The Gateway

It’s my goal to keep MC4 aligned to the Army’s strategy, mission, functions, tasks and resources. Most importantly, we need to provide our medical personnel and Soldiers with an efficient EMR system. We are making progress in this direction every day.

Over the years, we’ve received feedback from customers in theater who were issued equipment that didn’t quite align with their function. Others reported that they didn’t have enough equipment in some areas of their unit. We took this feedback, made some changes and starting with fiscal year 2013 (FY13), we’ll roll out the changes.

The system architecture envisioned in the original Basis of Issue Plans (BOIPs) for MC4 was based on a projection of available communications, information flow and Soldier usage. Our real-world experience in theater gave us a chance to refine and more clearly define what the overall MC4 system should look like when deployed. We’ve made these adjustments so everything more closely reflects the combat environment.

Deploying medical units, such as forward surgical teams, will receive more laptops and fewer handhelds. The footprints for those large and medium network servers will also be reduced to just the combat support hospitals and medical logistics companies that specifically need them.

To help with this process, we collaborated with the Army Medical Department Center & School combat developer to revise the BOIPs so they are based on the function and structure of the unit as opposed to specific personnel. With FY13 equipping documents, units will start to see changes reflected on their modified table of organization and equipment (MTOE) based on these changes from the revised BOIPs.

We are continuing to evaluate these new requirements to ensure we don’t unnecessarily increase property management burdens on units. The changes currently slated for FY13 will result in about 25 percent fewer MC4 handhelds and an increase of MC4 laptops by 50 percent across the entire force. As the changes to the BOIPs are being applied, they can be found in the authorization documents provided by the U.S. Army Force Management Support Agency.

I hope you’ll agree that restructuring the system architecture will provide a more usable system as it better aligns the equipment within a unit. Feedback is always welcome. I’d be interested in hearing what other changes we could make to improve the fielding process.

Have you ever been given a toy but told not to play with it? It’s like giving someone a toy airplane but not allowing them to fly it. What’s the point? For some time, MC4 users haven’t been able to use a bidirectional interface capability due to some data encryption issues.

We’ve been impatiently waiting to fully enable the MedWeb bidirectional interface with TC2, a digital imaging solution that will assist radiologists in identifying, interpreting, reporting, storing and transporting digital medical images. The capability has been in the field for a while, but now the long wait is over and we’re telling medical units in the field, it’s time to open up MedWeb and fully enable the bidirectional capabilities that allow users to map images to a patient’s inpatient medical record.

The Defense Health Information Management System (DHIMS) released MedWeb, which was added to TC2, the inpatient application on MC4 systems. The digital imaging solution is being turned on at a number of deployed medical treatment facilities (MTFs). It is operational at Camp Dwyer, Afghanistan and Craig Joint Theater Hospital in Bagram and we’re currently working with the Salerno to completely enable the capability. Once we have permission to install TC2 at Bastion, we will enable the MedWeb capability there also.

Until now, patient demographic data and other information have been manually entered into TC2 and MedWeb. As with anything that requires manual entry, there’s the risk of human error. Invalid patient demographics could be entered or images could be filed under the wrong patient. By fully enabling MedWeb, we will help increase patient safety.

With MedWeb, a radiologist can read and interpret the image and report their findings in TC2 or MedWeb. The interface will allow TC2 and MedWeb to communicate with each other so information only has to be entered once. This eliminates duplicative data entry and reduces the chance of having data corrupted by using a more tedious and labor-intensive dual entry system.

By the way, we’re 66 percent complete in fielding EMR 2.1.3.1. Some areas are further ahead than others, but we’ve made a lot of progress in the past few weeks. MC4 EMR 2.1.4.0 is already under development to bring additional capabilities and fixes.

Teamwork is a wonderful thing. We’ve been collaborating with the Defense Health Information Management System (DHIMS) to field a new capability that enables the electronic resulting of laboratory studies into a patient’s electronic medical record. This capability has been implemented at all hospitals in theater to reduce lab personnel workloads. The tool is already utilized in garrison-based hospitals, but it’s the first time it’s been added to the mix in theater.

