National Center for Telehealth & Technology 2010 Annual Report

Annual Report 2010

Acknowledgements.......................................2 T2 Director’s Message...................................3 Innovating with a Higher Purpose.................4 Leveraging the Virtual World for Real-World Therapeutic Tools................. 6 Ensuring Safety. Advancing Behavioral Science.......................................10 2010 T2 Presentations & Publications..........14 The Front Line in DoD Suicide Prevention and Behavioral Health Efforts.....18 Developing Highly Available Resources for High Priority Care...................22 Bringing Next-Generation Technology to Today’s Warriors........................................26 Supporting and Managing the T2 Mission and its Deliverables.....................30 T2 Financial Data FY 2010.............................31 T2 Partnerships & Collaborations..................32 T2 Leadership................................................34 T2 Staff.........................................................36

Acknowledgements Department of Defense Department of Veterans Affairs Military Health System Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury US Army and their Reserve Forces US Navy and their Reserve Forces US Marine Corps and their Reserve Forces US Air Force and their Reserve Forces National Guard Bureau US Army Medical Command Joint Base Lewis-McChord Madigan Healthcare System

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T2 marked 2010 as a milestone year in many ways.

Thanks to the hard work of a very dedicated staff and the many positive military, medical, government, institutional and private sector partnerships we’ve nurtured, we were able to deliver quality products across several key areas.

Our online applications, perhaps best represented by afterdeployment.org and suicideoutreach.org, have been deployed and have reached a point where their value is clearly recognized by a significant number of users, as well as our senior healthcare leaders and providers. We piloted our transportable telehealth units, launched our first mobile applications, released a major virtual world program addressing PTSD, and delivered on multiple research projects.

Indeed, I believe our work over the past year clearly demonstrates the essential role technology plays in addressing the challenges associated with deployment in the areas of psychological health and traumatic brain injury. In fact, 2010 saw us make really significant strides in our efforts to leverage technology to make a meaningful difference in the health and wellness of every beneficiary.

In this critical year, we have also achieved the 50% mark on staff hiring, establishing T2 as a “going concern” and allowing us to realize much of the potential that this organization has to offer service members and the medical community at large.

Achieving full staffing in 2011 will enable us to continue work on our goals, many of which are listed under the “On the Near Horizon” headings in this report.

The following pages provide an overview of the valuable research, development, products and programs that T2 delivered in 2010. You will also see many new assessment and treatment technologies we are developing in order to continuously improve the delivery of efficient, effective psychological health and traumatic brain injury support to the military community.

Going forward, we will be working with our partners in the Departments of Defense and Veterans Affairs to address licensing and credentialing issues necessary to fully

implement our vision for delivering information and care to our military community anytime and anywhere.

As you review this annual report I invite you to look on it as both a snapshot of the important work we have done and a demonstration of the critical importance of the work we will do tomorrow.

Sincerely,

Gregory A. Gahm, Ph.D. Director

3 The National Center for Telehealth & Technology

Innovating with a Higher Purpose.

The National Center for Telehealth & Technology

Rapid Response Leads to Rapid Growth

The National Center for Telehealth & Technology, or T2, is a dynamic technology organization that designs, builds, tests and deploys state-of-the-art methods for preventing, assessing and treating a broad range of psychological health (PH) and traumatic brain injury (TBI) conditions in service members, veterans, and their families.

Established in 2008 by the Department of Defense (DoD), T2 began the process of evaluating and testing available and emerging software, hardware and mobile devices to address the PH/TBI needs of our military community. The near simultaneous introduction of smartphones spurred a number of proposals to harness a technology that was to become ubiquitous across the entire patient and provider communities.

Comprised of fewer than 100 clinical psychologists, researchers, Web engineers, interactive designers, and support staff, T2 develops mobile applications, websites, and assessment and treatment tools; and conducts quality research.

As one of six component centers that make up the Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury, T2 is aligned with DCoE’s goal of establishing best practices and quality standards for the treatment of PH and TBI, while working to eradicate the stigma that sometimes deters people in the military community from seeking help for treatable conditions.

T2 is the only DCoE center located in the western United States, and is situated at Joint-Base Lewis-McChord, near Tacoma, Washington. T2 also maintains an office in the National Capital Region.

Designing, developing, and deploying web, mobile, and virtual-reality-based therapeutic tools for the military community.

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Similarly, the Internet had reached a mature stage, setting it up as another viable method for delivering information and access to care for service members, veterans and their families anywhere in the world.

Through 2009, and in concert with the Department of Veterans Affairs (VA) and civilian organizations, T2 psychologists, technology experts and researchers began the process of designing, developing and piloting web and mobile applications, virtual reality (VR) therapy tools, and several important suicide prevention tools and resources.

2010: A Watershed Year After three years of intensive work, 2010 saw the launch of several digital tools and applications to support our warriors, all of which are highlighted in the following pages.

The T2 Charge • Leverage innovative technologies to reduce barriers to care and fear of stigma.

• Develop psychological health and TBI telehealth standards, processes, and quality assurance protocols.

• Deploy technologies that support delivery of education and treatment in remote or underserved areas.

• Research and validate the safety and efficacy of technological applications for PH and TBI care.

• Serve as the primary Department of Defense office for the application of technology to PH and TBI care.

• Coordinate and collaborate with other DoD, VA, and civilian partners.

T2 is using real-world experiences of combat veterans to build sophisticated virtual worlds that enable service members with PTSD to relive and reprocess the traumatic events that hinder recovery.

Positioned for Productivity T2 is committed to providing members of the military community access to effective and life saving suicide prevention, Post-Traumatic Stress Disorder (PTSD), and TBI information and care ­– wherever and whenever they need it.

5 The National Center for Telehealth & Technology

Leveraging the Virtual World for Real-World Therapeutic Tools.

Innovative Technology Applications (ITA) ITA pilots and evaluates virtual reality, virtual worlds, and other innovative technologies with the potential to improve the PH and TBI resources for service members, veterans, and their families. ITA also assists in the development and dissemination of current best practices to support the growing number of mental health providers seeking training for VR and other technology applications. ITA is committed to exploring and testing the most promising emerging technologies for delivering high quality behavioral health and TBI services.

