The Gateway

Mobile electronic devices (MEDs) are a hot topic in the Army right now. While the Mobile Handheld Common Environment Working Group is actively working to determine the requirements for the Army’s ideal MED, MC4 is staying engaged. 

Force XXI Battle Command Brigade and Below (FBCB2) is working on two separate devices; a mounted and hand-held device that will support deployed Soldiers. The Joint Battle Command – Platform (JBC-P) mounted device contains an electronic casualty report (ECR), an application that captures information similar to the Tactical Combat Casualty Care (TCCC) card. MC4 is currently assisting with the development of medical apps that mimic current AHLTA-Mobile capabilities, such as the TCCC card and the Military Acute Concussion Evaluation (MACE) form that could run on the JBC-P hand-held device.

There’s value in having the TCCC card available on a MED that would allow any Soldier the ability to handle and document care. Point-of-injury (POI) care and even buddy care for that matter are critical to an injured Soldier’s lifelong medical record. If we can provide the means for a medic or fellow Soldier to document injuries as soon as a possible, there’s a greater chance that pertinent information will make it into the Soldier’s electronic medical record (EMR).

We are actively collaborating in preparation for the Capability Integration Evaluation (CIE) 13.1, formerly known as Network Integration Evaluation (NIE) 13.1, later this year to demo a mobile medical app on the JBC-P device. MC4 is in discussions with various other offices, such as the Directorate of Combat and Doctrine Development (DCDD), Telemedicine and Advanced Technology Research Center (TATRC), the Office of the Surgeon General (OTSG), and Connecting Soldiers through Digital Applications (CSDA) to name a few, to determine what effective role MC4 can play in the way ahead. Wherever possible, we will assist our partners in successfully capturing electronic health information on various platforms and uploading them into the MC4 system.

Handhelds will also serve as great platforms to access other resources. Since releasing the Commander’s Guide to MC4 available on ATN2GO, there’s a greater interest in accessing MC4 references on an MED. We are also working to determine how the Army Marketplace could serve as a home for MC4 references. We are evaluating what we need to do in terms of establishing business processes, determining roles and responsibilities and testing those processes with approved references and medical mobile apps before making them available to customers.

There have been a number of ground-breaking efforts by the Army to meet the needs of Soldiers with mobile apps, but one effort that still escapes the Army is documentation of the care provided at point-of-injury. Let's not kid ourselves, charting care does not come before life and limb. Yet, we're tasked with ensuring what's often the Soldiers' first and most important medical footprint is documented, somehow, someway. With that in mind, let's review what's been done and where we might be headed.

There is AHLTA-Mobile, a mobile app that provides the digitized version of the DD 1380 and SF 600, loaded on an MC4 handheld. In some instances it works fine, but in others it may not. Oftentimes, I've heard that many prefer to wait until they are back at their stations to enter all their notes after they've had a chance to shower, eat and refocus after a hard day's work on the battlefield. That's understandable, but we still need to find a way to take notes in real-time.

We can help Soldiers and providers communicate hundreds of miles apart using telehealth capabilities, but we can't figure out how a medic can do the same down range, smartly yet safely?

To add fuel to the fire, medics aren't required to use the handhelds, and Soldiers providing buddy care aren't equipped with handhelds. Finding a way to give fellow Soldiers and medics a tool where they can provide care and document care immediately is really what we need to accomplish.

At MC4, we're dedicated to keeping an eye out for a solution to this frustrating problem. When we are able to provide appropriate apps on mobile electronic devices, this tool will be better than the current AHLTA-Mobile software on the MC70. Voice recognition is an option that keeps surfacing in conversations. I agree that hands-free is a future goal, but only time will tell.

There's also the possibility of adding a smart card reader to the MC70 that would allow medics the ability to record medical information from the handheld in a non-connected environment. This is an inexpensive solution for documenting care and ensuring that information is transmitted to the Soldier's EMR.

Providing a link between the tactical radios and the MC70 would allow transmission of POI and routine medical information to the next level of care. A third solution still is using an audio recorder as a non-network device which would enable audio capture of POI medical information that travels with the patient. Additional information could be added by MEDEVAC.

We're closely tracking these potential solutions and getting involved and anticipating the Army's solution for tactical radios and smart devices so we can use new technology to solve POI care documentation. Participation in NIE adds an additional layer of validation of user requirements, new concepts, training and a chance to get user feedback.