The Bagram Craig Joint Theater Hospital (CJTH) and 325th Combat Support Hospital in Kuwait are already using it and this month, we fielded the solution to the 10th Combat Support Hospital (CSH) at Camp Dwyer, Afghanistan. Thus far, lab personnel at Dwyer have cut their manual entry for results by 75 percent!

This is being accomplished thanks to a capability that enables the lab equipment to communicate with TMIP Composite Health Care System (CHCS) Cache (TC2). With this new capability, lab personnel can automatically transfer order information to lab equipment and receive the results from the lab equipment into the TC2 application, eliminating dual entry.

A new hardware device and software solution provides a link to lab instruments with their MC4 system. Now when lab results for a patient come back, the system recognizes which patient record the data belongs to and automatically populates the EMR with the results.

For busy hospitals, this will help increase efficiency and patient safety. No longer will a lab technician have to manually enter all the lab results for each patient into their MC4 system. The new setup should also reduce patient data errors inherent with fat-fingering information into a system.

Laboratory personnel are also able to process large quantities of specimens safely, while reducing instances of lost or misplaced specimens thanks to a bar-coding, synoptic reporting and image management system. In one month alone, CJTH was able to process 6,924 tests.

Based on feedback coming in from the field, lab personnel are very excited about this new functionality. This streamlined process within the electronic health record (EHR) system is a wonderful thing and will eventually become standard for CSHs.

Timing is everything when it comes to medicine. In Nairobi, Kenya, we’re helping the U.S. Army Medical Research Unit (USAMRU-Kenya), an infectious disease research laboratory, to reduce the turnaround time for class VIII (medical supply) orders. They’re currently creating and maintaining spreadsheets, and waiting anywhere from 30 to 60 days for medical supplies to be delivered. That’s unacceptable, especially considering we have the tools and processes to automate and streamline their medical logistics challenge.

Soon we’ll be fielding equipment to the main lab and three outlying research labs, outfitting them with MC4 laptops and configuring them with the DMLSS Customer Assistance Module (DCAM) app. Outlying labs will be submitting their orders directly to the main research facility. There, they will be reviewed and approved upon receipt and passed to USAMMCE (United States Army Medical Materiel Center Europe). Once received at USAMMCE the materials will be pulled the same day and sent to transportation for shipment. If the materials aren’t readily available at USAMMCE because they’re out of stock or don’t store the material, the request will be procured locally or passed to a prime vendor for fulfillment. Essentially, the only delay that may interfere with the arrival of supplies is customs.

In the near future, medical material orders will be managed electronically, cutting procurement lead time down to seven to 10 business days. Once the Army network is established and the facilities have a workable domain, the shipping and receiving of medical supplies in Nairobi will certainly improve. This effort marks progress toward two of the items on my sneak preview list from last year—expanding capabilities to the U.S. Army Africa Command (AFRICOM) and fielding medical logistics systems to more units in need of automation.

As we share MC4-related news, tools and information on this website to benefit the medical IM/IT community, readers regularly sound off with their thoughts and opinions. Some comments spark productive, lively discussions that have debunked rumors or led to better tools for the end users, such as the stand-alone simulation data server.

I value your feedback and opinions. I routinely re-visit our articles or blogs to read new comments, and often forward them to our partners. Your feedback is important to the growth of this program, and the EMR, MEDLOG and medical C2 mission at large. By the way, our new website debuting this spring features new comments on the homepage. I know, shameless plug, but here’s another.

Check out the AMEDD Lessons Learned forum on MilBook. The AMEDD Lessons Learned Division started the forum to collect and disseminate information, as well as facilitate change throughout the AMEDD. It’s another venue for the medical IM/IT community to interact with peers, share ideas and ask for assistance.

Earlier this year, a MEDLOG officer used the forum to ask questions about the MC4 system. The user community responded, sharing first-hand accounts, successes and challenges. Last year, MC4 helped the 452nd CSH publish its white paper on the forum. The paper presented results of their Lean Six Sigma project about the use of AHLTA-T’s inpatient functionality versus TC2.

