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New Technology Tested at CERDEC C4ISR CGA E15 at JBMDL

August 10, 2015 posted by Leann Micheals

Leann Micheals, MC4's clinical applications consultant since 2004, is a nurse practitioner. She travels to theater and garrison training events to help medical personnel use MC4 systems.

MC4 successfully demonstrated new capabilities for the electronic capture and transport of medical data at an important testing event that took place in July 2015. The U.S. Army Communications-Electronics Research, Development and Engineering Center (CERDEC) Command, Control, Communications, Computers, Intelligence, Surveillance, Reconnaissance (C4ISR) Ground Activity (CGA) Event 2015 (E15) exercise demonstrates and evaluates emerging capabilities with Army health stakeholders. The event was hosted at Joint Base McGuire-Dix-Lakehurst (JBMDL), New Jersey by CERDEC.

The MC4 team worked closely with the Army medical community (physicians, PAs and medics) from a variety of backgrounds (JBMDL, Fort Detrick and Fort Rutgers) with a variety of skills (ground troops and medevac). We tested two new capabilities: Health Assessment Lite Operations (HALO), which is an easily configurable, fit-for-purpose medical-documentation application intended for use at Role 1 facilities in deployed environments that are lacking in network communications, and remote desktop services (RDS), a capability provided by Microsoft Windows Servers that enables remote access to applications. MC4 uses this capability to allow remote access to an AHLTA-T application hosted at a data center.

Over a four-week period, we set up, trained end users and implemented a test strategy that validated the lightweight HALO application and the RDS system as a collector of medical documentation. During the test week, we provided battle injury (BI) and disease/non-battle injury (DNBI) scenarios that replicated medical care provided in deployed environments. The medics and providers documented into the HALO application and these encounters were imported into AHLTA-T. HALO testing was also done at Fort Gordon connecting to the RDS at JBMDL and was successfully used with minimal training. Each completed encounter was transferred into the AHLTA-T RDS system. Feedback, issues and evaluations were gathered from the test players over the course of the test. Overall, HALO received high marks in ease of use from the test players and had 100 percent data transfer to the RDS system.

MC4 was also instrumental in providing the much needed infrastructure to serve as the access point to the authoritative electronic health record (EHR). By hosting the AHLTA-T server and collaborating with third-party vendors, MC4 was able to participate in captured medical data and show data flow and ingestion to the lifelong medical record. Types of data captures and transferred was physiologic monitoring, point of injury (POI) documentation, and medevac documentation in the helicopter.

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MC4 APM's Update on PKI-E Certificates

April 28, 2014 posted by Lt. Col. Keith Harley

Lt. Col. Keith Harley is the MC4 assistant product manager and project lead integrator for the MC4 electronic medical record (EMR) software version and brings extensive Army acquisition knowledge to the program.

As MC4 assistant product manager and lead integrator for system upgrades, I’m facilitating the planning, budgeting and execution for the MC4 upgrade, EMR, which is currently being fielded around the world.

An important part of this upgrade is enhanced system security. Per Army requirements, units must obtain Public Key Infrastructure - Equipment (PKI-E) certificates for each MC4 system. These certificates are important because PKI-E will enhance security and assure users they are communicating with trustworthy systems.

We’ve received questions from units experiencing difficulty in obtaining the PKI-E certificates. To help answer these questions, a tip has been posted on The Gateway with updated details about how to get support.

Here are a few important things to remember:

  1. Report all PKI-E issues to Fort Huachuca so they can review and update their current processes regarding the certificates.
  2. Submit an MC4 Help Desk ticket so MC4 can track and prioritize issues.
  3. Use the appropriate address or naming convention for MC4 systems that will connect to the ICANN (network).
  4. Contact the local S6/G6 or work with the NEC when connecting to the ICANN.
  5. If you are a trusted agent, delegated agent or system administrator, refer to the PKI-E certificate tip, which provides a link to specific instructions for requesting the certificates.

On behalf of MC4, I greatly appreciate everything the units are doing to ensure the EMR system upgrade is a success. Please continue to check out The Gateway for updates about how the fielding is going and the ways that MC4 supports all EMR users, Soldiers and veterans whose care is electronically documented in the field.