In 2010, ITA focused on studying the efficacy of virtual reality exposure therapy for PTSD, and created a smartphone application to accompany Prolonged Exposure therapy (PE), the “gold standard” for PTSD treatment.

T2’s Virtual Worlds Conference explored the state and future of VR as a therapeutic tool.

Virtual Worlds Conference

Dr. Kevin Holloway and Dr. Amanda Stewart discuss the unique therapeutic attributes of virtual worlds technology.

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In August 2010, the first National Center for Telehealth and Technology Virtual Worlds conference explored the opportunities and challenges of using virtual worlds technology to address psychological health needs. Military, civilian and academic virtual world innovators came together to view one another’s work in the field of shared immersive 3D environments, and to generate innovative ideas to help warriors. Invited speakers discussed key developments and research findings. Discussions were focused on future directions for leveraging virtual worlds to improve the psychological health of service members, veterans, and their families. Conference attendees were given the option to attend either in person, through interactive web conferencing, or through Second Life in T2’s virtual conference room. Due to the immense success of this first conference, and the continued changes in the world of technology, T2 plans to host a second annual meeting in 2011.

Virtual Worlds technology may be the next major innovation in web technology, transforming how users interact with data and with each other.

Accomplishments in 2010 • Hosted the first DoD conference on leveraging virtual worlds to assist warriors.

• Provided coordinated VA/DoD Clinical Training Workshops on Virtual Reality Exposure Therapy (VRET).

• Completed Virtual Reality Exposure Therapy Study; year two of four.

• Completed beta version of PE Coach smartphone app.

On the Near Horizon • 2nd Annual VW Conference.

• Release T2 Virtual PTSD Experience in Second Life.

• Launch a new study of the effectiveness of virtual reality exposure therapy for PTSD at Fort Bragg, NC. • Pilot the Virtusphere, an innovative virtual reality navigation device.

• Develop the DCoE Mild Traumatic Brain Injury App. • Pilot innovative virtual reality cognitive assessment tools.

Dr. Greg Reger explains to a guest how virtual reality therapy can help PTSD patients heal their psychological wounds.

7 Innovative Technology Applications (ITA)

Leveraging the Virtual World for Real-World Therapeutic Tools.

Virtual Reality Exposure Therapy for PTSD Effective treatment of PTSD requires patients to activate the memory of their trauma during treatment. Following combat deployments, many soldiers are emotionally detached and have difficulty with this aspect of the treatment. VRET facilitates emotional engagement by enhancing the patient’s ability to revisit the trauma memory with a sensory-rich environment that includes computer-generated sights, sounds, vibrations, smells, and naturalistic navigation devices to give users a sense of participating in an alternative environment, relative to their actual physical location.

The VRET study, a four-year clinical trial started in 2009, continued evaluating the effectiveness of traditional PE therapy and VRET for combat-related PTSD. This research trial, conducted in collaboration with the Department of Psychology at

Sarah Cavaliere guides a visitor through T2’s VRET driving experience.

Madigan Army Medical Center, and the Institute for Creative Technologies at the University of Southern California, will provide valuable information about the efficacy of VRET for soldiers with combat-related traumatic stress. Results may provide new treatment options for all soldiers, but would also be an option for soldiers who either do not respond to, or are reluctant to engage in, other established therapies. In 2011, this study will be extended to Fort Bragg.

Dr. Greg Reger demonstrates the VRET equipment to Maj. Gen. Lloyd Miles, deputy commanding general of the U. S. Army’s I Corps.

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VRET’s game-like video walkthrough experience can help soldiers feel more comfortable with the idea of therapy.

PE COACH The PE Coach, a smartphone application on the Android platform, was completed in December 2010, and puts resources for prolonged exposure therapy in the hands of the patient. The mobile application removes the need for the paper and pencil method of tracking homework, and allows patients to quickly and accurately record homework responses. It provides mobile device users constant access to interactive explanations of PE therapy, psycho-education on common reactions to trauma, and a training tool for breathing practice and rehearsal. Future direction for 2011 includes release of the app on the Android Market for free download, additional application testing, widespread dissemination across the DoD and VA, and development of the PE Coach for the iPhone .

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Adam Rodgers reviews T2’s mobile application, PE Coach.

Tracking and recording feelings in real-time improves the treatment protocol for patient and provider, leading to better patient compliance.

9 Innovative Technology Applications (ITA)

Ensuring Safety. Advancing Behavioral Science.

Research, Outcomes, Surveillance and Evaluation (ROSE)

Suicide Prevention and Counseling Research Grant

The Research, Outcomes, Surveillance & Evaluation division provides national leadership in the scientific study of telehealth and technology applications in support of T2 deliverables.

In 2009, T2 was awarded a Suicide Prevention and Counseling Research Grant by the Military Operational Medicine Research Program. In 2010, work continued toward the study’s goal of finding a definitive answer to the question of whether serving in Operations Iraqi Freedom or Enduring Freedom (OIF/OEF) is associated with an increased risk of suicide. Significant limitations and biases evident in prior research contributed to the confusion that exists today. Using multiple databases, this joint DoD/VA study will determine whether the deployments are indeed a risk factor for suicide, and fill an important gap in the epidemiological study of military suicide.

A key tenet of T2’s vision is providing “tested interventions” to warriors, veterans, and their families who are dealing with PTSD, traumatic brain injuries and other behavioral health issues. To ensure safety and efficacy, ROSE develops rigorous testing and evaluation routines for T2 applications, devices, and program prior to release for general use.

ROSE also conducts a comprehensive ongoing suicide surveillance program for the DoD and disseminates the data annually. This report details extensive information – over 250 individual data points – surrounding the circumstances of military suicides and self-harm behaviors. That data is compiled and analyzed to characterize suicide behaviors in a way that can help to identify risks and prevent needless deaths.

Given the fast pace of product development at T2, the ROSE research staffers are experts in study design and modeling who work quickly but appreciate and understand the critical importance of the work they pursue so passionately.

A negative outcome in a study might kill a project, but it will never harm a service member.

