Lessons from Battlefield EMR Adoption Can Be Applied Elsewhere


The unpredictable environment of emergency departments makes them excellent candidates for use of electronic medical record (EMR) systems to reduce patient errors and to improve quality of care. But clinical personnel often resist the introduction of new and complicated IT solutions, at least in part, because the process disrupts traditional workflows and requires additional training for staffs that are already time-constrained.

Introduction of the U.S. Army’s Medical Communications for Combat Casualty Care (MC4) system, a portable EMR system, faced similar resistance when it was first deployed in 2003, but has since won praise and contributed to saving lives. MC4 program manager, Lieutenant Colonel Edward T. Clayson, says comprehensive training program undertaken by the Army mitigated resistance and holds the lessons for civilian hospitals as well.

The MC4 system uses networked handheld personal digital assistants (PDAs), rugged laptop computers, deployable servers and scanners running homegrown registration, clinical decision support, order entry, and medical record software to access and document health services. For example, when a soldier is injured downrange, a medic on the scene can look up any medication allergies or concerns as well as input any point-of-injury care via a handheld device. 

As the soldier is moved on to a base clinic or on to subsequent levels of care, clinicians can access the record to make sure no medications or procedures are unnecessarily repeated. Despite the benefit of keeping a service member’s medical record complete and accurate, many medics were reluctant to use it when first introduced during Operation Iraqi Freedom.

To date nearly 18,000 persons have been trained on the system with 250 units utilizing it in countries like Germany, Kuwait, Qatar, Afghanistan, and Iraq. With over two million records entered, the use of MC4 is providing a longitudinal medical record that can be used to avoid medical errors, improve clinical decisions and help service members receive accurate disability ratings if their injury merits a discharge from the service. But getting to this stage wasn’t a trivial exercise.

“People are resistant to technology,” says Clayson. “To combat this, we provided a litany of training and support to end users.” That litany began by creating a training program drawn from experienced Army medics. “90% of our trainers are retired medical non-commissioned officers,” says Pedro Gomez, Chief of MC4 New Equipment Training.  “They’ve already been there and done that.”

By tapping that expertise, the MC4 program was able to create a unique three-pronged curriculum: an initial course that teaches users how to interact individually with the equipment; a second program where users train collectively in a simulated battlefield environment or at a pre-deployment staging area; and finally, on-site access to embedded experts during deployments.

“In any training environment, even under the best of conditions, users are only going to pick up 60-70% of what you are trying to teach them,” Clayson says. Breaking the training into distinct focuses, helped ensure at least the most important elements of each focus were retained, he says.

The MC4 team is also getting feedback from users. “We look at that feedback very closely,” says Clayson.  “Information on the training, equipment, and the experience helps us to reassess not only training but any hardware or software issues.”

Clayson believes the MC4’s focused training approach could easily be leveraged by civilian emergency departments who are moving towards mobile, digital medical record systems. By utilizing the expertise and work practices of emergency staff, hospitals can work with systems developers to create a personalized training program that will not get in the way of the actual work.

“You can’t just drop off the equipment, give users a quick training and leave. At the first problem, they’ll drop the system,” says Clayson.  “You need to help build trust with the system.  And until you do, I hate to use the term, but you are best served by holding their hands until they get there.”

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