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Top 2013 Content on The Gateway

December 17, 2013 posted by Rachel Collins

Rachel Collins is the manager of MC4's interactive website, The Gateway, and social media pages. She is the primary point-of-contact for story submissions.

Throughout 2013, information about the next iteration of the MC4 system, EMR, was the most popular among our readers. In preparation for receiving EMR it is still critical for customers to obtain PKI-E certificates to ensure the EMR system continues to work properly. EMR was also the topic that generated the most robust conversation online. We heard from users around the world who had questions about how to prepare for EMR We appreciate hearing from you and where we can improve our communication efforts.

Additionally, DCAM, AHLTA Warrior and TMDS were the most popular apps readers were interested in learning more about. Some significant changes occurred this year with DCAM and we noticed an increase in traffic to the tips and FAQs for these applications.

We will take into consideration what information readers frequented and found most useful as we prepare our content for 2014.

Top News Stories:

Top 10 Blogs:

Top 5 Tips and FAQs:

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Improving Customer Access to Information

October 10, 2013 posted by Rachel Collins

Rachel Collins is the manager of MC4's interactive website, The Gateway, and social media pages. She is the primary point-of-contact for story submissions.

If you are one of the subscribers to The Gateway Monthly, you may have noticed some changes on MC4’s website.

We’ve refreshed our About page to provide clarity about the program’s mission and vision. We’ve also recently updated the Policies and Guidelines pertaining to website and social media use in an effort to be more transparent. While MC4 is a medical IT program, we don’t publish or accept personally identifiable information or protected health information via transactions on The Gateway or in social media. Only unclassified, non-sensitive information is shared online to protect everyone’s privacy.

Making information accessible and easy to locate is at the forefront of the MC4 strategic communications office. We recently reorganized the PM blogs and news stories to help you locate relevant information on a particular topic a little faster. Now readers can filter blogs and stories by topic instead of by month or year only.

In recent months, we have reviewed tips and FAQs, updating them as necessary and removing others. We will continue to update these step-by-step instructions in the near future.

If, for whatever reason, you need assistance from MC4, you will now receive a confirmation email for online transactions. This way you have a copy of exactly what information you shared with MC4 for reference.

If you haven’t already, check out our Twitter, Flickr and YouTube pages and let us know what you think. We’re making more of an effort to provide MC4 updates and news on these platforms. Our photos on Flickr are very popular and we’re glad you’re enjoying them. Thank you for the more than 250,000 Flickr photo views since 2007! Hopefully you’ll have a chance to check out our improved photos page on The Gateway that now includes filters so you can search Flickr without leaving our website.

Please feel free to tell us how we can better serve you! What information would you like to see on The Gateway? What features can we add or changes can we make to enhance your experience on the site?

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MC4 Participation in NetMod 13

September 25, 2013 posted by Mark Gregory

Mark Gregory has been the technical chief for MC4 since 2005. He has made over a dozen trips to the Middle East to include Iraq and Afghanistan to experience the system from the user’s perspective and to gather requirements to enhance the systems performance.

MC4 successfully demonstrated new capabilities for the electronic capture and transport of medical data at an important testing event that took place in May and July this year: The Command, Control, Communications, Computers, Intelligence, Surveillance, Reconnaissance (C4ISR) and Network Modernization (NetMod) 2013 Event. Held during two separate sessions to assess emerging capabilities with Army health stakeholders, the event was hosted by Fort Dix, N.J., and was sponsored by the U.S. Army Communications-Electronics Research, Development and Engineering Center (CERDEC).

Danforth App

The primary objective of the E13 May exercise was to assess CERDEC's Multi-Access Cellular Extension Mesh network with the Army’s organic network capabilities to determine if the network is a feasible extension to Soldiers at point-of-injury (POI). To support this assessment, MC4 introduced new capabilities for the electronic capture/transport of medical data from POI to the next echelon of care. We provided battle injury scenarios and subject matter expertise to help integrate the new capabilities with the MC4 electronic medical record (EMR) system and provided MC4 Android-based App training and CERDEC-developed Telemedic App training (digital stethoscope) for two Fort Dix medics.

