of rabies exposure in the MC4 system.

This AIM form is based on a form created by DHIMS for garrison use; the garrison form was modified to work on the theater EMR systems. The updated theater AIM Form was inspired by theater requirements and the DOD rabies reporting form that must be completed for every rabies exposure. The AIM form also includes the most current recommendations and algorithms to treat someone with rabies exposure, so it will save time and help clinicians document the encounter.

I gathered local user feedback and distributed this AIM form for use and testing. Maj. Bennett was instrumental in providing feedback for the organization and flow of the new AIM form. Most of the changes we made were associated with the way the form itself was assembled. We reorganized the form into three tabs: patient history, animal history and clinical information. We also added a rabies follow-up section that will allow clinical staff to document vaccines and other patient follow-up information.

Feedback is still welcome as to what modifications would make it more user-friendly and relevant to local business practices.

There are four things that all nurses who use the MC4 system need to know.

• All patient care, inpatient care and short term problems such as viral illnesses, should be documented in the MC4 system. Information documented in the EMR system will become part of the Soldier’s permanent medical record. This allows a complete past medical picture to be viewable for yourself and any other medical personnel.

• AHLTA-T is used by nurses in outpatient clinics, the ER and some level II holding facilities. This application is organized in the subjective/objective and assessment/plan (SOAP) format and is fairly easy to use. At level III’s, TC2 is used for documenting inpatient care. This application is almost the same as Composite Health Care System (CHCS) with the same flow and navigation. In theater, however; TC2 is used to document the complete medical record, which is different than how CHCS is used in garrison.

• The applications within the MC4 EMR system are not nurse-friendly and require some workarounds. Nursing typically documents in a flow sheet format and these are not available in the system.

• There are AHLTA-T templates/AIM forms and TC2 templates that will help in mimicking a nursing documentation work flow. The TC2 templates replicate the flow sheets nurses are comfortable using. The templates/AIM forms for AHLTA-T pull all the nursing documentation together in an easy to use format, but do not have a flow sheet look and feel.

  I recommend reading the Tips and FAQs on AHLTA-T and TC2 for more information.

MC4 is always looking for feedback and nursing advocates within the military nursing community that affect change and improve the system from a nursing perspective. If you have feedback to share and/or are willing to be an advocate, please contact the MC4 Clinical Operations Office.

Our Afghanistan team’s goal is pretty straight forward — to continue to provide support to deployed units using MC4. Our primary purpose and our driving goal at MC4 is to enable the Army to document as many comprehensive electronic medical records as possible in order to provide the best care for our Service members. Afghanistan has always been a dynamic operation and later this year with the reduction of Army forces, it is more important than ever to focus on the fundamentals.

We intend to accomplish this by enhancing our tier 3 support, strengthening the Army’s tier 1 and tier 2 support, keeping the software versions current, and continuing to provide training to end users. We will also provide direct support as we field new capabilities by configuring systems and/or training users on how to utilize new capabilities like telebehavioral health (TBH), TC2/Medweb interface, and new trauma documentation templates for MEDEVAC units. We are currently looking for a unit to pilot the MEDEVAC trauma documentation templates before distributing this capability countrywide later this year.

MC4 is an Army system, not a commercial software suite. That means each unit owns their MC4 equipment and is responsible for the basic support. In 2012, we are seeking to provide more tier 1 training to Information Management Officers (IMOs) and Sustainment Automation Support Management Offices (SASMOs); and tier 2 training to system administrators (S6s) during our site visits. We will continue to work with the commands to establish this strong tier 1 and 2 support so that our MC4 personnel in theater can travel and see more units each month. This allows MC4 staff to help units become more self-sufficient and exceed the standard of documenting EMRs by documenting comprehensive, detailed EMRs that become part of the Service member’s lifelong electronic health record.

To enhance MC4’s tier 3 support, we are completing the EMR 2.1.3.1 software upgrade countrywide. The new software includes the latest security and computer updates; enhanced symptom descriptions and templates in AHLTA-T for TBI and mTBI; and most importantly, updates to EMR documentation software to include ICD-9 (International Classification of Diseases, 9th Revision) codes. We are also working with the theater signal commands to integrate MC4 on to the Non-classified IP Router (NIPR) network. This NIPR integration project provides enhanced security for MC4 systems, a greater standardization of configuration, and the ability to securely and remotely access the MC4 machines for troubleshooting purposes.

