The Gateway

As the electronic medical record system advanced and became the standard for health care, we improved our requisition process for medical material as well. Today, we’re able to turn around requisitions a lot faster with an electronic system, but over time we’ve realized there’s still room to improve.

Presently, we use a SAP based program called Theater Enterprise-Wide Logistics Systems (TEWLS) in the Army’s Medical Material Centers and U.S. Army Medical Materiel Agency (USAMMA) and Theater Army Medical Materiel Information System (TAMMIS) in our medical logistics (MEDLOG) companies and combat support hospitals. The Defense Medical Logistics Standard Support (DMLSS) is the medical logistics system used in DOD fixed facility hospitals.

Today, there are DMLSS applications being used in the role 3 hospitals in theater. When all the MC4 systems are updated with DMLSS 3.1.2 Generation IV and the DMLSS Customer Assistance Module (DCAM) 1.4.4, all the MEDLOG units will be on the same Military Health System platform. We’ll finally be able to get rid of TAMMIS, our 1990s legacy technology using function keys and green screens. The most important benefit of this fielding is that training will become simplified. All medical logisticians deploying to the Central Command area of responsibility (CENTCOM AOR) will be on a DMLSS-based system.

The DMLSS fielding team in Kuwait consisting of Soldiers and civilians from 6th Medical Logistics Management Center, MC4 and U.S. Army Medical Materiel Center-Southwest Asia (USAMMC-SWA) are working on getting all the MEDLOG organizations and warehouses using TAMMIS on the DMLSS platform. At end state, the process to obtain medical supplies in Kuwait will be exactly the same as any other CONUS installation medical supply activity (IMSA). The hospital, clinics, and class VIII warehouse will be on the DMLSS server and external customers will use DCAM.

It’s always a challenge to implement an information system because we’re talking about getting folks who aren’t familiar with MEDLOG to use the automated system to submit orders. The DMLSS fielding team is providing initial and over the shoulder training to ensure success, and once the fielding team leaves, the MC4 program office will be there to provide sustainment training and support.

The non-medical logisticians who use DMLSS can order supplies, equipment and medical equipment repair parts, if they need to. Once you are trained on DMLSS or DCAM, you have the keys to the kingdom and can order what you need to support the health care providers, everything from Band-Aids to surgical instruments.

While it’s not like going to a website and ordering books or video games, the system has become more convenient. As logisticians we often speak in itemized stock numbers and clinicians speak a language of clinic terms. When a doctor requests drugs that the non-medical logistician may not be familiar with in terms of stock numbers, they can search for part of the word and find the correct stock number/ item identification number and place the order.

When incidents occur, planners at all levels will review DMLSS orders from automated tools like TEWLS to research our on-hand quantities for vaccines, medications, or medical-surgical supplies to satisfy requirements. Planners and providers may also use the Joint Medical Asset Repository (JMAR) to look at critical item stockage levels in hospitals and medical logistics companies across the theater. This allows for the rapid movement of class VIII from one facility to another in an emergency.

When MC4 completes the DMLSS fielding, role 3 facilities and MEDLOG companies in the CENTCOM AOR will be using the DMLSS software. All other units in the AOR that require medical supplies will be using DCAM. The era of green screens and function keys will be over.

The medical logistician supports the medical professional. Our job is to provide the best MEDLOG support for the patient. At the end of the day, we’re helping a person or patient and we take that responsibility very seriously.

Lt. Col. David Sloniker, U.S. Army Medical Materiel Center-Southwest Asia Commander, Camp Sayliyah, Qatar

When faced with developing a Health Information Systems (HIS) policy, I was overwhelmed by the idea of writing something that would directly affect the way my unit did business. My unit manages the hospital and troop medical clinics throughout Kuwait, and although many of us have used MC4 or similar systems before, many had not – and I stood in the latter category. Soon after taking over the mission in Kuwait, we realized we needed one overarching policy that provided clear guidance on maintaining and updating electronic medical records (EMR), so we wrote a HIS policy.

First, I think it’‘s important to clarify the purpose of a HIS policy, for the 325th Combat Support Hospital, the primary purpose was to ensure all patient records actually make it into the patient’‘s electronic record. There are too many stories of Soldiers coming home from deployments, looking to continue their medical care with the Veteran’‘s Administration (VA), only to discover their records are incomplete or missing altogether (especially records associated with deployments). This is unacceptable in this electronic age. Our HIS policy clearly established which medical applications would be used in Kuwait; next, it set the standards for how each of those systems would be used at the different levels of care; and finally, it documented the required system maintenance for both the users and the system technicians.