Simulated POI data was successfully transported across a tactical network to an MC4 laptop at the battalion aide station (BAS). Also, MC4 software apps were installed on the Samsung Note II Android end-user devices (EUDs) that are currently being tested by the PEO Soldier/Nett Warrior (NW) program. The MC4 medical apps included MC4Core, which is the main app that houses the user and patient data and provides access to settings and import/export capabilities. Also installed were the Tactical Combat Casualty Care (TC3) card and the Military Acute Concussion Evaluation (MACE) exam apps; all apps may eventually be available for download by registered users of CERDEC’s Tactical Marketplace (TacMark).

Patient demographics were imported from a Common Access Card (CAC) using a BAI sled CAC reader connected via Bluetooth, or imported wirelessly, from AHLTA-Theater (AHLTA-T) on an MC4 laptop. POI encounters were exported wirelessly from the EUD to an MC4 laptop at the BAS. The medics made several valuable recommendations about the MC4 capabilities that were implemented and carried forward for the E13 summer exercise for further evaluation.

The primary objective of the E13 July exercise was to demonstrate new MC4 capabilities for the electronic capture and transport of POI medical data (using the NW EUD) along with MEDEVAC data on its way to a treatment facility. Two additional ground medics, a flight medic and a physician's assistant assisted alongside the Fort Dix medics in the evaluation of these capabilities.

These exercises were designed to mimic actual theater experiences, with a platoon of ground Soldiers, improvised explosive devices (IEDs) and battle injury scenarios.

MC4 collaborated with CERDEC to introduce the near field communication (NFC) smartcard, which served as an electronic information carrier (EIC), potentially filling a current capability gap at POI. The MC4 apps communicated with the NFC smartcard to retrieve patient demographics and store encounters for transport with the patients to their next level of treatment. The NFC smartcard data was then uploaded to AHLTA-T on the MC4 laptop via the NFC smartcard utility.

The event participants transferred the medical encounter data to the Theater Medical Data Store (TMDS) Training database from an MC4 laptop running the Theater Medical Information Program (TMIP).

Overall, I’m pleased to say the capabilities worked as designed and were well-received by the participants. Refined AMEDD requirements, along with user community feedback, will help determine if the MC4 apps and other emerging capabilities are feasible for POI applications in future deployments of the MC4 system. There is currently no plan to deploy these capabilities as there is no infrastructure in place to support them.

I’d like to thank folks who helped out with this test: Ground medics Sgt. Kelly Franco, Spc. Franklin Barbee, Sgt. Andrew Danforth and Sgt. John Meachum; flight medic Staff Sgt. Jeff Molles and physician assistant Maj. Joseph Eddins.

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TMDS and MSAT Receive New Updates

February 19, 2013 posted by Alvin Vaughn

Alvin Vaughn, deputy chief of MC4's Clinical Operations Office, developed his expertise using MC4 for medical surveillance while deployed to Iraq in 2007 with Task Force 146.

In February 2013 the Theater Medical Data Store (TMDS) and Medical Situational Awareness in Theater (MSAT) systems received a major release update. MSAT was updated to the release while TMDS was updated to the release. From the end-user’s perspective, this round of updates should primarily be viewed as modifications to field names and titles that will set the stage for the upcoming ICD-10 CM/PCS integration. However, end users should also know that there are a few notable enhancements in user functionality and features, particularly in TMDS.

Prominent Allergy Field:

Within the TMDS Patient Summary page, which is the primary interface used to search for patients, an allergy field depicting documented patient allergies is now prominent at the top of the patient record. Allergy information, that was previously documented using the DOD field health information system, can now be referenced more easily using the TMDS electronic patient record.

Discharge Summaries:

Inpatient discharge summaries are now available within the Ancillary Service and Progress Notes subsection of the Patient Summary page. This summarizing document of inpatient care and patient instructions can now be referenced without extensive searching through several patient notes and consult reports.