While users address additional topics other than MC4, the AMEDD Lessons Learned forum is another resource to help you maximize the potential of the MC4 system in garrison and on the battlefield.

Last month I traveled to the Republic of Korea. There, I met with commanders, providers and logisticians using MC4 systems and support services throughout the peninsula. I learned of some great initiatives taking place to expand the use of the system, while bringing new functionality to the region.

Providers in Southwest Asia have been able to track the follow-on care of their patient's medevaced to Landstuhl Regional Medical Center in Germany via the Bidirectional Health Information Exchange-SHARE (BHIE-SHARE) functionality in TMDS. While this type of visibility is important to providers, the digital connection between tactical and garrison MTFs does not exist everywhere. Now it does in South Korea.

Maj. Kevin Peck, chief information officer for the 65th Medical Brigade, made it possible for providers at clinics throughout the Korean theater to electronically view their patients' data captured at higher levels of care on the peninsula. This connection overcomes the difference in technologies used to capture the EMR, providing access to a more complete medical picture.

I also had the opportunity to monitor MC4's annual new equipment training in Korea. It's time we adjust our training strategy in Korea like we've done in the U.S. Instead of familiarizing users in a classroom setting, we'll be moving this training into field exercises and scenario play. This way, users will receive hands-on experience with the equipment in a real-world environment.

Should the Korean theater transition to hostilities, MC4 systems are already available and in use. To quickly respond to the needs in the region, we partnered with the U.S. Army Medical Material Agency at Fort Detrick, Md., and prepositioned MC4 contingency equipment in Korea. Units throughout the Pacific Command can use the systems to support humanitarian and other contingency missions.

Lastly, to better support the Korean area of operations we changed the assignment length of MC4 support staff to the peninsula from six months to two years. The extension allows the local units and MC4 team to develop a stronger working relationship to advance the use of the EMR system.

As MC4 expands our training support to field exercises in South Korea, I'll keep you posted.

Last month's feature article focused on the 452nd CSH's Lean Six Sigma project, which evaluated the inpatient functionality of AHLTA-T throughout the facility in Afghanistan. Recently, the 421st CSH produced a case study on the use of MC4 systems in Balad, Iraq, while deployed in 2007.

A team led by 1st Lt. Nadine Alonzo, PAD officer for the 421st CSH, evaluated the quality control processes related to patient documentation via MC4. The team also studied the configuration of MC4 systems throughout the facility, as well as the reliability of patient data transferring to TMDS and JMeWS.

System issues noted in the study, such as files not transmitting to TMDS, have long been resolved with the fielding of MC4 EMR 2.1 last summer. Changes to local business processes, enforced by published fragmentary orders, made significant improvements to the use and maintenance of MC4 systems by unit personnel.

The two studies demonstrate how units have not only embraced the use of the EMR system, but strived to improve the system's use and functionality through their own ingenuity. Their efforts are commendable and benefit Service members by way of a more complete, lifelong medical history.

Since 2007, agricultural specialists from the National Guard, also known as Agribusiness Development Teams (ADTs), have been working with Afghanistan farmers to help the local population become agriculturally self-sufficient.

ADT members, who have expertise in farming, raising livestock and cultivating natural resources, are accompanied by medics who administer care in the field. These medics are now using MC4.

Today, MC4 fields systems to ADTs and trains their medics on how to digitally notate patient care via MC4. By arming these medics with the tools and skill sets at Fort Hood, Texas, prior to the team's deployment to Afghanistan, we're creating another breed of Army EMR system users on the front lines.

Traditionally, deployed units look to MC4 personnel to provide complete training and systems support on the MC4 systems used to document patient records and order class VIII supplies. As I've previously mentioned, our strategic crosshairs are focused on empowering units to train and sustain themselves.

Recently, a Special Forces medic, deployed to Iraq with Special Operations Task Force-North, shouldered this effort for his team stationed at remote locations.

MC4's deployed personnel trained the medic to use the applications to collect patient data, order and monitor class VIII supplies, as well set up and support MC4 systems. Armed with this knowledge, the medic spent approximately nine weeks installing MC4 systems at more than 10 locations.