As with any other Standard Operating Procedure, you don’‘t really understand the importance until you see it in action. Our nursing staff keeps it on hand and references it regularly. As a result of the policy, our network runs smoother because it receives the proper maintenance. We recently expanded our medical information system network to include the aid stations run by other units. By including all clinics on the same network, providers at a troop medical clinic and at the hospital are able to easily access notes written by a Soldier’‘s aid station provider. These units agree to follow our HIS policy as a precondition to being granted access to our network. This overall integration of medical treatment facilities enables us to provide quality control over the medical records, and it provides secure and appropriate information sharing between providers.

My second recommendation is not to write your HIS Policy in a silo; you will need the input (and ultimately the cooperation) of all unit stakeholders (doctors, physician assistants, nurse practitioners, nurses, technicians, communications support, etc.) who will be using the system. And once the policy is ready for publication, you will need your command to champion and enforce the policy to ensure it is followed!

My third recommendation is to review other units’‘ HIS policies; when writing our unit’‘s policy, I reviewed policies previously used in the Army Central Command (ARCENT) and Iraq as a starting point. This helped to ensure we included all key points and provided a couple of different examples of how other commands operated. This review also helped us understand the importance of establishing a quality assurance (QA) program. We now have an established QA team that conducts weekly checks of the electronic health records; which helps us identify both system and user errors, further ensuring the accuracy of the patient’‘s medical record.

And finally, I strongly recommend that you establish and practice this policy prior to your deployment. It might be a pain, but it will be worth the effort when you don’‘t have to back track to change procedures after people start working.

Capt. Colleen Chianese, Systems Administrator, 325th Combat Support Hospital, Kuwait

I was deployed with the Expeditionary Medical Facility – Kuwait from February through August 2007 as an individual augmentee from National Naval Medical Center (NNMC), Bethesda, Md.

I worked as a primary care physician in the Troop Medical Clinic at Camp Arifjan. This was a far cry from my regular practice as a pediatric nephrologist at NNMC and Walter Reed Army Medical Center.

But I was well-prepared by the general military medical training I received while at these two medical centers. Plus, I had the support and teamwork of a great group of corpsmen, nurses, physician assistants and other physicians.

I used MC4 daily to document the care administered to approximately 25 patients every day and to write prescriptions. The MC4 electronic prescribing tool was excellent, customizable and a time-saver. The web-based radiology system was fast and great for wet reads by the primary care providers. In my opinion, it was better that any of system I’ve used in stateside military treatment facilities.

MC4 gave us the ability to see prior notes. It made the continuity of care seamless with a minimum of delay in implementing care plans. This was especially true for patients whom were medevaced out of theater for chronic conditions. The electronic documentation prevented "doctor-shopping," as well as pursuing medical treatment plans which had already been tried and had been unsuccessful.

Interconnectivity was a problem. Unlike AHLTA, MC4 wasn’t networked within theater. Unfortunately, there was no direct link between our clinic and the smaller referring clinics and hospitals in Iraq. Documentation from the emergency department, inpatient ward or specialty clinics located in the tent hospital just 50 yards away wasn’t accessible through MC4. Theater Medical Information Program software was available, but too cumbersome to use in a busy clinic with 20-minute appointments.

Service members were concerned and often asked if any of the medical records generated in theater would ever make it to their permanent medical record back in the States. This was especially true if their medical condition had a high chance of becoming a chronic disability. We were told that MC4 encounters were uploaded to AHLTA on a regular basis. The lack of interconnectivity within theater made us doubtful.

During my deployment, I kept my list of encounters from one day for every month I was deployed. This amounted to 115 records.

I returned to my stateside position in September 2007. At that time I checked to see if the records I entered into MC4 did indeed make it into AHLTA. Initially, none of my records were in AHLTA. Not even the ones from six prior. Thereafter, I checked every two weeks. In early November, every record appeared in AHLTA.

The next time I deploy, I can confidently tell my patients that their theater records will make it into AHLTA – albeit with a 2-8 month lag.

Lt. Cmdr. Greg Gorman, Pediatric Nephrologist, National Naval Medical Center, Bethesda, Md.