The Gateway

Over the past three months, MC4 subject matter experts have shared their insights and best practices to help MC4 users navigate the Commander's Guide to MC4. In case you've missed the postings, there were 12 different subjects discussed; here's a quick recap:

• Annex A: Establishing a Unit Health Information System Policy
• Annex C: A Toolkit for Presenting MC4 to Your Unit
• Annex D: MC4 Training: Plotting the Course
• Annex E: Simplifying the MC4 Equipment Requisition Process
• Annex F: MC4 News that Can be Used
• Annex G-1: Add the Guide to Your Packing List
• Annex G-2: Documenting Inpatient Care at Level II MTFs
• Annex G-3: Managing Inpatient Diagnoses at Level III
• Annex G-4: Why Enclosing Encounters in Theater is so Important
• Annex H, K, L: Set Up and Maintenance Processes Outlined
• Annex I: Restocking Medical Supplies with Ease
• Annex J: Simplifying Medical Surveillance with MSAT

If you have not yet had the opportunity, then I encourage you to read through all of the blogs and leave comments. We'd love to hear your recommendations on how future iterations of the Commander's Guide can be enhanced.

The heart and soul of Medical Situational Awareness in the Theater (MSAT) is medical surveillance. Annex J, Appendix J-1 of the Commander's Guide to MC4 explains how MSAT can assist in generating data slides that will depict the medical situation of a unit. Along with the Commander's Guide there is a medical surveillance reference guide that explains how to make reports using Business Objects.

MSAT has a large number of report options. My personal recommendation is to begin by focusing only on three to four reports that most closely pertain to a unit’s surveillance requirement. Here are a few hints on how to effectively use this function downrange:

• Create one or two filters. First, make one basic filter that includes your subordinate units. Also consider making another filter that includes the units that are physically located in your area of operation. To learn more about creating filters in MSAT, read Creating Joint Medical Workstation Filters in MSAT .

• Use Patient Workload reports. MSAT can help give visibility to the number of medical visits from reporting units. It is infantry simple to create an activity report of medical encounters. It is also simple to download the Patient Encounter Module (PEM) count information into Microsoft Excel and then create a table or graph that can be used for briefing slides, etc.

• Conduct disease and injury surveillance. Discovering disease outbreaks is the most important feature available in MSAT. There are many canned reports within MSAT that a headquarter staff officer, clinician or nursing leader can use for basic battlefield medical surveillance. This includes several styles of disease non-battle injury (DNBI) reports, pre-defined symptom group reports and existing custom surveillance reports (CSRs). Users can subscribe to these CSRs as these will meet the needs of most MSAT users.

• Create customized surveillance reports. An MSAT user can make custom ad hoc medical surveillance reports using the International Classification of Disease, 9th Revision (ICD-9) codes. Users can also create reports based on the MEDCIN terms in AHLTA-T encounters.

• Use Business Objects reports. Business Objects reports are powerful!! MSAT Business Object reports are a commercial-grade reporting tool that enables users to generate many standard report templates that are present in JMeWS. The program allows users to search in detail for a large percentage of data elements from any encounter. MSAT Business Objects reports provide a robust reporting tool that will search the entire Theater Medical Data Store (TMDS) and MSAT database. Business Objects is a little tricky to learn, but once a user gets the hang of it, it can make life as a non-commissioned officer or staff officer easier.

MSAT has a lot of screens, tabs and choices. The easiest approach for quickly using this web-based program is to focus on the three to four reports that produce the basic data that are necessary for the job. The next step is to export the information into Excel where pivot tables and graphs can be presented during the command briefs. Once a user is comfortable with the basics, then trial and error represents a great methodology for either modifying existing ad hoc reports, or creating new ones from scratch.

I strongly recommend that MSAT users dig deeper and obtain more information on how to use these tools. Check out The Gateway for more Tips and FAQs on MSAT and Business Objects.

Quality health care begins with class VIII, or medical supplies. The United States deploys world class medical personnel to care for our wounded warriors, but unless they have the right item at the right place and at the right time, then we are limiting their ability to provide the best care possible. The Commander's Guide to MC4 provides leaders and MC4 end users the guidance they need to ensure medical supplies are available when needed.