Experts in study design and modeling who understand the importance of the work they pursue so passionately.

Dr. Nigel Bush tests the user interface of a T2 mobile app currently in development.

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DoDSER: The Most Comprehensive Resource for Suicide Data Collection and Analysis

The Effect of Telephone Follow-up on Outcome for Warriors with Mild TBI/PTSD Recent combat operations significantly increased the number of service members with symptoms of TBI. The Concussion Treatment After Combat Trauma study (CONTACT) is a T2/University of Washington (UW) joint activity and part of the INTRUST Consortium, a national PTSD/TBI research team. The study will evaluate the efficacy of the Individualized Scheduled Telephone Counseling (ISTS) process over 12 telephone sessions in six months.

Building on UW’s success with ISTS in civilian populations, the T2/UW team is designing new methods and procedures to help soldiers with mTBI reduce associated anxiety and depression. The study will be the first large-scale test of the benefits of mTBI-related education, training in problem solving, and behavioral strategies delivered by telephone to a military population.

In developing its products, T2 puts a high priority on evaluating each with scientific rigor.

The DoD Suicide Event Report (DoDSER) surveillance program asks designated civilian and military professionals to collect standardized records following suicides and suicidal behaviors, review the records for key information, and submit the information via the web. All Active component; Active Guard and Reserve; and activated Reserve and Guard suicides and attempts resulting in hospitalization or evacuation trigger a DoDSER. The report may also be submitted if suicidal ideation is expressed or non-lethal self-harm takes place.

Demographics, event details, behavioral health treatment history, military history, and information about other potential risk factors are all recorded.

Further refinements are aimed at continuous improvement of the reliability and utility of data for suicide prevention. Several pilot studies are now underway to extend the usefulness of the data, including a study exploring the feasibility of collecting DoDSER control data. Collaborative studies are exploring how together DoDSER, VA, and Centers for Disease Control and Prevention (CDC) data might further increase its utility, range, and value.

Research, Outcomes, Surveillance and Evaluation (ROSE)

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Ensuring Safety. Advancing Behavioral Science.

Leveraging DoD Suicide Event Reports for Enhanced Surveillance and Prevention The ultimate goal of the DoDSER program is to improve suicide prevention in the DoD in order to reduce future suicides. In 2010, T2 launched two studies with a common goal: Reduce suicide risks for active and retired service members.

Augmenting DoDSER with CDC Data to Improve Surveillance and Prevention Like DoDSER, the CDC’s National Violent Death Reporting System (NVDRS) collects standardized information on civilian suicides and violent deaths in 18 states, with the expectation that all 50 states will be funded in the future. While the two surveillance programs are similar in nature, the data points are not identical.

T2 is examining whether civilian and military systems might be used together to improve suicide prevention among service members. Integrating programs could give mental health professionals the ability to identify military suicide attempt cases that later end as civilian suicide. Together, the two datasets have the potential to more accurately assess unique or prevalent triggers and responses in the military population. This information could lead to enhanced suicide prevention programs in the future.

“The DoDSER report is one of the most significant resources available regarding military suicides.�

- Mark A. Reger, Ph.D. 12

Dr. Nancy Skopp and Dr. David Luxton review the 2009 DoDSER Annual Report.

Identifying Military Risk Factors: A Pilot Solution Existing military suicide surveillance systems help describe suicidal behaviors and risk factors. However, in order to statistically determine risk factors, information about the broader population is needed. For example, in civilian studies, men are at increased risk. In order to confirm this statistic across the military, we need to know the number of suicide cases that were male, and the percentage of those that were male. If the percentage of males is equal in both groups, gender would not be considered a significant risk factor for men in the military.

Therefore, estimates of the rate of each DoDSER item (e.g., divorce, owning a firearm, disciplinary action) are needed for the broader population. While this level of detail is very difficult to obtain, T2 is piloting a system for collecting this information at a single large Army installation.

Testing and Refining Mobile Devices & Applications for Psychological Health Smartphone apps have tremendous potential for improving delivery of evidence based information, resources, and treatments to US service members. T2 is the leading developer of military psychological health apps and functions, with many apps in production or under development. Before release, each mobile function or app must be systematically tested, evaluated, and refined to ensure that it is effective and intuitive. Right now, T2 is evaluating the two-way video capability of the iPhone 4 for hand-held mobile telehealth therapy, with four important apps in late-stage testing: R

• T2 Mobile Screener - A portable self-assessment screening tool for

measuring psychological and physical symptoms in the field.

• Breathe 2 Relax - Demonstrates and guides deep breathing techniques to reduce stress.

• MoodTracker - Enables users to create a personal graphical record of their post-deployment mood changes.

• Mobile PE - Allows PTSD patients undergoing prolonged exposure therapy to track the progress of daily homework exercises.

Exploring the Potential of Digital Diagnosis and Treatment Technologies Most service members and behavioral healthcare providers own or have ready access to a range of cell phones, smart phones, tablet computers, and PCs. T2 is aggressively researching digital delivery of behavioral health care and information to service members in the field and at home, using existing and next-generation personal electronic devices.

Assessing the Military’s Appetite for Personal Technology The Personal Technology (PTEC) study is identifying the platforms, devices, and online resources that exhibit the highest levels of acceptance, utility, and anticipated longevity. With that information, T2 can more effectively and efficiently pursue personal technology development efforts. PTEC studies respondents’ use of computers, the Internet, cell phones, smart phones, gaming devices, and other mobile/portable technologies, as well as broadcast, streaming, interactive, and downloadable video content. Data collection began in late 2010, at JBLM, and preliminary analysis and reporting of results are scheduled for spring 2011.

Web-Based Care – Proving the Value of Digitally Delivered Health and Wellness Information The Web-Based Care survey, a companion study to PTEC, assessed the awareness, attitudes, and use of healthcare websites and online health care resources among service members and military healthcare providers. The project surveyed service members and providers at a military medical center in mid 2010. Results showed that the majority of both categories use the Internet often, use Internet self-care resources, are open to additional Web-based resources and capabilities, and choose Web-based resources to supplement face-to-face care. The combined results will help T2 and other developers target their efforts on the most promising technologies for delivering psychological health services in the military.