At MC4, we strive to continue to improve and enhance our support to the Army even during the draw down in Iraq and projected footprint reductions in Afghanistan. If a new upgrade, business practice or product can help to improve the care of Soldiers, I will ensure we field it.

Last fall, the 212th Combat Support Hospital (CSH) and the 30th Medical Command (MEDCOM) conducted a unique training exercise at the Joint Multinational Training Center (JMTC) training area in Grafenwoehr, Germany. During this field training exercise (FTX), more than 240 actual sick-call patient encounters were documented into the live AHLTA-T application on MC4 computers, and more than 350 notional patient encounters were also documented.

The exercise included an abundant variety of trauma and medical encounters, and it included two epidemic events. The success of the exercise depended on minimizing any confusion between the notional and real sick call patients that were included in the exercise.

Patient encounters were documented in AHLTA-T. MC4 staff, including myself, were onsite to help ensure that the patient data was properly moving forward to the Theater Medical Data Store (TMDS), the Medical Situational Awareness in the Theater (MSAT) application, to the training servers and to legacy AHLTA.

From my account, this training exercise was a success and serves as an excellent model for future training exercises; it stands as a benchmark for future medical brigade and CSH certifying exercises.

Notable accomplishments
The 212th CSH entered a substantial number of well-documented notional encounters. This is impressive because nearly all the encounters had detailed provider notes as well as satisfactory nursing documentation. Kudos to the CSH's hard working staff!

The abundance of both notional and actual encounter information gave the 30th MEDCOM an opportunity to analyze the exercise events with much greater detail than a typical training event.

Challenges
Both the CSH and the MEDCOM had several challenges that needed to be overcome in order to make this exercise a reality. Initially, there were multiple challenges regarding the initial setup of the training server; challenges that could have threatened the conduct of this training event. But once we made it past these hurdles, MC4 staffers were in full swing recommending best clinical business practices and consulting commanders with questions about individual unit needs and requirements.

The greatest risk associated with the exercise was the possible inadvertent entry of a patient into the wrong system. Real patients and real social security numbers cannot be entered into a training system; the consequences of this are serious. Also, it was important not to enter notional patients into the real electronic medical record system.

To ensure that no errors were made, the CSH paid strict attention to the separation of notional and live data, and the physical location of notional and live computers. Equally important was labeling the computers, properly training users (including patient administrators, the sick-call facility members, the providers, the medical screeners and the nurses), and continually emphasizing to the CSH staff the importance of not mixing the live and notional patients.

I strongly advise using these same proven methods during any future exercises that try to work with notional and live patients during the same event. The complexity of such an exercise required a lot of preparation, but in the end we demonstrated that the MC4 EMR system could successfully and concurrently document a large number live patient encounters and simulated patient encounters during a training exercise.

Learn More
The large numbers of both real and notional documentation was unique during this large scale exercise. The work that was done by the 212th CSH is available for review today; I recommend reviewing the documentation of this exercise to see exactly how the patient encounter data is displayed in the real system and to learn how to use these tools while exercising the mission command of level II and III medical facilities in a deployed environment.

• View the entire live encounter information that was done during the FTX by logging into TMDS.
• Review the notional information on the AKIMEDA TMDS training server.
• The exercise training encounter data can be viewed on the AKIMEKA MSAT Training Server.

A provider asked, "What influences a medical provider’s ability to completely fill out the theater electronic medical record (AHLTA-T and TC2)?" As a physician, and as a former MC4 user in Iraq, I thought I’d share my shortlist of success factors for maximizing the use of TC2 in theater.