At level 1 and 2, the responsibility for medical resupply is often an additional duty assigned to a unit medic. Annex I, Appendix I-1, Deployed Medical Logistics Standard Operating Procedure of the Commander’s Guide is designed to take the guesswork out of class VIII, allowing the medic more time to focus on patient care and less time managing the supply room.

This appendix provides guidance on how to set up and use the DMLSS Customer Assistance Module (DCAM) to place orders. It discusses the best business practices for downloading the supplier's catalog, placing orders, adding items to the local catalog and most importantly— how to determine what materials need to be ordered and check the status of a current order.

Answers to frequently asked questions are also addressed in this section, like:

• Will my order be delayed because it had to be passed to a higher level supplier?
• Was all or part of my order cancelled because my request exceeded the supplier’s maximum release quantity or the item is no longer available?

Processing receipts and maintaining a local catalog in order to make the supply process easier in the long run should not be overlooked, so we made sure to include this as well.

In future blogs I will discuss in more detail how to identify and order the correct item using Medical Product Data Bank and DCAM and discuss the importance of status and how to interpret and use it to your advantage. In the meantime, I encourage you to post any questions you may have about DCAM, DMLSS or medical logistics in general that can be answered on The Gateway.

Novice and experienced MC4 users alike can benefit from the wealth of information available online. The Gateway is the place for MC4 users to interact with other end users and learn best practices for managing electronic medical records (EMRs), streamlining medical supply management or enhancing situational awareness. Annex F of the Commander's Guide to MC4 highlights the features and resources that are available on this public website.

The Tips and FAQs section is a must read for MC4 end users. As updates to hardware and applications are fielded, features change and processes that were once followed are modified. Each month, MC4 subject matter experts provide detailed step-by-step instructions and answers to frequently asked questions to assist medical staff in navigating these changes. Templates and forms are also available to providers, nurses and medics to assist with patient care documentation.

Additionally, MC4 gurus regularly blog about how MC4 is being used and offer suggestions on overcoming challenges. MC4 users around the world also share their stories in field blogs, and are always welcome to share their story.

If the answer to a question isn't addressed in a tip, FAQ or blog, consider reaching out to the MC4 team. The Gateway is the main portal for requesting MC4 materials, training and assistance, or contact the appropriate region support office directly for more information.

Find a story that others might be interested in reading? There are several features on the website that make it easy to share MC4 information with others. Consider sharing an article on Facebook, Twitter or Google+ using the Share function that appears in the Resources box with every story, blog, tip and FAQ. Or, simply share a story by clicking on the Email Page icon that appears on every page.

We'd love to hear from our readers! Please consider leaving a comment or giving a thumbs-up for a blog or tip that has been helpful by using the comment and recommend functions. To complete an MC4 user survey or contact us directly via email to share your impressions of the website, click on the Feedback button that appears on the left side of every page.

I encourage every MC4 user to sign up for email updates from The Gateway homepage. Subscribers will receive The Gateway Monthly with a summary of the latest stories, Tips and FAQs and other new content. Download the Commander's Guide for more information on the features and resources available online or browse The Gateway to read the latest MC4 news.

One question that is frequently asked in deployed medical units is “What is MC4, and what does it do?” Even with the numerous training resources made available to medical units prior to their deployment, and those that can be found on The Gateway, this question can still be heard in theater — so we’ve carved out a section in the Commander's Guide, specifically Annex C, to answer these questions in a presentation style format.

Unit leaders, both officers and non-commissioned officers (NCOs), can utilize pre-approved MC4 presentations to inform their users and command leadership about the MC4 program and the role MC4 computer systems play in accomplishing their electronic health record (EHR), MEDLOG, and medical surveillance missions. The annex also provides links to briefs that graphically demonstrate how the MC4 system works within the medical logistics community as well as best practices for clinical workflows gleaned from years of supporting Operations Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn. I highly recommend all unit leaders use these presentations to introduce unit personnel to the latest and greatest information from MC4.

Once you have passed the MC4 overview stage of informing your unit about MC4, and you are ready to provide unit personnel more in-depth information, unit case studies, and user-specific tools and resources, then I recommend that you subscribe to The Gateway. Next week, our public affairs staff will blog about these particular resources online and how to make use of them for your operational needs.

Where’s our MC4 equipment? Have you ever found yourself asking this question? If so, the answer may be as simple as thumbing through the Commander’s Guide to MC4. Annex E addresses a myriad of equipping, fielding and sustainment topics. Below are just two likely scenarios that demonstrate how the Commander’s Guide can transform a stressful situation into a more manageable position.