He also trained more than 20 medics scattered throughout the operational area at remote treatment facilities to use and support the systems. The medic completed the task with little assistance from MC4 personnel.

This "train-the-trainer" effort enables Special Forces medics dispersed throughout Iraq the ability and autonomy to digitally capture patient data, better manage their class VIII supplies, as well as keep their systems operational. His efforts demonstrate what a unit can accomplish when it takes ownership of the tools provided.

Seven months ago, we began fielding the latest EMR upgrades (EMR 2.1.1.1) and hardware refreshes. Today, we’re 75 percent complete and our technical support teams are currently working the last mile to upgrade units in remote theater locations. We have equipped all level III facilities, as well as units supporting the Multinational Forces and Observers effort in Egypt and units throughout Europe and South Korea.

The feedback I’ve received from theater has been positive. In February, Maj. Daniel Bridon, assistant chief of staff, signal (G6) for Task Force 30th Medical Command presented tangible evidence of the upgrade’s impact at the AMEDD Information Management Conference in Atlanta, Ga. He reported that staff can now transfer outpatient medical records from MC4 systems to the clinical data repository in less than three minutes, as opposed to the two to 24-hour timeframe previously required.

He also stated that incidents of duplicate patient records in Afghanistan dropped from approximately 20 per month to about two per month. This is a result of scanning common access cards and electronically validating the information against a trusted or authoritative data source of military personnel and contractors. He also said the ability for users to view patient diagnoses by the types of injuries admitted and treated is a marked improvement.

I’d like to encourage your feedback on the latest system training and fielding efforts by completing the MC4 User Survey. Your input will be shared in confidence with DHIMS, the EMR software developers, and among our staff for continuous improvement to training and support services.

When I’m passionate about something, I don’t hold back. I thought I’d take this opportunity to address what seems to be a well-documented case of intestinal issues among Soldiers in deployed environments. Having been to numerous countries on countless tours with the Army, I can attest to the fact that, yes, diarrhea happens.

Why is this relevant to MC4? Since 2006, Col. William Grimes, former TF 62 commander, has been advocating the importance of proper medical C2 in the combat zone. He cites examples of how utilizing MC4 data in Iraq enabled him to quickly switch a sports medicine doctor for an internal medicine specialist to address an outbreak of diarrhea—a trend he says otherwise would have taken weeks to identify.

Most recently, the 34th "Red Bull" Infantry Division in Iraq described how they’ve been using MC4 to track and analyze disease non-battle injuries (DNBI), such as diarrhea and food borne illnesses.

Historically, issues such as these have been the leading cause of crippled units. It is widely thought that it contributed significantly to Rommel’s Afrika Korps defeat in World War II.

Currently, the Armed Forces Research Institute of Medical
Sciences (AFRIMS), in Bangkok, Thailand, uses MC4 systems to document Soldiers’ occupational health care. We look forward to continued partnership with AFRIMS, furthering the Army’s research and monitoring of DNBI outbreaks throughout Southwest Asia.

My point—outbreaks of infectious diarrhea are important to medical commands because they are often symptoms of other issues, like dirty water, unsanitary cooking facilities or poor hygiene. Identifying the sources of these symptoms can mean the difference between a ready and fit unit, and one that is quickly incapacitated to the point where they are unable to accomplish their mission objectives.

Other examples of where using MC4 helped commanders with their medical C2 responsibilities include:

• 2009: 3rd MDSC identifying and tracking possible H1N1 cases occurring throughout Kuwait
• 2008: AMEDD improves helmet gear and body armor based on wound patterns and point-of-injury medical assessments
• 2008: 79th Medical Squadron in Iraq identifies vehicular rollover injuries resulting in equipment training deficiencies
• 2008: TF 261 identifies varied levels of TBI associated with increased incidents from ground travel; treats chicken pox outbreak within local force population
• 2005: Maj. Gen. (R) Elder Granger identifies CSH blood supply error, fully-implements MC4 making 86th CSH first fully-paperless MTF in Iraq

Keep this in mind the next time your unit deploys with MC4 systems. The cumulative medical data captured among your Soldiers may help identify a larger, more important issue that lies below.