1. Every clinician should receive adequate training on how to use the deployed medical documentation systems. AHLTA is similar enough to AHLTA-T that most active-component providers have no difficulty picking up the differences. CHCS and TC2 are also very similar, but most of the TDA inpatient facilities are now using Essentris for electronically documenting inpatient care. While CHCS is simple to use, competency with the application is essential. Word templates (with drop-down menus for choices) can assist with quickly creating electronic documentation in CHCS. Dragon Naturally Speaking is a tool that can facilitate efficient documentation in TC2. It is critically important that the provider understands and knows how to use these applications. Check out the TC2 page on the MC4 website for instruction.

2. All providers already know the importance of accurate medical documentation – all of us need to be aware of this when we document our care. Each of us needs to acquire habits that are efficient and result in a product that is usable and informative. Providers need to keep focused on why they are being required to document in the deployed medical record. The notes that are written today will remain with that individual for the remainder of their life. If the entry is done correctly, this will assist the Soldier while he/she receives the best possible treatment during the active duty years and beyond.

3. The command should put an emphasis on quality medical documentation. Providers will quickly and accurately learn how to document care in TC2 if their command appropriately emphasizes the importance of electronic EMR documentation. The Commander’s Guide to MC4 outlines the details of how the applications on MC4 should be used. If this guide is integrated into the standard operating procedures (SOPs) of the unit, it will be easier to improve medical documentation.

4. Maintain a reliable and functioning MC4 system. It is absolutely important that the system works. Just like the fighting force needs to have working weapons, we need to have functional tools that ensure that we can create useful, working reports that can be used as we treat patients.

5. It’s important that every deployed provider take advantage of previous experiences and opportunities to focus on learning AHLTA & CHCS. These previous experiences will enhance a provider’s documentation abilities during deployment.

Beginning this December, formal MC4 training for physician assistants (PAs) will be offered on a quarterly basis as part of the Basic Officer Leader’s Course at Fort Sam Houston, Texas. I’ve been working with the AMEDD Center & School (AMEDDC&S) to develop a two-day MC4 training session just for PAs because it’s important for them to become competent in using the MC4 system.

While PAs are predominantly stationed at level I facilities and use AHLTA-T, AHLTA-Mobile, and TMDS, I can’t stress enough how important it is to also be familiar with MSAT. Some PAs will be commanders of a forward surgical team (FST) or a combat support hospital (CSH), and they will be responsible for pulling together a Medical Situational Report for higher command. Knowing how to pull appropriate data from MSAT is vital in being able to prepare this report.

PAs should also strive to become subject matter experts on the MC4 hand-held device because they are responsible for training medics on how to use this mobile device. The more familiar PAs are with the device, the easier it will be to get medics acquainted as well.

Training in garrison is a great way for PAs to become comfortable with MC4. Unfortunately, not all PAs who graduate from Phase II PA School will have the opportunity to train as they fight. Sometimes, by the time a PA is commissioned and assigned to a unit, they are deploying. For this reason, it’s vital that PAs receive as much MC4 application training as possible before they graduate from Phase II PA School. To help accomplish this, we recommend that PA School Phase II coordinators request a visit from MC4’s clinical operations office (CLINOPS) to brief the PA students prior to their graduation from PA School.

There are plenty of other training opportunities and resources available for PAs. The Commander's Guide to MC4 that was released this summer is a great resource. Army PAs should check out Annex G regarding EMR documentation and Appendix G-1 for level I and II outpatient EMR standard operating procedures. PAs should also check The Gateway’s Tips & FAQs section for updates on how to best use MC4 or to download templates or forms.

PAs interested in fine-tuning their MC4 systems skill set should contact the nearest MC4 region support office or contact MC4’s CLINOPS Office for information on training opportunities.

Documenting nursing care in TC2 can be difficult since the business flow for nursing is not easily replicated in TC2. MC4 created templates in Microsoft Word to better organize nursing documentation.

Drop-down menus and free-text boxes within the templates allow nurses to document the care administered and then enter the information into the lifelong electronic medical record. MC4 produced a guide to protect and unprotect templates in order to utilize the fields and then copy the data into the progress note.

Download TC2 templates from the MC4 website to help assist with nursing documentation.

While deployed to Kuwait during 2010, I developed an instructional guide to train Service members who needed an overview on the MC4 system during reception, staging, onward movement and integration (RSO&I) training. During that time I trained users on how to access medical data from the Landstuhl Regional Medical Center in Germany via BHIE-SHARE within TMDS. Within the program there’s a Remote Data button, but there was no documentation to support its use or function.