Our wounded warriors deserve high-quality tested interventions.

13 Research, Outcomes, Surveillance and Evaluation (ROSE)

2010 T2 Presentations & Publications Presentations delivered by T2 staff in calendar year 2010: Bush, N., Bell, K., Brockway, J., Dikmen, S., Fann, J., Tempkin, N., Reger, M. A. (2010, November). Individualized telephone support for Service Members with mild TBI/PTSD. Slide presentation at the International Society for Traumatic Stress Studies 26th annual meeting, Montreal, Canada.

Mishkind, M. (2010, November).

Featured symposium: Telehealth access to PTSD and TBI assessment and treatment.

Chair symposium at the International Society for Traumatic Stress Studies 26th annual meeting, Montreal, Canada.

Bush, N. (2010, November).

Featured symposium: Mobile devices for providing assessment and support to US Service Members and Veterans. Chair Symposium at the International Society for Traumatic Stress Studies 26th annual meeting, Montreal, Canada.

Reger, G. (2010, November).

Featured symposium: Virtual reality/ virtual worlds/avatars. Chair symposium at the International Society for Traumatic Stress Studies 26th annual meeting, Montreal, Canada.

Cuilla, R. (2010, November).

AfterDeployment.org: Web-based behavioral health tools supporting the military. Slide presentation at the International Society for Traumatic Stress Studies 26th annual meeting, Montreal, Canada.

Skopp, N., Bush, N., Luxton, D., & Sirotin, A. (2010, November).

Childhood adversity and military suicide: military unit cohesion and intimate relationships as protective factors. Slide presentation at the International Society for Traumatic Stress Studies 26th annual meeting, Montreal, Canada.

Cuilla,R. (2010, November).

Featured symposium: Internet applications for PTSD care of Veterans and Service Members.

Chair symposium at the International Society for Traumatic Stress Studies 26th annual meeting, Montreal, Canada.

Bush, N., Skopp, N., Luxton, D., & Gahm, G. (2010, August).

Posttraumatic spiritual growth and suicidal ideation in the US military.

Poster presentation at the annual American Psychological Association Conference, San Diego, CA.

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Luxton, D. (2010, August).

Disrupted sleep and suicidal thinking in a clinical military.

Poster presentation at the annual American Psychological Association Conference, San Diego, CA.

Skopp, N., Luxton, D., Bush, N., Kinn, J., Reger, M. A., & Gahm, G. A. (2010, August). Military suicide surveillance and research. Paper presentation at the annual Force Health Protection Conference, Phoenix, AZ.

Skopp, N., Swanson, R., Luxton, D., Reger, M. A., & Maxwell, J. (2010, August). Validation of selected post-deployment health reassessment screening measures.

Poster presentation at the annual American Psychological Association Conference, San Diego, CA.

Skopp, N. A., & Logan, J. (2010, July).

Linking surveillance systems: Using technology to understand suicide among military personnel. National Center for Telehealth and Technology Webinar, Joint Base Lewis-McChord, WA.

Bush, N., Skopp, N., Luxton, D., & Reger, M.A. (2010, August).

Posttraumatic growth as a protection against suicidal ideation after deployment and combat exposure. Poster presentation at the annual Force Health Protection Conference, Phoenix, AZ. Holloway, K. (2010, August).

Leveraging the affordances of virtual worlds to improve psychological health care. Slide presentation at the annual Force Health Protection Conference, Phoenix, AZ.

Mishkind, M., & Gahm, G.A. (2010, May). Telemental healthcare in clinically unsupervised settings. Panel presentation at the American Telemedicine Association 15th Annual Meeting and Exposition, San Antonio, TX. Holloway, K., & Gahm, G.A. (2010, May). Innovative uses of virtual worlds for psychological health care. Slide presentation at the Federal Consortium for Virtual Worlds, Washington DC. Gahm, G. A., Holloway, K. (2010, January). Virtual technologies to improve healthcare. Slide presentation at the Military Health System Conference, National Harbor, MD.

Articles authored and coauthored by T2 staff in calendar year 2010: Johnson, D. (2010, January). Care for caregivers: Strategies for institutional and self-care. Slide presentation at the Military Health System Conference, National Harbor, MD. Gahm, G.A., & Reger, M.A. (2010, January). Improvements in suicide surveillance: The DoD Suicide Event Report (DoDSER). Slide presentation at the annual DoD/VA Suicide Prevention Conference, Washington, DC. Luxton, D., & Kinn, J. (2010, January).

The Caring Letters Project. Slide presentation at the annual DoD/VA Suicide Prevention Conference, Washington DC. Reger, G.M., Parsons, T., Rizzo, A. A., & Gahm, G. A. (2010). Virtual reality assessment of cognitive functions: A promising tool to improve ecological validity. Brain Injury, 7, 24-26.

Duma, S. J., Reger, M. A., Canning, S. S., McNeil, D., & Gahm, G. A. (2010).

Longitudinal mental health screening results among postdeployed U.S. soldiers preparing to deploy again. Journal of Traumatic Stress, 23, 52-58.

Fritch, A. M., Mishkind, M., Reger, M. A., & Gahm, G. A. (2010). The impact of childhood abuse and combatrelated trauma on postdeployment adjustment. Journal of Traumatic Stress, 23, 248-254.

Lee, J. A., Luxton, D. D., Reger, G. M., & Gahm, G. A. (2010). Confirmatory factor analysis of the Posttraumatic Growth Inventory with a sample of soldiers previously deployed in support of the Iraq and Afghanistan wars. Journal of Clinical Psychology, 66, 813-819.

Luxton, D. D., Sirotin, A. P., & Mishkind, M. C. (2010). Safety of telemental healthcare delivered to clinically unsupervised settings: A systematic review. Telemedicine and e-Health, 16, 705-711.

Luxton, D. D., Skopp, N. A., & Maguen, S. (2010). Gender differences in depression and PTSD symptoms following combat exposure.