My Patient List:

The most notable TMDS upgrade is a new feature that enables providers to add and remove patients from a My Patient List report within the provider’s TMDS user account – this new functionality will allow providers an easier method to track their patients in TMDS. According to the Defense Health Information Management System (DHIMS), this list automatically updates the patient's location and diagnosis derived from the most current outpatient, inpatient, or TRAC2ES encounter.

TMDS provides a very intuitive push pin icon on each patient record within the Patient Summary page. The provider may click on this icon to add the patient to the My Patient List; providers can then navigate to the My Patient List report under the Reports tab to view and remove patients from this list.

For more information regarding TMDS or MSAT, and for additional guidance regarding registering for an account in either of these systems, refer to Annex J, “Medical Surveillance” of the Commander’s Guide to MC4.

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Filtering Data in MSAT for Historical Trends, Retrospective Analyses

January 31, 2013 posted by Alvin Vaughn

Alvin Vaughn, deputy chief of MC4's Clinical Operations Office, developed his expertise using MC4 for medical surveillance while deployed to Iraq in 2007 with Task Force 146.

Often the need to understand past trends in diseases and injuries arise as deployed leaders address the theater medical support requirements. One such recent example involved the need for Task Force MED-Afghanistan to query the number of Service members who experienced concussion injuries over the course of twelve months so that they could decide the best location to stage medical treatment equipment and personnel.

Every week an inquiry similar to this example appears on the desk of deployed commanders and staff throughout the world. This type of request, however, is often difficult to respond to even when the request only requires a few months of past population health history. The latest major update to the Medical Situational Awareness in Theater system (MSAT) now provides tools to facilitate this type of retrospective analysis.

All deployed U.S. military facilities are required to document patient care for Service members using one of the approved deployable Department of Defense electronic medical record applications, AHLTA-T or TC2. Check out Annex 1 in the Commander’s Guide to MC4 for more information on this subject.

Once documented, the patient record is then transmitted to the Theater Medical Data Store (TMDS) and to the DoD Central Data Repository (CDR) where it becomes a part of the respective Service member’s CONUS-based health care record.

This health information is organized into data fields and “objects” within the classified MSAT system. It’s here within the MSAT that aggregated population health information is accessible by the appropriate force health protection, clinical operations, and environmental science personnel; this capability allows staff officers and leaders to focus their data-mining efforts, and it allows them to conduct near real-time health surveillance of their area of operations.

Prior to the current release of version, when a medical treatment unit departed the theater of operations its UIC was marked inactive within the MSAT. Although all patient treatment records associated with the UIC remained in the MSAT system, they were no longer accessible to user level system queries.

Today, inactive units are now accessible via the filter interface within the JMeWS tab of the MSAT. This gives commanders the ability to aggregate medical information from all TMIP-J enabled medical assets, past and present – including past encounter data provides a more comprehensive picture of the past medical trends and current threats facing deployed units.

For more information on how to conduct queries for health data of inactive/departed medical units within MSAT, read this tip: Setting up Custom Filters to view Historical Trending in MSAT.

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The Value of Repositories for Deployed Health Records

December 18, 2012 posted by Dr. James G. Jolissaint

Dr. James Gregory Jolissaint, MC4’s medical director and chief of clinical operations, served as the command surgeon for the U.S. Forces Korea, United Nations Command, and the Eighth U.S. Army.

Electronic medical records are usually stored in repositories – these repositories accumulate the electronic medical records that contribute to a lifelong, longitudinal medical record for Service members (Army, Navy, Air Force, and Marines).

The MC4 system includes various applications that allow deployed medical personnel to document the health care delivered to deployed Soldiers. AHLTA-Mobile and AHLTA-T are used to document out-patient care; and TC2 is used to document inpatient care, record laboratory results, record radiology interpretations, and track pharmacy items issued to Service members. When these applications are used properly, then the health care documentation that is recorded using AHLTA-Mobile, AHLTA-T, and TC2 is transmitted to and stored in a web-based application called the Theater Medical Data Store (TMDS).