Earlier this year I deployed to Afghanistan. In my free time, I researched how to access past medical records via BHIE-SHARE in TMDS. I found that this can be accomplished via BHIE-SHARE and the Remote Data button. I documented the steps to help medical personnel access patient encounters, medications and lab results from garrison located in the CDR. By utilizing BHIE-SHARE, medical personnel do not need to use AHLTA Warrior and they eliminate the need for a separate account requiring a username and password.

Administering anthrax vaccines is a common occurrence in theater clinics. All Soldiers need to have the series and thus need the immunization while in theater. Documenting this encounter electronically can be a little tricky since anthrax ICD-9 and CPT codes need to be updated. The software still reads SQ even though the immunization is given IM. Because the SQ cannot be changed in the V codes or CPT codes, we recommend the following tip:

• Document Anthrax Immunizations in AHLTA-T

These recommendations are easily added to your favorite procedures and diagnoses for easy access. They can also be entered into an immunization encounter template or AIM form. If you need help developing these templates or forms, contact your MC4 representative or post a comment on this blog.

During a recent deployment to Afghanistan, I was a member of the technical support team assigned to the 115th Combat Support Hospital (CSH) at Camp Dwyer. Dr. Greg Jolissaint, MC4's Clinical Operations Office medical director and chief, visited the CSH and observed the business process utilized by the medical personnel to document patient care.

We discovered that an extensive amount of inpatient data charted on paper forms had to be scanned into TMDS to complete a patient's treatment record. I knew I could recreate the Blood Transfusion Vital Signs Flow Sheet, ICW Vascular Flow Sheet and Patient IV Flow Sheet as electronic templates.

After three days of development and testing, the flow sheets were ready for use. I shared the templates with the chief nurse of the 115th CSH. He provided instructions to the staff on how to use the new tools. I provided over-the-shoulder training to verify the proper use of the templates. Now users enter notes directly into each template and easily port the data into TC2.

To download or share these templates, visit the TC2 templates page.

This week's cool technology is not about any specific hardware or software, but is about a trend.

Mobile technology for healthcare is fast replacing desktops and laptops in many settings.

As of this morning, there are 1600 iPhones and 300 iPads connected to the BIDMC network, using our administrative and clinical applications. These were all purchased by individual clinicians and staff to enhance their productivity. All we do centrally is provide the server components to access applications (web servers, citric, active synch) and enforce mobile device security polices.

Mobile devices for healthcare are becoming increasingly important at the bedside, in the home, and in hostile environments.

Here's a YouTube video illustrating how the Medical Communications for Combat Casualty Care (MC4) handheld is used to record patient encounters on the battlefield.

Given the increasing prevalence of Traumatic Brain Injury (TBI) in the military due to powerful explosive devices the Army is using handhelds to track and treat personnel with TBI.

The Army is piloting iPads/iPhones/iPods, Android devices, and Windows Smartphones for training.

There's speculation that the military may issue a smartphone to every solider.

Some IT leaders consider mobile computing to be a burden and distraction - a wild west of client devices brought in by customers demanding new services. The reality is that CIOs should develop a mobile device strategy assuming that tablets, smartphones and laptops will replace desktops in many settings. By defining security policies and providing server side applications, IT organizations can become mobile device enablers and leverage the momentum created by users who are investing their own time and resources to make them work.

Mobile devices purchased and supported by users, connected to standardized central services. That's cool!

Republished with permission from Dr. Halamka’s blog at http://geekdoctor.blogspot.com.

While I was in Iraq in 2010 to assist with the Tele-behavioral Health Initiative, I showed Lt. Col. Raphael Semidei and other providers how to organize and use shortcuts for patient documentation. They enable providers to spend more time treating patients and less time trying to locate commonly used diagnoses and procedures. These tips work best in clinics that see similar injuries and illnesses.

• Add Favorite Diagnoses in AHLTA-T
• Add Favorite Procedures in AHLTA-T
• Use the Diagnosis Icon in AHLTA-T