Depression and Anxiety, 27, 1027-1033. doi: 10.1002/da.20730

Rizzo, A. S., Difede, J., Rothbaum, B. O., Reger, G., Spitalnick, J., Cukor, J., McLay, R. (2010). Development and early evaluation of the Virtual Iraq/ Afghanistan exposure therapy system for combat-related PTSD. Annals of the New York Academy of Sciences, 1208, 114-125. doi: 10.1111/j.17496632.2010.05755.x.

Maguen, S., Lucenko, B. A., Reger, M. A., Gahm, G. A., Litz, B. T., Seal, K. H., Marmar, C.R. (2010). The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans. Journal of Traumatic Stress, 23, 86-90.

15 Research, Outcomes, Surveillance and Evaluation (ROSE)

The National Center for Telehealth & Technology

The Front Line in DoD Suicide Prevention and Behavioral Health Efforts.

Population and Prevention Programs (P3) P3’s population health focus is evident in its ongoing development of technologybased solutions aimed at preventing the onset of mental health problems; helping users identify and measure existing problems; and reducing the impact of mental health conditions by employing evidenced-based behavior-change strategies.

P3’s population is the broad continuum encompassing the military community, including all branches of military service and their delineated ranks, ethnicities, and educational experiences, as well as military families, and the providers who render clinical services.

P3 has two essential lines of business: web-based applications, and mobile applications. The objective of P3’s psychologists, designers and developers is to maximize access to care by supporting a wide array of devices already in the hands of the majority of our population, such as desktops, laptops and smartphones.

“Excellent information for soldiers and their families and a great resource for people in the helping profession to assist soldiers and their families, very easy to access and use.”

- DoD Psychologist

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AfterDeployment.org Website Launched in August 2008, afterdeployment.org offers a wide range of behavioral health resources in support of service members, veterans, families, and health care providers serving the military community. Some of the site’s 18 modules (Health & Wellness, Resilience) are generally intended to promote well-being (primary prevention). Alternatively, the site’s twenty-nine self-assessments provide users with symptom detection (secondary prevention). Other modules (Anger,

Depression, Post-Traumatic Stress) offer behavior-change tools aimed at limiting the severity and duration of existing behavioral health conditions (tertiary prevention).

The site’s “always on” availability allows visitors to work at their own pace, using materials that best fit their individual concerns or conditions. The site’s anonymous access reduces or eliminates stigma while removing common barriers to care.

More immediate consultation is available via ready links to hotlines and an outreach call center. Healthcare providers can access the site to download materials that augment their practice.

In 2010, the site underwent a major refresh. Expansion included six new topical libraries and seventeen additional self-assessments, an upgraded “look and feel” of the video-based personal stories obtained from service and family members, and opportunities to network via community forums and subject expert blogs. The site established a social media presence on Facebook and Twitter, introduced easyto-download podcasts highlighting warriors’ deployment challenges, and added a provider portal that offers health care workers client guides, practice guidelines, links to continuing education opportunities, instruction concerning the site’s selfassessments, and quick facts about diagnosing and treating PTSD and TBI.

“Everyone goes through a lot when service members are deployed.

It’s good to have resource like this as a support for everyone involved” - Service Member

On the Near Horizon • Next-phase enhancements to afterdeployment.org:

- Remodeled topical videos and interactive workbooks.

- Lifelike online “coaches” to simplify complex content.

- Graphical characterizations depicting post-traumatic stress.

- Mobile afterdeployment.org available on handheld devices.

- Artificial intelligence (avatars) guiding users to topical content.

- Customizable dashboards.

• A web app with tracks for kids, families, and educators.

• A “virtual handheld clinic” to include a suite of mobile apps.

• Web and mobile, games for learning, podcasts, Web novels, texting tools, and an apps store.

• A virtual call center offering immediate consultation.

• Apps to link content and enterprise-level tools like Electronic Medical Records.

• Enhanced social media apps for the military community.

• Surveillance/assessment apps for military personnel.

• Healthcare provider simulation training.

• Efficacy studies.

19 Population and Prevention Programs (P3)

The Front Line in DoD Suicide Prevention and Behavioral Health Efforts.

SuicideOutreach.org Website The sheer number of decentralized DoD and non-government web-based resources targeting suicide prevention can cause confusion when seeking assistance.

Together with the Suicide Prevention and Risk Reduction Committee (SPaRRC), T2 developed suicideoutreach.org. This one site centralizes suicide prevention resources and provides access to information on suicide facts and misconceptions; risk factors and warning signs; steps for taking action; and dealing with grief reactions. There are links to self-assessment tools, the National Suicide Hotline and DCoE’s Outreach/Chat Center, a resource library and suicide materials developed by each military service branch, the National Guard, the Reserves, and VA.

Dr. Robert Ciulla outlines 2011 afterdeployment.org updates for and Dr. Karl O.“Skip” Moe.

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SuicideOutreach.org consolidates access to all DoD and VA suicide risk reduction websites in one place.

Dr. Perry Bosmajian explains the features of T2’s MoodTracker app to a guest.

T2MoodTracker

Mobile Applications

T2MoodTracker was released to the Android Market in September 2010, to help users track their emotional states. The app, a winner in the Apps4Army contest, provides user-friendly touch-screen “visual analogue” scales to help users recognize situations, stressors and behaviors that may increase feelings of depression, anxiety, or PTSD-related behavioral health issues.

T2 began development of mobile applications with the aim of improved access to pre-clinical solutions and resource materials covering many post-deployment challenges. Handheld devices are “always on,” “hip-pocket” accessible, and can be downloaded anonymously, supporting stigma-free access to behavioral health resources. What’s more, apps can be customized to meet the specific needs of the end-user. Smartphones can deliver user-friendly assessment surveys, hotlines, streaming video, and resource locators virtually anywhere.

T2MoodTracker has been downloaded more than 10,000 times since its September 2010 release.

21 Population and Prevention Programs (P3)

Developing Highly Available Resources for High Priority Care.

Clinical Telehealth (cTH) The Clinical Telehealth division maintains a leadership role in the field of long-distance or remote delivery of behavioral healthcare. In addition to pioneering the use of delivery systems and communications technologies in healthcare, cTH maintains a high profile as an advocate working to establish standards for - and break down barriers to - providing even the most remote patients with highly qualified specialists in TBI, PTSD, and other behavioral health conditions.