TMDS is the Department of Defense (DOD) repository for deployed medical records that provides theater medical providers, garrison health care providers (in CONUS, Europe, and the Pacific Regions), and Veterans Affairs health care providers with access to Service members’ deployed health care documentation. Similarly, institutional AHLTA serves as the DOD repository for Service members’ outpatient medical records. AHLTA stores medical records that are generated in both the garrison and the deployed environments. Since the medical information that was generated using AHLTA-Mobile and AHLTA-T is transmitted to TMDS, it is also transmitted to AHLTA.

The forwarding of deployed patient care documentation is invaluable because it gives providers, who will manage a Soldier’s follow up care, visibility of their deployed medical history.

If a medical center provider is trying to understand which resuscitative interventions occurred in Iraq or Afghanistan when a wounded warrior was injured in combat, they can easily access that information using TMDS. If that same wounded warrior is a Reservist or National Guard Service member who will need follow-up care in a Veterans Affairs clinic after they demobilize, then the Veterans Affairs provider can access TMDS to see what care was rendered while that Soldier was deployed.

If that same Veterans Affairs provider needs to review the recommendations made by providers at Walter Reed National Military Medical Center or San Antonio Military Medical Center after the wounded warrior was evacuated home, they can access AHLTA to review those recommendations. And finally, if a wounded warrior can no longer serve on active duty, and they are required to be processed by the military medical disability system, and/or the Veterans Affairs disability rating systems, then both DOD and VA disability providers have access to all of the Service member’s records that are stored in TMDS and AHLTA so that a comprehensive and fair evaluation and rating can be assessed for each wounded warrior.

The key to “medical repository success” for the Army is the MC4 system. When Army medics, nurses, physicians, pharmacists, laboratory technicians and radiology technicians are all doing their job properly, and these health care personnel are recording their evaluations, results, and recommendations in AHLTA-Mobile, AHLTA-T, and/or TC2, then each Service member treated by these Army medical personnel will have the peace of mind knowing that their health care is documented electronically, and that it is stored in a repository that is accessible by every DOD and VA provider who may ever care for them.

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MC4 MEDLOG Customers Upgraded to 21st Century

November 20, 2012 posted by Rocky Henemyer

Rocky Henemyer, MC4's medical logistics (MEDLOG) guru since 2008, has more than 20 years of MEDLOG experience in the Army. He supports MC4 training and fielding efforts for DCAM and DMLSS.

Over the past year, MC4, the 6th Medical Logistics Management Center (MLMC), the Office of the Surgeon General/Medical Command and the Joint Medical Logistics Functional Development Center (JMLFDC) have been working together to complete the fielding of upgrades to the Defense Medical Logistics Standard Support (DMLSS) in theater.

The 582nd Medical Logistics Company supports over 250 customers in Afghanistan and was the last unit to successfully transition to DMLSS 3.1.2 Prime Vendor Generation IV app, a joint medical logistics system. The unit is using DMLSS to order, receive, store and issue supplies, stocking more than 800 lines of class VII supplies. They are also using the system to provide and document medical maintenance work orders.

Initially, the transition was challenging for units in dealing with network connectivity issues, learning a new system and adapting to new business processes.

In total, five units have transitioned to DMLSS or have been upgraded to 3.1.2. This has allowed the Army to sunset a legacy medical logistics system that has served Soldiers since Desert Storm, Theater Army Medical Materiel Information System (TAMMIS).

With this final conversion, DMLSS has become the system used by all Service Level 3 hospitals and by all Army and Marine Corps medical logistics companies in the area of operation that submit medical supply requests to U.S. Army Medical Materiel Center – Southwest Asia (USAMMC-SWA), the Theater Lead Agent for Medical Material (TLAMM).

This transition places all the medical logistics automated information systems within the same development and management family ensuring that the systems (DCAM, DMLSS and TEWLS) can interoperate seamlessly and any issues can be entered into the MHS Help Desk and addressed by a single overarching organization, Defense Health Services Systems (DHSS).

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MC4 uses Smartphone to Transfer POI Data at NetMod E-12

September 27, 2012 posted by Mark Gregory

Mark Gregory has been the technical chief for MC4 since 2005. He has made over a dozen trips to the Middle East to include Iraq and Afghanistan to experience the system from the user’s perspective and to gather requirements to enhance the systems performance.