In the next couple of weeks, we'll be talking to Lt. Col. Daniel Kral, the chief technology officer at the Office of the Chief Information Officer with the Army Medical Command, about point-of-injury documentation. He's written a white paper on how to improve electronic health record documentation at all levels of care in theater. He has some interesting insight that we'll be sharing with you in an upcoming feature on The Gateway.

Each day the Army's getting closer to identifying an approved mobile electronic device for Soldiers downrange. Meanwhile, we’re continuing to test how our systems and processes will fare in enabling medics to better document care—on the move—using that device.

A few months ago, we worked with our partners at the Telemedicine and Advanced Technology Research Center (TATRC) and the Communications-Electronics Research, Development and Engineering Center (CERDEC) to successfully transmit electronic point-of-injury (POI) data from a commercial device to a central repository. The pilot successes and the medical transmission of data occurred in 60 seconds!

During an exercise at Fort Dix, N.J., medical personnel completed a digital version of the Tactical Combat Casualty Care (TCCC) card and a Military Acute Concussion Evaluation (MACE) form using the Samsung Galaxy S and the Dell Streak 5 (Android version 2.2 based operating system as reference platforms). The system worked as it was designed and the data was transmitted in less than 60 seconds from the hand-held device to AHLTA-T using a cradle connected to an MC4 laptop. Once the data was synched with AHLTA-T, it was then submitted directly to the Theater Medical Data Store (TMDS), the web-based application used to view Service members' medical treatment information recorded in the combat zone. The Motorola XOOM tablet was also used to capture the TCCC.

We set out to evaluate how well mobile hardware and accompanying apps would perform in a field environment and whether these were practical devices for medics to use when documenting patient care downrange. We used a prototype app, Patient, which was developed specifically for interfacing with the TCCC and MACE prototype apps. The two-day evaluation provided us the insights we need to make some adjustments.

The Android-based devices were pretty popular among the staff, but they did pose some difficulties for individuals who have larger fingertips. The Motorola XOOM tablet was definitely the favorite among the group because of the 10-inch touch screen, but its size and shape aren't practical for a medic on the move.

Overall, the handheld devices themselves were well received, but the tablets in particular need some improvements. We had to break out the beach umbrella to compensate for the sun glare on the touch screens. Thankfully, upcoming versions of these devices will correct this environmental concern so we don't have to arm every deployed medic with a beach umbrella, too.

These initial evaluations are encouraging and I do believe we can take this process overseas, but we're still waiting to hear from the Army as to which mobile hand-held devices/platforms will be chosen for use downrange. In the meantime, we're already seeing how the MC4 system can operate on commercial devices.

Voice recognition software is nothing new, especially to providers who use it in their everyday practice. After all, most people speak faster than they type, and many providers would agree they'd prefer to keep their hands free of pen and paper, or a computer, when working with a patient, documenting a surgical procedure, or interpreting an X-ray. One solution we've provided, since 2009, is the option of using voice recognition (VR) software with MC4 systems.

Part of the MC4 qualified software list, Dragon Naturally Speaking (DNS) provides VR capabilities to deployed providers, enabling them to more efficiently document the care of Soldiers, synchronizing the encounter with the patient's electronic medical record (EMR). Don't just take my word for it; read what health care providers who have first-hand experience with DNS and MC4 have said.

Deployed medical staff who have prior experience with DNS and are interested in using the software and the headset with their MC4 systems in theater should contact their MC4 field support representative or region support office. Providers who have DNS software already and would like to bring it to theater to use on MC4, feel free! Remember to bring your DNS profile with you, too. MC4 has purchased Plantronics DSP 500 USB Headsets for providers to use in theater should they forget to bring their own headset and microphone hardware with them downrange. For the past two years, MC4 trainers and systems administrators have been providing over-the-shoulder basic support for health care providers using DNS, but I encourage users to access a new resource available online for training and support.

In October 2010 a new website, AMEDD Clinical Systems Exchange (ACSE), pronounced "ACE," launched to replace the former MAPS portal. The site, accessible at https://www.us.army.mil/suite/page/617087, has been enhanced to support all information systems users and key members of the Army informatics community.

This summer, the Army will conduct the 2011 Integrated Network Baseline Evaluation (INBE). This six-week test at Fort Bliss, Texas, and White Sands Missile Range, N.M., will evaluate developmental tactical networks, as well as network and systems integration for future brigade combat team (BCT) modernization efforts.