The cTH mission is to establish a functional, sustainable DoD PH/TBI clinical telehealth care system. To that end, cTH psychologists, researchers, and technical specialists focus not only on data-driven healthcare solutions, innovative delivery systems, and effective leadership, but also on standardization, education, and forward looking planning and policy initiatives.

As the primary DoD component focused on the evaluation, modification, and standardization of PH/TBI telehealth technologies, platforms and policies, cTH coordinates with other DoD, VA and federal-level partners to deploy solutions to the most pressing access-to-care barriers. This includes providing leadership and education to ensure standard use of and planning for DoD telehealth practice; and designing clinical operations, technology solutions, and delivery platform pilot studies for evaluation.

“Being able to get care for my husband has helped me and my family and really gave new hope.�

- Military Spouse 22

Bradley Smith, Karl Stubbeman, and Dr. Matt Mishkind evaluating a smartphonebased telehealth solution.

In the operational area, cTH is working to meet the rising number of PTSD and TBI cases by serving as the lead DoD coordination and resource center for a network of telehealth systems comprised of the military, the VA, the TRICARE Management Agency (TMA), and civilian provider partnerships. By leveraging these existing provider resources, cTH is improving access to care for servicemembers, veterans and their beneficiaries in an effective, efficient, and collaborative way. cTH also designs and deploys innovative solutions such as the Transportable Telehealth Unit (TTU) pilot that sees regular clinical use in American Samoa.

On the policy side, cTH is leading the effort to revise and streamline entrenched procedures and policies that stand as barriers to widely available telehealth care.

These include state-based licensure, requirements for local privileging of healthcare providers, and definitions of where and how clinical care is delivered. The goal is to allow providers to build and maintain therapeutic relationships with patients regardless of time or location.

TTU Transportable Telehealth Units TTUs are transportable space solutions that expand PH/TBI health care to DoD beneficiaries who might not otherwise have access to, or even seek, care. Built to conform to standard shipping dimensions, these highly mobile telehealth modules can travel in or on a vessel, railcar, or transport vehicle. Outfitted with off-the-shelf hardware, TTU’s provide a number of two-way audio and video conferencing stations and private meeting space to deliver behavioral healthcare to more people by making distant providers readily available regardless of location.

In October 2010, the first clinical pilot TTU arrived in American Samoa and is being used regularly and successfully by patients there to engage with providers at Tripler Army Medical Center in Honolulu, 2,500 miles away.

cTH Accomplishments 2010 • Lead for DoD/VA Integrated Mental Health Strategy.

• Clinical Telehealth Metrics Study Design.

• TTU Telehealth pilot program in American Samoa.

• Evaluated use of TTUs to deliver care.

• Telemental Health Videoconferencing Training Program launched.

• Smartphone Utility Evaluation.

On the Near Horizon • Deliver in-person telemental health training program.

• Augment training modules using technology applications.

• Usability tests on different mobile health platform designs.

• Implement DoD/VA Integrated Mental Health Strategy to develop technical, business and clinical processes for joint telemental health services.

• Lead Federal Partners Telemental Health exploratory committee.

TTU pilot module arrives in American Samoa.

• Define policies to effectively expand the scope of telemental health care delivery.

23 Clinical Telehealth (cTH)

Developing Highly Available Resources for High Priority Care.

IMHS Telemental Health The DoD/VA Integrated Mental Health Strategy (IMHS) is a program to design and develop shared technical, clinical, and business processes and resources to coordinate delivery of telemental health services. Currently in development, the IMHS group is assessing needs of both providers and beneficiaries. The assessment will be followed by a pilot program for evaluation and refinement, with the goal of sharing surge and ongoing care resources, and an operations manual to describe the processes to share telemental health resources successfully.

Smart Phone Evaluation Begun in November 2010, the Smart Phone Evaluation is assessing the potential of video teleconferencing applications on handheld devices like Apple’s iPhone 4 for delivering telemental health care, and investigating whether handheld video can expand and facilitate access to care for service members, veterans, and their families.

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Bi-level TTU testing and demonstration mock-up illustrates the design’s flexibility, utility, and mobility.

MTU Mobile Telehealth Units Currently in development, MTUs are essentially self-propelled versions of the TTU, built on a customized bus chassis. MTU’s are designed to facilitate the rapid reallocation of telehealth resources to address, for example, post-deployment spikes in behavioral health needs, and to reduce patient concerns surrounding any perceived stigma that might accrue from visiting a clinic or hospital for mental health services.

“The fact that I didn’t have to drive hours to see my psychologist when I got back from deployment saved me time, money and probably my life. Thank you for remembering us.”

- Army Reservist

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Telemental Health Videoconferencing Training Telehealth multiplies the efficiency and effectiveness of DoD health provider resources and increases access to care through information and telecommunication technologies. The timely development and successful integration into the overall DoD health system requires provider clinical, technical, and procedural competence through education. The DoD Telemental Health Training Program provides on-site training for behavioral health providers, technicians, and clinic managers to safely and effectively deliver telehealth services. Each session includes the following topics: Introduction to Telehealth and Telemental Health, Effectiveness Research, Program Development and Policies, Providing Care, Business Models and Sustainability.

“I didn’t expect to talk to a counselor right after I redeployed. Being able to connect through the camera was a cool experience and made me feel like they cared about my health.�

- Active Duty Member Clinical Telehealth Metrics While there is some national consensus on the expected outcomes of telehealth programs (e.g., access to care, satisfaction, cost reduction), there is as yet no identified consistent model with which to evaluate telehealth programs.

T2, in collaboration with other national experts, is in the process of developing a standardized model to measure the effectiveness of telehealth programs.

A standardized metrics model will allow DoD agencies to consistently define and report on the critical outcomes that their respective telehealth programs are designed to meet. This will allow senior leaders to make informed and data driven assessments of the degree to which telehealth programs are meeting their goals. T2 will lead coordination efforts to co-author a paper on the existing telehealth metrics and submit it for publication in the first half of 2011.