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

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

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

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

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Tools to Analyze Medical Surveillance Data

June 14, 2012 posted by Dr. Ken Meade

Dr. Ken Meade, MC4's chief of clinical operations in Europe and the Far East, was the deputy commander for clinical services for the 212th Combat Support Hospital, Miesau, Germany, and medical director for the Landstuhl Army Medical Clinics in Belgium, Italy, Kosovo, Kuwait and Qatar.

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

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

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

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

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

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

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Rabies Encounters Documented with Ease

June 7, 2012 posted by Leann Micheals

Leann Micheals, MC4's clinical applications consultant since 2004, is a nurse practitioner. She travels to theater and garrison training events to help medical personnel use MC4 systems.

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

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

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

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

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4 Things Nurses Need to Know about MC4

May 8, 2012 posted by Leann Micheals

Leann Micheals, MC4's clinical applications consultant since 2004, is a nurse practitioner. She travels to theater and garrison training events to help medical personnel use MC4 systems.

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

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

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

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

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

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

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

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Training Exercise uses Notional and Real Patients

March 8, 2012 posted by Dr. Ken Meade

Dr. Ken Meade, MC4's chief of clinical operations in Europe and the Far East, was the deputy commander for clinical services for the 212th Combat Support Hospital, Miesau, Germany, and medical director for the Landstuhl Army Medical Clinics in Belgium, Italy, Kosovo, Kuwait and Qatar.

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

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

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

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

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

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

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

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

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

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

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

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

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5 Influential Factors for Inpatient EMRs

September 15, 2011 posted by Dr. Ken Meade

Dr. Ken Meade, MC4's chief of clinical operations in Europe and the Far East, was the deputy commander for clinical services for the 212th Combat Support Hospital, Miesau, Germany, and medical director for the Landstuhl Army Medical Clinics in Belgium, Italy, Kosovo, Kuwait and Qatar.

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

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

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

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

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

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

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What Physician Assistants Need to Know About MC4

September 14, 2011 posted by Ray Sterling

Ray Sterling, chief of MC4’s Operational Medicine Branch, Clinical Operations Office, is a subject matter expert on documenting medical data at level 1 and 2 care.

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

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

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

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

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

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

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Nursing Documentation Aided with Templates

August 20, 2011 posted by Leann Micheals

Leann Micheals, MC4's clinical applications consultant since 2004, is a nurse practitioner. She travels to theater and garrison training events to help medical personnel use MC4 systems.

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

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

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

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Access Garrison Records Using Fewer Accounts

June 21, 2011 posted by Aubray Hudson

Aubray Hudson, MC4 trainer since 2007, is a retired medical NCO with more than 30 years of training experience. He served as the lead MC4 trainer in Kuwait for three years and supported missions throughout SWA.

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

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

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O. Bradshaw

The fewer the passwords the better, thanks for the update!

June 22, 2011

Tricky Anthrax Codes

June 14, 2011 posted by Leann Micheals

Leann Micheals, MC4's clinical applications consultant since 2004, is a nurse practitioner. She travels to theater and garrison training events to help medical personnel use MC4 systems.

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

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

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Showing 1 comment

there are a lot of "needs" in this write up

June 16, 2011

3 Templates for Faster Data Entry into TC2

June 6, 2011 posted by Dave Buesing

David Buesing, an MC4 trainer since 2008, is a retired noncommissioned officer with extensive experience with Army medical IT systems. He has deployed to Kuwait, Iraq and Afghanistan in support of the MC4 mission.

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

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

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

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

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These templates are handy, thank you!

June 8, 2011

Cool Technology of the Week

April 15, 2011 posted by Dr. John D. Halamka

Dr. John Halamka is the chief information officer for Boston's Beth Israel Deaconess Medical Center and dean for technology at Harvard Medical School.

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

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

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

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

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

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

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

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

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

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

Republished with permission from Dr. Halamka’s blog at

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June 2, 2011

3 Shortcuts to Charting Notes in AHLTA-T

April 5, 2011 posted by Leann Micheals

Leann Micheals, MC4's clinical applications consultant since 2004, is a nurse practitioner. She travels to theater and garrison training events to help medical personnel use MC4 systems.

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

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