Imagine that a company commander has just received deployment orders. As part of their pre-deployment checklist, they notice a significant shortage of MC4 systems based on the current modified table of organization and equipment (MTOE) document. To ensure that the unit is properly equipped and trained prior to deployment, commanders should follow the step-by-step instructions on how to request the MC4 system outlined in Annex E.

Here’s another scenario. Imagine you’re the logistic staff officer (S4) with a deployed unit and the commander is pounding on your door asking for additional MC4 systems above the MTOE authorizations in order to support split-based mission requirements. Again, there is no need to worry as Annex E provides all the trouble-free steps you need to follow to request additional MC4 systems.

The two scenarios mentioned above only provide a requisition point of view. However, Annex E of the Commander’s Guide provides other series of knowledge appendices. In fact there are four general topic areas:

• Customer Request for Equipment (Appendix E-1)
• MC4 Equipment Fielding Process (Appendix E-2)
• Equipment Refresh Process (Appendix E-3)
• MC4 Equipment Repair and Disposal (Appendix E-4)

All of these appendices provide essential information to the commander and their supporting staff to ensure the unit is properly equipped, trained and prepared for their support mission.

I encourage all commanders to peruse these appendices prior to deployment or redeployment to ensure there is a basic understanding on how to request and maintain a high operational readiness of the MC4 system.

Medical treatment facility (MTF) commanders and clinical leaders closely monitor the number and types of patients evaluated, treated and evacuated from their facilities. This data is crucial in managing manpower and other resources which impact the mission, as well as the quality of patient care, and the completeness and accuracy of the electronic medical record (EMR). Annex G, Appendix G-3 of the Commander’s Guide to MC4 provides resources to help medical units proactively prevent problems that arise when a patient diagnosis is improperly documented or not accounted for at all.

The primary diagnosis for every patient encounter, as indicated by the ICD-9 code, must be appropriately assigned by the provider at the time of admission, or at least prior to discharge, transfer or evacuation. The ICD-9 code should reflect the patient’s condition or illness. The diagnosis then populates two databases: the Theater Medical Data Store (TMDS) and Medical Situational Awareness in Theater (MSAT). If a specific ICD-9 code is not entered, the databases will populate with “No Diagnosis.”

An incorrect or absent diagnosis code can rob the patient, the health care team, and the Veteran’s Administration of valuable information needed to provide care to the Soldier, plan for future treatment and rehabilitation, or submit disability claims.

Additionally, the absence of a specific diagnosis in TMDS and MSAT can deprive the command of the ability to accurately analyze illness and injury patterns, identify emerging health threats, and project future resource needs.

For example, the sudden appearance of multiple patient encounters for Salmonella Gastritis, which would appear in TMDS and MSAT as ICD-9 003.3, could alert the medical command to an outbreak of food-borne illness among Soldiers who ate at the same dining facility. The opportunity for intervention could be lost if the encounters were recorded as “no diagnosis.”

Similarly, a Soldier who is injured by a vehicle-borne improvised explosive device will likely need extensive treatment, rehabilitation and long-term care from the VA, in addition to screening for related injuries such as TBI and PTSD. The impact of the injuries on the Soldier, and the draw on resources to the command could be overlooked if the patient encounter is recorded as “no diagnosis.”

An outline of the sequence of events that support proper recording of patient diagnoses can be found in Annex G, Appendix G-3, of the Commander’s Guide. I encourage all deployable MTF commanders and clinical leaders to read this section of the guide to learn more about electronically admitting and dispositioning patients.

While operating as the MC4 Southwest Asia (SWA) operations manager, I’ve personally experienced a significant uptick in the use of MC4 to capture electronic medical records (EMRs), which until now was an uncommon practice in a theater of war. This has not been easy, especially during the early years in Iraq and Afghanistan. With each new command and unit rotation, MC4 support personnel have noticed a consistent trend: customers routinely faced the same issues, asked the same questions and generally lacked a clear understanding of their role in system usage and support.

We realized that a tool was needed to help capture lessons learned and solidify best business practices—hence the Commander's Guide to MC4 was born. From its infancy, I’ve personally seen this effort turn from a single page policy memo to what it is today—a comprehensive set of best practices and system usage materials.