Army Capt. Bradley Smith and Karl Stubbeman testing the videoconferencing functionality in the TTU test bed at JBLM.

25 Clinical Telehealth (cTH)

Bringing Next-Generation Technology to Today’s Warriors.

Technology Systems (TS) The Technology Systems division of T2 is the Web and applications development team tasked with turning visionary ideas into practical realities.

Technology Systems Web and applications developers, 3D and animation designers, database administrators and network specialists lead and manage the process of building and testing the systems and software behind T2’s intuitive, user-friendly products. These accomplished and creative technical specialists build sophisticated applications and then rigorously test, hack, and attack them to expose any vulnerability and, should one be found, address it. Testing then continues until deployment of a secure, robust application is assured.

Working closely with T2 psychologists, the Technology Systems team ensures that the TBI and behavioral health technologies developed meet their therapeutic or assessment objectives and, due to the sensitive nature of their focus, remain stable and reliable.

The Technology Systems group is currently developing, testing or maintaining 14 technology-based websites, smartphone apps and therapeutic tools, with another 20 projects in various states of consideration and review.

Brilliant technologists building tools to improve and save lives in the military community.

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T2health.org Promotes and Delivers T2 Initiatives and Information T2health.org serves as a showcase, gateway and information resource that puts people in touch with T2’s tools, research and online resources. Starting with its “.org” top-level domain name, T2health. org is designed to be user-friendly and reduce unnecessary anxiety or anticipated stigma when seeking help for behavioral health issues.

T2health.org increases visibility of T2 and its programs to DoD leadership, Congress, researchers and the public. Site design and development were performed entirely within T2, involving representatives from all T2 divisions.

First released in December 2008, a planned redesign will expand T2’s web presence and further improve the site’s usability and aesthetics. Social networking components will increase interest across a wider population while providing valuable traffic and usage data to T2.

Work that is as important as it is innovative.

Building a Community for PH & TBI Researchers The Psychological Health and Traumatic Brain Injury Network (PHTBIN) is a platform for coordination and information sharing among agencies and institutions involved in psychological health and traumatic brain injury research and practice. As a networking site similar to LinkedIn, registered medical and research professionals will use PHTBIN to interact and collaborate with colleagues, “joining” projects and working virtually with peers.

SM

PHTBIN combines the goals and objectives two cancelled projects: Federal Interagency TBI Research (FITBIR), and the R&P Communities of Practice (CoP), and unites them under the new moniker.

PHTBIN is due to be delivered to DCoE in February 2011. Requirements discovery began in mid-September 2010, with a revised version of the FITBIR requirements. Requirements were established in early November, and active development began soon thereafter.

TS Achievements 2010 Application Development & Testing • Breathe2Relax App. • T2 MoodTracker App. • PE Coach App. • SuicideOutreach.org Website: SPaRRC/VA partnership.

• Thought Record App - VA partnership.

• Trigger Log App - VA partnership.

• Psychological Health and Traumatic Brain Injury Network (PHTBIN) - professional social networking platform.

Database Management, Maintenance & Support • DoD Suicide Event Report (DoDSER) Awards Earned a 1st & 2nd prize in the “Apps for the Army”(A4A) application development challenge for T2MoodTracker and Tactical Breather applications respectively.

On the Near Horizon The agenda for 2011 includes all of T2’s virtual reality, online and mobile app projects detailed within this annual report.

27 Technology Systems (TS)

Bringing Next-Generation Technology to Today’s Warriors.

The Enclave: T2’s Technology Incubator.

The Enclave is T2’s development center where software engineers design, test and refine T2 apps and websites. Built on cutting edge hardware and software, The Enclave’s servers host the databases, websites, and files needed for development.

The Enclave employs virtualization technology to create a fast, flexible development infrastructure at a much lower total cost. Server and workstation hardware on site is maintained by T2, with network and perimeter security devices being maintained

by Madigan Army Medical Center (MAMC) network administrators.

Due to stringent security requirements, the Enclave is not accessible from the

Marc Wheeler animates a 3D character for use in T2 Breathe2Relax mobile application.

internet, and only those internet sites required for development purposes are accessible from within it. When in-house application testing is complete, they are transferred to the Ft. Detrick, MD, Network Enterprise Center (NEC) for external testing and production.

Dave Coleman and Dan Schwesinger discuss the DoDSER test database.

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T2’s web developers, 3D animators and software engineers in the Technology Systems division have created a highly productive interactive design studio.

The TS team works closely with T2 psychologists to ensure new TBI and behavioral health technologies meet their therapeutic or assessment objectives and remain stable, accessible, and reliable as well.

BioFeedback Facilitation BioFeedback devices monitor measure and report physiological functions to help diagnose and treat a range of ailments. T2 is developing software tools that sense and record data and make it available for evaluation and interpretation on a mobile device via a Bluetooth connection.

T2 has developed the base software necessary to gather data from a single device that collects heart rate, respiration rate, skin temperature and physical orientation. While development to support a heart-rate-only device and an EEG brainwave device is planned but not yet scheduled, development time to include support for these devices is minimal.

Ft. Detrick: T2’s Technology Proving Ground Applications and websites arrive at the Ft. Detrick NEC for external testing and demonstration after initial development activities at The Enclave, T2’s technology incubator at Joint Base Lewis-McChord.

The Ft. Detrick NEC is a secure facility that also provides hosting services for all branches of the government. Network security at Ft. Detrick is maintained and monitored by the Theater Network Operations and Security Center (TNOSC), and access to servers and information is strictly controlled. For security purposes, only a few T2 system engineers have access to the Ft. Detrick network. For applications testing, firewalls and other security components are configured to allow user access to the datacenter.

Emily Fantelli captures a soldier’s heart rate, respiration, and temperature; testing a T2 biofeedback application in development.

29 Technology Systems (TS)

Supporting and Managing the T2 Mission and its Deliverables.

T2 Operations In 2010, Operations responded to T2’s transition from development to production by supporting the many programs and projects with flexible and responsive processes that kept pace with the growing and changing needs of T2 psychologists, developers and designers.

Operations supports the center with general administration, human resources, finance, logistics, public affairs and the National Capital Region office.