MC4 was selected to participate in order to determine the requirements to operate current and emerging medical IM/IT systems in a deployed environment. The 2nd BCT, 1st Armored Division, will utilize MC4 in conjunction with Army Battle Command Systems and new MC4 enhancements, such as telemedicine capabilities at the battalion aid station and brigade medical company levels.

MC4's involvement is a direct result of engagement by Army Col. Brian Lien, Forces Command (FORSCOM) surgeon, and Army Lt. Col. Dan Kral, medical communications capabilities manager at the Army Medical Department (AMEDD) Center and School, Directorate of Combat and Doctrine Development, on behalf of MC4. This is an excellent opportunity to ensure that AMEDD requirements are represented and tested in support of the Army's brigade modernization efforts. During the coming months, we'll train the 2nd BCT, 1st Armored Division, to use and support MC4 systems with new capabilities for the event, as well as in their garrison aid stations.

Other systems to be used throughout the evaluation include the Joint Tactical Radio Program (JTRS), Ground Mobile Radio (GMR) and Force XXI Battle Command Brigade and Below (FBCB2). By testing system capabilities in the BCT structure, the multi-week scenario will help to create a baseline of network requirements, as well as uncover any gaps and vulnerabilities in the current network. This information will be invaluable as we deploy new technology to the field.

MC4 continuously evaluates the latest technologies to help deployed providers, commanders and logisticians record, track and share medical data. Case in point, check out MC4’s support of the Tele-consultation Project in Iraq, the Hands-free EMR Pilot and the Tele-behavioral Health Initiative.

Now we’ve turned our attention to mobile devices and their feasibility versus the thick clients MC4 deploys. We’re testing tactical EMR apps, specifically AHLTA-T and TC2, on the iPad, iPod Touch, iPhone, HTC EVO and Samsung Epic. Early results show that both apps can technically operate on the Apple iOS and the Droid OS using the devices’ stretch, tap and swipe functionality.

While the initial tests show promise, there is still a long way to go before we consider fielding these technologies. They must clear a myriad of hurdles, including data-at-rest encryption requirements, clearance for wireless use in theater, and a bevy of DOD and local signal certifications.

Testing remains a big part of what we do at MC4. Some of the hardware and apps we evaluate pass with flying colors; in turn we field them as soon as possible. Others never make it out of the lab. I’ll continue to keep you posted on this endeavor and welcome your thoughts on this topic, so post away!

Users now have a new web-based tool for medical surveillance. The Medical Situational Awareness in the Theater (MSAT) portal combines JMeWS with enhanced mapping and reporting capabilities. The new functionality gives commanders more resources to perform command and control activities, thus improving the decision-making process on the battlefield.

Commanders can geographically view outbreaks and potential health threats. Armed with this information, they can reallocate resources to best protect the fighting force. They can also generate a large number of reports using the new Business Objects functionality based upon the medical data captured by units using MC4 systems in the field. This is a significant upgrade from the 12 canned reports built into the JMeWS-only website.

Registered JMeWS users can use the same login credentials to access the MSAT portal. The old JMeWS website will remain active until the end of the year. Users can access training videos and the MSAT user manual on AKO, as well as contact the medical surveillance helpdesk for more information.

Point-of-injury medical data recorded by first responders is a critical piece of a Service member's medical history. The data provides key information for clinicians throughout the continuum of care, informs research for the development of material solutions designed to improve Soldier protection and improve trauma care, as well as validates future claims for VA medical benefits. While critically important, initial battlefield care is rarely recorded.

First responders and medics have their hands full treating wounded warriors before they're medevaced to the nearest treatment facility. At best, medics use a grease pencil to write notes on tape attached to the injured Soldier or, in some cases, directly on the Soldier. Obviously, this information never makes it into the Soldier's medical history.

To eliminate this documentation vacuum, MC4 is working with military stakeholders to test hands-free devices to capture point-of-injury care. At the forefront of this effort are digital voice recorders. The devices must overcome the challenge of minimizing battlefield noises while preserving the human voice. Also, the unstructured recording needs to be converted into a structured, mineable patient note and be compatible with DOD EMR systems, including MC4.