The DOD recently mandated that all Service members be inoculated to protect against the H1N1 virus. In Afghanistan, the Air Force is making use of the MC4 system to keep track of the spike in vaccinations.

Staff Sgt. Jennifer Wollersheim, an Air Force immunization technician deployed to Balad, Afghanistan, provides immunizations to approximately 100 Service members every day and charts the information in MC4. Without this documentation, it’s possible that Service members would need to take additional time away from their duty to receive the inoculation again.

This is another example of how the data captured in EMR systems helps to eliminate duplicate procedures, as well as better maintain availability levels of the fighting force. DHIMS is currently working to integrate the MC4 EMR applications with each of the services medical readiness reporting systems. We look forward to the improvement to the system.

A monthly training class held at the Air Force Theater Hospital in Balad, Iraq, exposes combat medics, with varied military occupational specialties, to the latest theater processes and procedures.

During the six-day training course, MC4’s deployed technical support teams provide a brief overview on all of the applications on MC4 systems. Medics also have the opportunity to receive additional over-the-shoulder MC4 training onsite.

While MC4 is not officially indoctrinated into the curriculum, it provides another touch-point with the system for medics to take the information back to their units.

Earlier this year, the level III facility at Kandahar Airfield, Afghanistan, transferred command from Canadian forces to the U.S. Navy. With the move came the transition from documenting patient care on paper forms to electronic medical records (EMRs).

MC4’s technical support teams (TSTs) are diligently working with the clinical staff and coalition partners, many of whom have never used MC4 before, providing over-the-shoulder instruction, implementing best practices and assuring incoming personnel don’t miss a beat and can hit the ground running.

The Afghanistan theater presents a unique challenge as coalition medical forces often work in U.S. medical treatment facilities and U.S. providers in coalition medical treatment facilities. Collaborating with sister Services and with NATO partners to do what’s best for Service members in creating a complete medical picture will remain a challenge. Perhaps this exciting effort—U.S. Navy and Canadian providers working side-by-side, using a U.S. Army EMR system—serves as a model of success.

In September, I completed a six-week trip throughout Iraq. I met with commanders, providers and systems support personnel to get their take on the use and support of MC4 in their treatment facilities.

I also spoke with providers and brigade surgeons representing more than 25 battalion aid stations or other level I facilities in Iraq. Every one of them said that their staff used MC4. Some locations didn’t have network connectivity to automatically transmit patient encounters, but they still captured the information via MC4.

This level of system use is a significant improvement over what I discovered during my trip to theater earlier this year. At that time, about 50 percent of the level I facilities used MC4 to document care. I believe the heightened use of the system is the result of local command emphasis and enforcement of the 2008 policy mandating the use of MC4.

I also gained a unique perspective on the true importance of charting at the lowest level of care. A physician assistant at a battalion aid station relayed to me that for every 100 Soldiers he treated at his level I, approximately 10 might be seen a level II facility for additional care. Of the 10 seen at a level II, about two receive follow-on care at a level III facility. Thus, most of the lasting injuries are first treated at the first level of care, reinforcing the importance of digitally and accurately charting injuries at level I.

Soldiers, such as Master Sgt. Wynton Hodges, continue to benefit from this documentation. When they return to the states and require follow-on care, as well as apply for VA medical benefits, they have the necessary data.

I’m concerned by the lack of MC4 use at the point of injury and level I care.

It is well-documented that first responders say they do not have time to chart medical care on a handheld device when treating injured Soldiers on the frontlines. Certainly, the care and safety of Service members trumps all other priorities. Throughout my travels, I also witnessed the use of MC4 at approximately 50 percent of divisional aid stations.

From what I gathered from these divisional medical assets, about 25 percent of those not using the system blame it on connectivity issues. The other 25 percent can be attributed to lack of system knowledge, ambivalence or resistance to using the system for various reasons. I want to strongly encourage users to provide more constructive ideas and feedback for improving this situation, like Sgt. Michael Ferguson’s workaround for documenting medevac pre-hospital care in last month’s issue.

