Ready for Patients
Soldiers stage medical equipment and beds at the CenturyLink Event Center in Seattle, during the last week in March 2020, as part of the Army’s response to the coronavirus. MC4 systems were part of the deployment to Seattle. Note two MC4 laptop systems on a table in the left bottom foreground. (Photo Credit: Canadian Broadcast Corp.) VIEW ORIGINAL

The Army’s Health Assessment Lite Operations (HALO) application was deployed to medical forces during the recent COVID-19 pandemic. HALO is a digitized version of the Standard Form 600 used by DOD medical personnel to document patient treatment for wounded, injured or sick patients. The software was developed by the Medical Communications for Combat Casualty Care (MC4) product management office, the Army acquisition program with primary responsibility for providing Army operational health IT capabilities for deployed medical forces. The current version of HALO is designed primarily for documenting outpatient treatment at Role 1 battalion aid stations and Role 2 military treatment facilities (MTFs).

After HALO was successfully launched on Nov. 15 at the U.S.-NATO hospital in Kabul, Afghanistan, an updated version was ready for a planned Army rollout to deployed units worldwide. However, no one could have predicted using the application in response to the COVID-19 crisis a few months later.

Check the Records
MC4 field support representative Craig McDowell assists setting up the Application Virtual Hosting Environment (AVHE) that allowed the 121st Field Hospital Isolation Center to remotely access hospital records during the COVID-19 response on March 24. (Photo Credit: U.S. Army photo by MC4) VIEW ORIGINAL

In early March, the MC4 program started its COVID-19 efforts by providing equipment, training and technical support to dozens of Army medical units worldwide. At the Carl R. Darnall Army Medical Center at Fort Hood, Texas, training and support was provided to medical staff of the 581st Medical Company Area Support to pre-screening COVID-19 patients at the hospital. The program deployed field service representatives to the CenturyLink Field Event Center in Seattle and to the Javits Center in Manhattan, New York. Army medical providers providing COVID-19 support in New York have documented over 600 patient encounters using HALO through April 15, with a number of additional sites planned.

In February 2020, in order to learn more about these recent developments and the next steps for HALO, I sat down with MC4 Product Director Tracy Ellis and MC4 Technical Management Division Chief Jay Patnaude, who oversees HALO’s development.

Paul Clark: Can you tell me about electronic health records (EHRs) and why they are important to operational medical forces?

Ellis: Documenting health care for deployed service members is a critical part in continuity of care, patient safety and ensuring that proper medical care is provided when they leave the service.

Electronic documentation has many advantages over paper records. When there is network connectivity, EHRs can be transmitted in seconds and are then viewable by medical personnel with network access. Electronic records also aren’t as easily lost when compared to paper records. Information in the electronic record can be data mined to support medical research and to provide leadership with near real-time information for use in decision-making. Finally, a comprehensive, lifelong EHR provides medical information to ensure that the service member gets the right care at the right time—whether in service or when their care transitions to the [U.S. Department of Veterans Affairs] or civilian sector upon separation.

Clark: What operational challenges does this present?

Ellis: In operational settings, the No. 1 issue is that network communications are not always available or can become degraded—the term used by the military is disconnected, intermittent or low bandwidth. That is why there’s a requirement that deployed operational health IT systems have the ability to continue to document health care in a degraded network environment. While the legacy AHLTA-T [Armed Forces Health Longitudinal Technology Application – Theater] EHR software provides this capability, it depends on a server to store the patient encounter. If the connection between the provider’s computer (i.e., the client) and the server is lost, it requires reconfiguring the provider’s computer as a client-server to operate in this environment. This is normally handled by deployed personnel with systems administration expertise—who may or may not even be co-located with you. HALO was designed specifically to allow electronic documentation to continue and then forward the patient encounters once communications are restored, with no additional steps required.

Up and Running
Soldiers of the 627th Hospital Center use MC4 system laptops during the COVID-19 response at the CenturyLink Convention Center in Seattle on April 7. (Photo Credit: KOMO ABC 4 News) VIEW ORIGINAL

Clark: If HALO is designed for situations with low bandwidth, or when network communications go out, can you explain how that works; perhaps provide a scenario?

Ellis: Much like your internet and cable in your home, the time it takes to install your cable connection and issues such as weather, technical issues, user error and low bandwidth can all affect your service. Take all of these factors, then add in potential for disruption of the communications network by our adversary, and you can see examples that could create a disconnected network environment that could last from a few minutes to a few days or longer.

Clark: You began HALO deployment in Afghanistan back in November. How did that go?

Ellis: The November deployment to Afghanistan exceeded our expectations. Forty-one hospital staff members (20 U.S., 21 NATO) received two hours of HALO training prior to the software’s go-live date. Most were able to document patient care electronically using HALO without further assistance from the HALO training team.

Clark: Can providers communicate with each other through the application? Can you explain a bit about its capabilities?

Ellis: HALO allows a patient encounter to be open and accessible to other providers who may have a requirement to also provide documentation or co-sign. An example might be the physician who is documenting his or her notes while a medic is continuing to monitor and document vital signs. HALO provides an alert anytime more than one individual is documenting in the open patient encounter. The legacy AHLTA-T software does not allow more than one individual to access the open encounter.