In my experience one of the most critical phases and least discussed within the medical community is the implementation and sustainment of the MC4 system. After all, health care providers cannot use the system if it's not setup and maintained properly. The Commanders Guide is designed to provide a systematic approach to implementation, sustainment and redeployment procedures for unit level system administrators (ULSAs) to leverage and for commander's to enforce. For personnel technically supporting MC4 systems in Southwest Asia, they should administer and train by the following best practices found in Annex H, Annex K and Annex L.

Annex H provides guidelines for establishing the support roles and responsibilities between MC4 personnel and ULAs. It is critical for unit commanders and ULAs to read and understand the Tiered Support Structure by which MC4 support personnel reference while operating in SWA. The EMR Service Level Agreement (SLA) and Preventive Maintenance Check and Services (PMCS) document is accompanied by several must-have checklists, which cover in detail all the required tasks necessary to complete the implementation and PMCS process within a level I, III and III facility.

Annex K outlines the critical tasks to initializing the MC4 system. Several checklists help outline the processes for medical facilities to perform quality control checks, which ensure each step of the implementation process has been completed. Performing these checks will safeguard the system from potential business process pitfalls due to gaps in operations, like missing equipment or provider's not having the proper TMDS privileges.

For redeploying units, Annex L will provide a comprehensive list of the key steps to completing a proper transfer of authority (TOA) between an incoming and outgoing unit. Several configuration changes to the MC4 system need to occur during TOA. The Level I and II MC4 System RIP/TOA SOP and Level III MC4 System RIP/TOA SOP explain the particular requirements and steps on how to execute the changes.

Download the Commander’s Guide to learn more about effectively managing medical facilities in Southwest Asia.

For many years AHLTA-T has enabled providers to successfully document outpatient care. The app works well at all medical treatment facilities (MTFs) for documenting emergency room care and outpatient clinic care. At level 3/role 3 MTFs, such as combat support hospitals (CSHs), TC2 is used to provide deployed users with both ancillary services, including order entry and result capabilities, and inpatient documentation functionalities. A documentation gap has been observed, however, at level II/role II MTFs in Afghanistan, causing confusion among medical staff as to how to document patient care.

The conundrum for providers and nurses is determining how patient care should be documented if a patient is admitted to a holding cot or bed, and nursing/clinical care is provided at the level II MTF for up to 72 hours. Block 2 of AHLTA-T that was fielded in September of 2009 provided an inpatient solution for this problem. While not a perfect solution, it allows functional users to document patient care in a fashion that is more consistent with an inpatient setting, without needing the full functionality that is inherent to the TC2 application.

A Lean Six Sigma project was conducted to demonstrate that AHLTA-T is an ideal way to document care at level II/role II MTFs. A step-by-step process was developed by MC4 Trainer James Mitchell in conjunction with the commander and functional users of the 452nd CSH at Forward Operating Base Salerno. I traveled to Salerno to provide some clinical perspective on the solution they developed.

This collaboration resulted in the Level II+ Inpatient Electronic Medical Record (EMR) Standing Operating Procedures (SOP) that comprises Annex G, Appendix G-2 of the Commander’s Guide to MC4. I encourage anyone assigned to a level II MTF to review this appendix, and share it liberally with anyone who can possibly gain benefit from it as a reference. The process of using AHLTA-T for inpatient care is always evolving and I would appreciate hearing from anyone who has a new or better way of using this application.

A Service member’s electronic medical record (EMR) begins with the providers and medics at level I and level II medical treatment facilities (MTFs) who are responsible for documenting patient care. Every level I battalion aid station (BAS) and every level II medical company will probably have a different business process (BP) for performing this mission, but the most important thing to remember is that electronic patient care documentation is not done to benefit clinical providers or medics—it is done to create an enduring health care record for ill and wounded Soldiers who are treated on and off the battlefield. Annex G, Appendix G-1 of the Commander's Guide to MC4 provides end users with the information they need to properly accomplish the very important job of managing EMR documentation.

