By Colonel Roman Bilynsky, Deputy Commander for Clinical Services, General Leonard Wood Army Community Hospital, Fort Leonard Wood, Mo.

Ensuring high quality health care is critical in garrison and remote locations on the battlefield. The Army Medical Department (AMEDD) has many organizational systems, processes, directives and regulations in place to ensure that providers are competent at all levels of care.

Competency factors include the skills and abilities essential for successful job performance of every staff member. These factors directly correlate to performance standards and are the basis for competency assessment and evaluation.

Utilization of MC4 in theater allows practitioners across the battlefield to perform local and remote peer review of medical documentation. This evaluates the provider’s cognitive thinking skills of physicians, physician assistants, nurse practitioners and medics by identifying the subjective and objective data relevant to one's clinical practice. Additionally, the information provides a basis to determine if any action is warranted. Peer review of medical records may be performed as needed, including daily, weekly, monthly or quarterly.

The goal of electronic medical records (EMRs) is to ensure a complete medical encounter. The foundation is the subjective, objective, assessment and plan (SOAP) note.

Additional encounter details include current and past medications, allergies, history of the current illness, radiology and laboratory studies, discussion of various diagnoses, and plans for follow-up or reevaluation. MC4 provides the tool required by health care providers to achieve this goal.

Supervisors may use MC4 systems to provide indirect supervision of a provider's performance through retrospective review of selected records, as well as observe the results of the care provided. Criteria used for this review relate to quality of care, quality of documentation, and the staff member's authorized scope of practice.

At Camp Bucca, Iraq, the outpatient component of MC4 (AHLTA-T) was used to complete medical record review-based provider peer assessment. The ability to sort patients by provider and immediately view notes was superb. It would be extremely labor and time intensive for treatment facilities to locate paper medical records for review. Instead, a reviewer can sit at an MC4 laptop and pull up notes from current or past providers for a quality assurance assessment.

Peer review in theater should be done at all levels of care in Iraq and Afghanistan where MC4 is available. Peer review is an integral part of providing health care and it ensures consistent quality, regardless of where the care is administered.

Peer review might be more important in theater because providers serve with different Military units—Active duty, Reserve and National Guard. Many providers have either never used a military EMR system or they have not been subject to peer review in a military health care organization.

While the review of EMRs from MC4 systems is invaluable in a deployed environment, it is not the only criteria reviewed. Two additional components reviewed during competency evaluation are psychomotor and interpersonal skills.

Psychomotor skills, or knowledge-based physical tasks, include the performance of selected patient care or support functions that require manual dexterity and an understanding of the specific order of steps that are required. This may include the procedure to start intravenous (IV) fluids, administer an intramuscular (IM) injection or perform cardiopulmonary resuscitation (CPR).

Interpersonal skills are also very important in the treatment facility. Providers need to establish a rapport with a patient, interview the individual to learn about the ailment and work with other staff members.

Technology is changing and improving the way providers train and administer health care. It is possible that providers may participate in some form of virtual reality training in the deployed environment in the near future. The proliferation of webcams and Voice over Internet Protocol (VoIP) communications, in conjunction with MC4 systems, may provide the ability to see and hear remote patient evaluations and observe a provider’s interpersonal skills via the Internet or satellite uplink.

Specific requirements for medical record documentation are addressed in AR 40-66, Medical Record Administration and Health Record Documentation. Detailed requirements for provider competency assessment and evaluation are outlined in AR 40-68, Clinical Quality Management.

EMRs are vital to the maintenance and integrity of medical records, both for coalition forces and detention health care operations. Rapid deployment of MC4 after entry operations with medical and field units will optimize the delivery of health care on the battlefield, as well as during stability and sustainment operations.

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Col. Roman Bilynsky served as the deputy commander for clinical services for Task Force 115 Medical at Camp Bucca, Iraq, from 2008 to 2009.