After testing the hands-free voice recorders in simulated battlefield conditions, Army medics plan to field-test prototypes to determine the feasibility of use by medics and first responders in real-world situations. A poster, developed for the Advanced Technology Applications for Combat Casualty Care Conference in Tampa, Fla., describes this hands-free EMR effort.

I'll continue to provide updates in future blogs of our involvement of the research process with this endeavor, as well as our continued efforts with the Telemedicine and Advanced Technology Research Center (TATRC) and Defense Advanced Research Projects Agency (DARPA).

In April, flight medics in Afghanistan initiated the use of a new tool to electronically chart the care given during medical evacuations (medevacs), as well as at the point of injury. MC4 technical support personnel worked with OTSG, as well as with medics and flight surgeons assigned to C Company, 2-3rd Aviation Regiment at Bagram Airfield, to develop an Alternative Input Method (AIM) form for in-transit care that works with the outpatient application, AHLTA-T.

The template allows for the capture of data from multiple sources used during medevacs into one streamlined template, including any data recorded by medics at the point of injury and forms completed en route by flight medics. The development of the new AIM form builds upon a template created last year by a flight medic to better document the care administered while in the air.

The new AIM form also augments the efforts under way by trauma nurse coordinators (TNCs), who collect trauma data to populate the Joint Theater Trauma Registry (JTTR). Previously, TNCs gathered in-transit data only from paper forms. As a result, staff had to scan and manually transfer data to the trauma database.

This AIM form should assist TNCs to populate JTTR faster and more accurately with data from AHLTA-T and the Theater Medical Data Store (TMDS). Flight medics will continue to use paper run sheets during treatment, but now have a digital form available to better transfer the information into a Service members’ longitudinal health record.

The new medevac template not only bolsters Service members’ electronic medical records with information previously not documented, but also provides researchers additional information to assist with the development of future life-saving technologies for the battlefield.

I have frequently mentioned that MC4 continuously evaluates the latest technology to help deliver the best products and services to help you, the user, to successfully achieve your EMR and medical logistics missions. In May, MC4 began fielding one of these new products—the Dell Latitude E6400 ATG laptop—as part of our technical refresh in support of the next generation of software.

The Area Support Group-Qatar at Camp As Sayliyah was the first unit to receive the new ruggedized Dell laptops with faster processor speeds, longer battery life and lighter weight compared to the current MC4 laptops used on the battlefield and in garrison clinics.

The hardware fielding coincides with MC4 Basis of Issue Plans (BOIPs), established by the Army as the objective baseline for the distribution of equipment by type of unit.

Questions regarding when, or if, your unit will receive new laptops, as well as specifics about the hardware, can be directed to your local MC4 region office. Technical documents regarding the new hardware are available for download in the hardware section of our Web site.

In June, MC4 received approval to field the latest release of DHIMS’ tactical software on MC4 systems, EMR version 2.1.1.1—also well-known as Block Two, Release One (B2R1). The authorization to operate (ATO) spans three years.

This summer, MC4 will deploy multiple technical support teams consisting of operations leadership, systems administrators, trainers and DHIMS subject matter experts to ensure the transition from EMR 1.5 to EMR 2.1.1.1 goes smoothly and is well-coordinated.

The upgrade brings improved network security with the migration to Windows XP and Server 2003. The long-anticipated additions of Alternate Input Method (AIMS) forms and Military Acute Concussion Evaluation (MACE) forms will improve user efficiency and better facilitate the capture and evaluation of traumatic brain injury data. Additionally, Block Two includes significant upgrades to the outpatient application (AHLTA-T), patches to the inpatient system (TC2) and new ad hoc reporting features.

We will provide additional details on this upgrade, as well keep you updated on the fielding progress, in both the newsletter and on the MC4 Web site.

UpToDate is an evidence-based, peer-reviewed, preferred medical resource designed to provide medical professionals access to current clinical information. With UpToDate, medical personnel get specific, detailed answers to clinical questions in their office, exam room or bedside. It covers more than 7,700 topics in 14 medical specialties and includes more than 80,000 pages of text, graphics, links to Medline abstracts, more than 260,000 references and a drug database.

Medical personnel have been requesting permission to install this medical reference tool on their MC4 laptops. After extensive testing, UpToDate is now listed on MC4’s qualified software list, permitting users to install UpToDate on their MC4 systems.

The software is not automatically loaded onto MC4 systems, so users need to request the most current version of UpToDate, by contacting Ann Potter, Library Program Office, U.S. Army Medical Command.