I also want to emphasize the importance of capturing point-of-injury and pre-hospitalization information, beyond the creation of lifelong medical histories. Currently, Service members working for the Joint Theater Trauma System are located throughout the Iraq and Afghanistan theaters and their sole responsibility is to enter point-of-injury care thorough theater hospitalization information into the Joint Theater Trauma Registry (JTTR) system on MC4 laptops.

Senior leaders analyze this critical information to develop new equipment and life-saving techniques, including body armor and the length of time a tourniquet can be on a patient. JTTR personnel informed me that the only point-of-injury data they are generally receiving is from coalition partners.

Collecting patient data at the point of injury through the entire evacuation chain by U.S. staff is an area that needs to be addressed and improved very quickly in order to best serve the Soldiers of today and tomorrow. Again, I welcome your constructive feedback.

During the last two months, I traveled throughout theater and visited many treatment facilities. I talked with more than 50 providers and learned how they use MC4 on the battlefield.

The biggest complaint I heard from users was the perceived inability to view historical patient data with the MC4 system. Many providers on the battlefield do not realize that they already have the tools they request at their finger tips. This tells me that MC4 is not doing enough to inform users of these capabilities. I made the same conclusion in last month’s article regarding informing users of system changes and improvements.

Users can view previous patient encounters generated in theater with the Theater Data Medical Store (TMDS). The Web-based application offers worldwide visibility and accessibility to wounded warriors’ deployed medical records.

Providers also have access to AHLTA Warrior, a VPN connection that offers read-only access into the clinical data repository to view a patient’s stateside medical history. Both methods of viewing historical patient data may help prevent redundant tests and treatments.

To increase TMDS and AHLTA Warrior use and awareness, I have instructed MC4’s technical support teams (TSTs) in theater to immediately contact every provider. I have placed the onus on the TSTs to educate the deployed user community on the capabilities of these two valuable tools, provide demonstrations and help users establish accounts with both programs.

Commanders need up-to-date surveillance data to properly monitor and allocate personnel and supplies throughout their area of responsibility. Having the ability to review and filter near real-time medical data can reduce the time required to make these decisions.

The web-based application Joint Medical Workstation (JMeWS) gives commanders the ability to view encounter data, disease and non-battle injury rates and analysis, as well as symptom-based information. Patient data can be monitored for abnormalities and alerts can be set when data exceeds pre-determined ranges.

While many commanders utilize JMeWS to enhance their decision making on the battlefield, they also understand that the surveillance data is only as good as the data entered by medical personnel at medical treatments facilities (MTFs).

During previous rotations, Col. William Grimes, former commander of Task Force 61, and Lt. Col. Darlene McCurdy, former commander of TF 146, established and improved business processes so that critical information was captured uniformly in their MTFs. The improved data fed into JMeWs, providing a more accurate snapshot of events for these commands.

A similar endeavor is currently under way in Iraq by TF 44. As I mentioned last month, the command instituted a policy mandating the use of MC4 systems to capture all outpatient and inpatient data. The effort will pay dividends as commanders gain a clearer view of their medical landscape.

Commanders wanting to become better versed in JMeWS can contact their local MC4 country site lead to schedule classroom training or individual, over-the-shoulder training. Additionally, MC4 offers JMeWS computer-based training modules to help users learn at their own pace.

In the coming months, I will travel to theater to get a first-hand account of the great progress commands, such as the TF 44, are making by incorporating JMeWS into every aspect of their medical operations.

I commend Task Force 44 for recently directing all reporting medical units to document one hundred percent of care (both inpatient and outpatient) using MC4 systems. To ensure success, the command’s G6 personnel are digitally tracking compliance. The high level of support and commitment by commanders assures all Service members that they will receive the longitudinal health records and continuity of care they deserve.

Over the next several months, we will continue to highlight the efforts of Task Force 44 personnel using MC4 systems to improve the provision of healthcare in Iraq. Improved documentation of patient care improves and leads to a more complete and accurate medical picture for tactical commanders.