The average professional types 50 to 70 words per minute. LTC John Mansfield, a urologist at the U.S. Air Force (USAF) Theater Hospital in Balad, Iraq, claims he falls within that range. “Not bad, but I can talk at about 120 words per minute,” Mansfield said, wearing a headset that he carries with him to his 10 workstations throughout the area.

At each clinic and operating room, Mansfield and his colleagues are required to record patient care and capture surgical procedures electronically via laptops using the Army’s Medical Communications for Combat Casualty Care (MC4) system. Use of the system is part of the military’s ongoing effort to ensure that all deployed service members have a lifelong, electronic medical history. All U.S. Army and USAF combat support hospitals and medical treatment facilities in Southwest Asia are outfitted with MC4 systems.

Mansfield has been the only urologist on staff in Balad since January. He sees about 150 patients per month, both outpatient and inpatient visits, involving mostly trauma and kidney stone ailments. While his workload doesn’t rival that of an emergency room, Mansfield’s specialty requires him to be on the move and to have access to patient information on the fly. Like most doctors in the combat zone, he doesn’t have time to stop and type everything he does, so he has improvised.

By synching the newly deployed voice recognition (VR) software — Dragon Naturally Speaking Medical Version 9.5 — with his MC4 systems, Mansfield found ways to cut his documentation time in half, saving time and resources in the process.

“The system can handle up to 140 words per minute,” Mansfield said. “I produce longer, more thorough, descriptive notes if I talk and not type. Time to produce the note is precious — it must be fast. The notes have to get into the electronic medical record somehow, either by me typing them in or having someone else type them. Transcription here in Iraq is very difficult and costly, and there’s always a delay. With VR software, our notes are better quality than before.”

Not only is Mansfield the first to use the VR software with MC4, he’s the first to implement a VR roaming medical network in a medical treatment facility on the battlefield. “Every user of the software must customize the speech engine to his own voice and style of speech,” Mansfield explained. “This is called their ‘speech file.’ This takes about 15 minutes or so. Normally, if I wanted to dictate at more than one computer, with each one located at my clinic, my office, the recovery room, and the operating room, I would need to train all four MC4 laptops individually. You can imagine that most physicians are not willing to do that. With the new network or roaming capability that MC4 set up, my speech file is maintained on a server, so I can access it from any of my laptops on which VR software is loaded. It allows me and other physicians to roam from place to place while dictating to any of our current 10 MC4 laptops.

No Coincidence
Mansfield did not volunteer to be the VR software guinea pig without knowing the repercussions. As Company Commander for the 375th Medical Operations Squadron at Scott USAF Base, IL, Mansfield and his colleagues have done their research on VR software and have been using it extensively for 8 years. “I use the VR software at home and it interfaces with AHLTA [Armed Forces Health Longitudinal Technology Application], so using it to interface with MC4 is the same,” Mansfield said. AHLTA is the electronic medical recording software used at DOD medical facilities in the U.S., including Walter Reed Army Medical Center, Washington, DC, and Brooke Army Medical Center, Fort Sam Houston, TX. MC4 systems include the battlefield version of AHLTA.

“When VR started in the 1980s, it got a bad rap early on because of limited vocabulary and limited hardware,” Mansfield said. “Since 2006, there’s been a dramatic improvement, including the improved accuracy of the software, better speech engines, a 300,000-word vocabulary index with 60,000 medical terms, and new roaming capabilities. Plus, the MC4 hardware is good and flexible enough.”

Radiologist MAJ Michael Matchette, tasked with interpreting all of the imaging done at the Balad USAF Theater Hospital, finds that the VR set-up with the MC4 system helps radiologists the most because they dictate more than any other specialty in the hospital. “VR significantly improves my productivity, Matchette said. “For some complicated studies, like a CT [computed tomography] of the chest, abdomen, and pelvis, I can’t just say ‘normal study.’ I must list pertinent negatives. In those cases, I can create a template of pre-dictated normal study and paste it in with a single command. Other patients with abnormal findings may have a long dictation and I am a slow typer.”

Prior to the VR software being used, trauma scan reports, such as scans of the head, face, neck, or chest, were long, hand-written reports placed at the patient’s bedside. This is where Matchette sees the biggest benefit of the VR system. “It saves time, [which is] especially critical during mass casualties,” he said. “I can get a more complete report in the computer and do it in less than half of the time. It allows me to have full trauma scan reports in the computer, often by the time the patient goes to the operating room. Plus, my report never gets lost if the patient is moved.”

VR Training
In 5 weeks, Mansfield and MC4 personnel have trained 16 surgeons in various disciplines on the system, from orthopedic surgeons to ear, nose, and throat specialists to neurosurgeons. Reviews are mixed, but he holds hope that the proven success will bring everyone onboard. “Some love it and use it exclusively, and some do not like the change,” Mansfield said. “VR software fundamentally changes the way you approach medical documentation and some do not want to face that change. Many are using the VR software to complete operative reports and clinic notes in MC4, and literally hundreds of reports have been produced with the VR roaming software. The more success providers see users of VR software have, the more they are willing to try it.”

Mansfield recalls a night in Balad when he was treating a wounded Soldier who was bleeding from a dressing over a complex hip/pelvis wound. “The only medical record I could access was a scribbled pencil note that I could not read,” Mansfield said. “I basically had to start from scratch with the Soldier. It would have been much less invasive to him if I accurately knew the extent of his wounds and surgeries with a good, thorough, legible medical record that I could access electronically.”  

Mansfield’s experiences have motivated him and the MC4 technical support personnel to extend their training outreach efforts to providers in Iraq, Kuwait, and Afghanistan, offering to host two VR training sessions at the USAF Theater Hospital in Balad this spring. The plan is to demonstrate the value and capabilities of using VR with MC4. “Training is essential,” Mansfield said. “If I take a microphone and software and give it to doctors and do not provide training, less than 10 percent will be using the software 30 days later. However, with several hours of training, they can see the strengths of the software, and quickly get through the learning curve.”

Mansfield also hopes to influence his successors by providing a 2- to 3-week overlap period during the next rotation of USAF personnel scheduled to carry on the electronic medical recording initiative when he’s gone. “Already, outside people have commented on the improved quality of notes being produced by surgeons using VR software with MC4,” Mansfield said. “As these Soldiers transition to the U.S. Department of Veterans Affairs for care and long-term disability issues, our documentation will be key to their ability to get the benefits that they have sacrificed so much for. Great documentation of medical care here in theater is vital to the long-term health and welfare of our fighting men and women. I’m hoping this effort has enough momentum and foundation to be continued by others when I leave.”