Although each MTF will have its own BP for setting up sick call flow like performing patient registration, obtaining and documenting vital signs, and establishing patient treatment areas, Appendix G-1 provides medical personnel with a streamlined process for accomplishing other tasks. This section of the Commander’s Guide contains the best practices for registering patients in AHLTA-T and/or TC2 with a CAC scanner, updating patient demographics, correcting duplicate patient records, and transferring a SOAP (Subjective, Objective, Assessment and Plan) note from a medic to a designated provider, to name a few. Medical personnel serving at level I or level II MTFs can download AHLTA-T sick call templates to assist with documenting common sick call complaints.

Caring for sick and wounded Soldiers starts at level I and level II MTFs. Therefore the Commander’s Guide should always be part of a BAS’s packing list for CONUS and OCONUS missions since it can guide medical personnel in the development of their clinical workflow. “Training as you fight” cannot be overstated and since training begins with the development of a training plan, I recommend that non-commissioned officers and officer leaders use the Commander’s Guide to develop their training plans for conducting level I and level II health care in garrison and in theater.

MC4 offers diverse training opportunities to ensure the U.S. Army’s health care personnel remain the premier professional force in documenting care in a Service member’s lifelong electronic medical record (EMR). To optimize every valuable training opportunity, MC4 supports a three-phased training approach, which is detailed in Annex D of the Commander's Guide to MC4.

The first phase, Individual and Small Unit Training, provides new equipment training (NET) that familiarizes systems administrators and functional users with MC4 system capabilities through role-based instruction. Following NET, unit leaders conduct focused section training to improve each Soldier’s MC4 skills using the MC4 sustainment training available on AKO.

MC4 also offers refresher “warrior approach” training for units that received NET all too long ago. For professional filler system (PROFIS) personnel, who typically rotate independently of the unit, MC4 offers training at the continental United States (CONUS) Replacement Center (CRC). Soldiers who are eager to become even more proficient can use the self-study training aids (computer-based training, or CBTs, and training manuals) also available on AKO.

The second phase, Command and Staff Training, includes command-level exercises, such as command post exercises (CPXs) and staff exercises (STAFFEXs), which enable commanders and their staff to work through scenarios that demonstrate how MC4 applications support command oversight of medical assets and battlefield medical surveillance. These events provide hands-on experience in processing and analyzing information to gain situational awareness and make informed decisions using MC4 systems.

The final phase, Collective Training, offers a great opportunity for Soldiers and leaders to practice their MC4 skills in response to real-world situations. Typically conducted just prior to deployment, mission rehearsal exercises (MRXs), culminating training events (CTEs) and certification exercises (CERTEXs) help build the cohesion necessary for command, medical, and administrative personnel to work as a team. They also help validate the unit’s ability to complete its mission command and health care delivery roles while demonstrating proficiency on the MC4 system.

Ideally, MC4 training begins during the Reset or Train/Ready Phase of the unit’s Army Force Generation (ARFORGEN) cycle. Units desiring MC4 training or assistance in creating and executing a comprehensive MC4 training plan should reference Annex D, which outlines how to best leverage MC4 region support offices.

When providers leave theater without signing AHLTA-T encounters they’re essentially creating a pause or gap in medical information. Unsigned AHLTA-T encounters simply remain on MC4 systems and when the next rotation of medical staff arrives they’re left with unfinished business. This means data hasn’t flowed from the local MC4 system to TMDS and then to the Clinical Data Repository (CDR), where it becomes part of Soldiers’ lifelong electronic medical records, nor has it been transmitted to MSAT where commanders view roll-up data and make decisions based on trends. The burden then falls to the incoming medical staff.

Understandably, incoming providers are uncomfortable with closing open encounters that they have no knowledge, nor do they care to bear the burden of liability for medical information they had no part in documenting. Yet, the encounters must be closed to ensure continuity of care and to eliminate the gap in the patient’s medical history, which can impact future medical benefits and disability evaluations.

After working closely with the Office of the Surgeon General and local commands, MC4 has developed a work-around for closing open encounters. This process was formalized and is detailed in the Administrative EMR Closure Standard Operating Procedure (SOP) documented in Annex G, Appendix G-4 of the Commander's Guide to MC4.

The Commander’s Guide to MC4 contains important business practices that empower operational medical commanders with the knowledge and tools that will help them to successfully perform their assigned missions using an electronic medical record system. Developing a unit level health information system (HIS) policy is one of the key predecessors for establishing a tactical automated medical information system.