During an exercise in 2019 at Fort Detrick, Md., PFC Byron Pascua uses the MC4 scanner to document blood using MC4 systems. (Photo Credit: U.S. Army photo by Paul Clark, MC4) VIEW ORIGINAL

Clark: So how does HALO save the Army money?

Ellis: Because HALO is simple and easy to use, the savings are realized by reducing the number of hours spent on trainers and training. Since HALO is so easy to support, it will allow Army IT personnel to spend more of their time supporting other applications. And the small size of the HALO application compared to the legacy application has the potential to reduce hardware costs.

Clark: As an Army acquisition program, what are you doing to support the Army’s leadership priorities and support multidomain operations? In other words, how does MC4 remain relevant?

Ellis: The deployment and further development of HALO supports the Army’s priorities—people, readiness, modernization and reform. Improving the ability to document care for Soldiers supports health care delivery, which is all about taking care of people. Advances in operational health information systems, such as HALO, provide real-time data in support of medical mission command. This helps maintain readiness through the ability to rapidly shift resources in support of the fight. While the focus of this interview is on HALO and electronic health care documentation, MC4 deploys operational health IT solutions that support all 10 health care functions, including medical logistics, preventive medicine and medical mission command. In each of these areas, we see the value of lightweight, scalable, cost-effective solutions that incorporate commercial-off-the-shelf hardware and software solutions that can be rapidly modified and deployed in support of multidomain operations ranging from early-entry operations through large-scale combat operations. And the rapid, incremental delivery of capability is consistent with modernization and reform efforts by leveraging the power of operational health information systems to help maintain the Army’s competitive edge.

Clark: Isn’t the DOD already moving out with modernizing its EHR? Why not just use that solution in the deployed environment rather than develop an application like HALO?

Ellis: Military Health System Genesis is military medicine’s modernized, enterprise-level EHR that has also been adopted by the VA. But it is not ready to field to operational forces. Until it is ready, being satisfied with the legacy operational health care applications is not the answer, especially when there are opportunities to rapidly deliver enhancements and additional capability in the interim to our deployed Soldiers. HALO is an example—a cost-effective improvement over the legacy EHR that will serve as a bridging solution until the modernized solution is ready to deploy to operational forces.

Clark: How many encounters can be pushed at the same time? Where does the data go?

Patnaude: The transfer of the medical encounters is seamless. Regardless if the medic has communications or not, HALO is designed to constantly monitor for a connection and when it has one, it automatically bursts encounters to the HALO HUB [server] it’s connected with. The HALO HUB will then transmit encounters to Theater Medical Data Store and the Clinical Data Repository, the Soldier’s lifelong EHR. HALO has the ability to send data in any format to any medical system that it’s allowed to communicate with.

Development of the HALO software started in 2017 on the lightweight, fit-for-purpose solution that provides medics and providers an easy-to-use, simple interface for capturing patient encounter health data. (Photo Credit: U.S. Army photo by Paul Clark, MC4) VIEW ORIGINAL

Clark: Is HALO compatible with AHLTA-T and other applications?

Patnaude: HALO is a lightweight software at only 90 megabytes in size. It’s designed to work with AHLTA-T and can communicate with any other application. It’s also what we call hardware agnostic [meaning the software is compatible or interoperable with a variety of standard devices, laptops, smartphones, desktop computers and tablets].

Clark: Is the training intensive?

Patnaude: No. HALO was specifically designed to be easy to use. There are online training materials for HALO; however, most medics pick up how to use HALO in five to ten minutes.

Clark: It’s really that easy?

Patnaude: Yes. In fact, from what we’ve seen so far, after that initial interaction, we just let the medics explore the HALO application and answer questions as they come up. They intuitively get it after only a few minutes of use.

Clark: Does HALO require a lot of support?

Patnaude: No. HALO is designed to be updated remotely by pushing software to the locations throughout theater. If a unit is not on the network, then we can send them one CD and the units’ S-6 can easily patch or upgrade the system.

Clark: What stood out for you from the November 2019 Afghanistan post-deployment survey on the level of satisfaction between HALO and AHLTA-T?

Patnaude: I thought it was pretty revealing to see the comment from an emergency room nurse [Capt. Lesley Tarongoy, U.S.-NATO hospital, Kabul, Afghanistan]. She wrote an emphatic “NO!” when asked if she wanted to go back to AHLTA-T after using HALO. To see similar answers given by 100 percent of the respondents was pretty satisfying.

Medical providers register the very first patient encounters using HALO at the Role 2 hospital at Kabul, Afghanistan on Nov. 15. Since then over 1,000 patient encounters have been registered at the hospital using HALO (Photo Credit: U.S. Army photo by MC4) VIEW ORIGINAL

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PAUL CLARK provides strategic communication support to MC4 for CACI International. He writes about the MC4 acquisition program and topics supporting Army operational health information technology that impact deployed medical forces. He is a veteran of the U.S. Army and has a B.S. in biology from Northern Arizona University.

This article is published in the Summer 2020 issue of Army AL&T magazine.

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