Annex A of the Commander’s Guide outlines valuable resources that will assist commanders as they draft a unit HIS policy. This section contains the references that should form the basis for such a document, including the 2008 Assistant Secretary of Defense for Health Affairs Memorandum titled Policy on the Worldwide Use of the Theater Medical Information Program-Joint and the 2008 Central Command Area of Responsibility Health Information System Use Policy. These policies provide unit leaders with a basic outline and key elements that should be included in a unit level HIS policy.

Commanders are advised to include directives for the proper use and support of MC4 systems within their HIS policy. This system usage section should identify which applications clinicians should use based on their assigned mission. For instance, AHLTA-T should be used for outpatient care, TMIP Composite Health Care System (CHCS) Caché (TC2) for inpatient care, and DMLSS Customer Assistance Module (DCAM) for class VIII supply ordering and tracking.

The system usage section of a unit HIS Policy is also a great place for commanders to describe their expectations regarding which unit clinical and clinical support personnel should have access to and be competent in using the Theater Medical Data Store (TMDS), the theater repository for closed AHLTA-T and TC2 medical records. Commanders should also ensure this usage section outlines which headquarters staff personnel should have access to the Medical Situational Awareness in Theater (MSAT) application to track unit medical readiness and conduct battlefield medical surveillance.

To help commanders have a better sense of how a unit HIS policy should be structured, examples are provided in Annex A. An inclusive and appropriately implemented unit HIS policy will serve as the cornerstone for establishing a unit’s tactical automated medical information system, and it will serve as the focal point for unit leaders to establish MC4-supported individual and collective training. The information available in Annex A of the Commander’s Guide is just one example of how the guide is a very useful tool for unit leaders.

Check out Annex A today and download a searchable version of the Commander’s Guide from AKO or download the ATN2GO app and access the Guide at anytime, from anywhere, via an iPhone, iPod Touch, iPad or Android device. We welcome your feedback.

We're launching a series of blogs that will help MC4 users take advantage of the resourceful, yet voluminous, Commander's Guide to MC4. This comprehensive reference contains numerous recommendations and business practices for medical leaders at all levels of military health care, and it enables commanders and their headquarter staffs to successfully perform their assigned medical missions while using MC4-supported systems. To help medical personnel navigate the updated Commander's Guide, MC4 subject matter experts (SMEs) will be blogging about how to utilize the information provided in each section of this comprehensive resource.

I am very excited about the 2011 version of the Commander's Guide. When I commanded Task Force Med Falcon V in Kosovo from 2001 to 2002, and then the 18th Medical Command and 121st Combat Support Hospital (CSH) in Korea from 2006 to 2008, we used CHCS II, or legacy AHLTA, to document patient care. In fact, we were never required to establish and use a deployed, automated medical information system.

Today, we expect units to execute this task regardless if Soldiers know anything about the MC4 system. I honestly can't fathom how I could prepare my medical unit to be competent in setting up the MC4 system and using the medical apps without studying the Commander's Guide to develop a pre-deployment training plan.

Each section of the guide provides need-to-know information to ensure a continuous and systematic approach to support the creation and transmission of lifelong electronic medical records (EMRs). The information in the guide is applicable to all levels of medical staff. Some sections of the Commander's Guide will help medical headquarters staff officers perform near-real-time monitoring of diseases and injuries, and manage their medical battlefield operating systems, while other sections will help medical personnel efficiently order and track medical supplies.

The guide will also help clinical personnel create comprehensive, lifelong, accessible outpatient and inpatient EMRs. Additionally, unit communications personnel can use the guide to obtain the details they need to establish and maintain an electronic network to support outpatient clinics, hospitalization, medical logistics, medical maintenance, and the ancillary support medical services necessary for ensuring high quality health care.

The Commander's Guide to MC4 is free of charge and easily accessible. Download a searchable version from AKO or download the ATN2GO app and access the guide at anytime from anywhere via an iPhone, iPod Touch, iPad or Android device.

Throughout the blog series, SMEs will help medical units maximize the tools and resources that are available by providing overviews of the processes and checklists that are contained in the guide, as well as offer guidance on how to adopt the content into everyday practice. By implementing the Commander's Guide, units will certainly be successful when performing critical medical missions in garrison, during field training exercises and downrange.

Be sure to visit the MC4 website frequently to learn more about the Commander's Guide or subscribe to The Gateway by signing up for email updates. I welcome any comments and suggestions as we work to improve the guide over time.