“T2 in the midst of growth and evolving into a well-organized but agile center of innovation. Operations provides the backbone to support T2’s maturation.”

- Dr. Karl O.“Skip” Moe Human resources activity increased in 2010, as T2 came closer to its permanent staff hiring goal. The number of government civilian employees increased from 23 to 45, a significant increase toward the 75 authorized positions for T2. Additional staff support for T2 is provided by contract employees.

Plans for T2 to move into renovated offices in 2010 were delayed to 2011. The growth of staff positions required operations staff to find creative ways to accommodate the growth in the temporary modular building.

With that growth, financial resource management became an important area of focus with greater attention on budgeting and managing the complex flow of funds required to operate the center. While the first two years of the center were focused on establishing programs and projects, 2010 was the first year T2 operated with a baseline budget and established the required oversight to ensure proper accountability for all sources and expenditures of funds.

Dr. Karl O.“Skip” Moe, Adora Stone and Santina Saxby review a mock-up of the 2010 Annual Report.

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2010 was also the first year T2 began announcing major activities and new products in the national news media, with Public Affairs producing national news releases and providing the staff training for news interviews.

T2 Financial Data FY 2010 FY 2010 Budget Expenses T2’s spending reflects our priorities for delivering highly effective therapies that meet our objective of creating “technology to make people healthy.”

The accomplishments of 2010 were the result of our emphasis on applying promising technology so that our military community understands the causes, symptoms, and help available for addressing psychological health and traumatic brain injury.

The Operations Division’s strategic planning has made growth possible.

Moses Victor and Georgia Tagaras-Gordon look over plans for T2’s move to permanent quarters at JBLM.

31 T2 Operations (OPS)

Partnerships & Collaborations Significant Collaborative Programs, Projects & Partnerships in 2010 In 2010, T2 worked together with nearly 50 individual DoD, VA, academic, and private sector partner organizations to complete, commence, or continue work on over 60 suicide prevention, behavioral health, and TBI research projects, programs and presentations, elements of which are reflected in the preceding pages.

Afterdeployment.org

Department of Defense Suicide Event Report (DoDSER)

• • • • • • •

• • •

Canadian Institutes of Health Research Department of Veterans Affairs San Jose State University Student Veterans of America Trauma and Neurosurgery Program, St. Michael’s Hospital, Toronto U.S. Army Telemedicine and Advanced Technology Research Center VA National Center for Post-Traumatic Stress Disorder

Caring Letters Project • • • • • •

Landstuhl Regional Medical Center Madigan Army Medical Center Naval Medical Center San Diego Tripler Army Medical Center VA Palo Alto Health Care System VA Western New York Health Care System

Prolonged Exposure (PE) Mobile Application • •

VA National Center for Post-Traumatic Stress Disorder Center for Deployment Psychology

Post-Traumatic Stress Workshop Study •

Department of Veterans Affairs

In-Home Tele-Behavioral Health Safety Study •

Portland VA Medical Center

Mobile Telehealth Unit •

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TRICARE Regional Offices – North, West

• •

Air Force, Army, Marine Corps, Navy Suicide Prevention Programs Armed Forces Medical Examiner’s Office System Behavioral and Social Health Outcomes Program, U.S. Army Public Health Command (Provisional) CDC National Violent Death Reporting System Mental Illness Research, Education and Clinical Centers, Denver VA Medical Center

Insomnia study comparing Sleeping Better web-based workshops with current protocols •

University of Texas

Injury and Traumatic Stress (INTRUST) Research Consortium •

University of Southern California

Featured Symposium on Technology-Based Trauma Assistance for Service members, Veterans, and their Family at the 2010 Annual Meeting of the International Society for Traumatic Stress Studies • • • •

VA National Center for Post-Traumatic Stress Disorder Emory University Office of Mental Health Services, Veterans Health Administration Weill Medical College, Cornell University

Telemental Health • • • •

American Telemedicine Association Federal Partners Workgroup TRICARE Management Activity VA Puget Sound Healthcare System

Research Papers TRICARE Assistance Program Data Analysis and Reporting •

TRICARE Regional Offices – North, South, West

A Standardized Metrics Model of Telemental Health Evaluation: Is it Time?

Virtual Reality Cognitive Performance Assessment Test Training

•

•

A Technology Application of the Caring Letters Suicide Prevention Outreach Program

Institute for Creative Technologies, University of Southern California

Virtual Reality Prolonged Exposure Randomized Clinical Trial and Virtual Reality Prolonged Exposure Training • • • • •

Baltimore VA Medical Center Emory University Institute for Creative Technologies, University of Southern California Madigan Army Medical Center Weill Medical College, Cornell University

Virtual Worlds Conference and Workshop • • • • • • • •

2B3D Centers for Disease Control and Prevention Institute for Creative Technologies, University of Southern California Maya Realities Myoonet U.S. Army Telemedicine and Advanced Technology Research Center University of California, Davis University of Washington

War Memories Study •

Department of Veterans Affairs

•

U.S. Army Telemedicine and Advanced Technology Research Center

Madigan Army Medical Center

CONTACT- The Effect of Telephone Follow-up on Outcome for Warriors with Mild TBI/PTSD •

University of Washington

Development and Test of a Stigma Measure for AfterDeployment.org •

Iowa State University

The Association between Suicide and OIF/OEF Deployment History • • •

Defense Manpower Data Center Environmental Epidemiology Service of the VA CDC National Death Index Program

The Feasibility of Using DoDSER Data to Support VA Clinicians •

Denver VA Medical Center

Validation of Computer-Based Administration of the Post-Deployment Health Reassessment (PDHRA) •

Columbia University

33 The National Center for Telehealth & Technology

T2 Leadership

Gregory A. Gahm, Ph.D.

Mark A. Reger, Ph.D.

Director National Center for Telehealth & Technology

Deputy Director National Center for Telehealth & Technology Division Chief Research, Outcomes, Surveillance & Evaluation (ROSE)

34

Karl O.“Skip” Moe, Ph.D., ABPP

Thomas E. Broyles, FACHE, PMP

Chief of Staff

Deputy Director National Capital Region

Robert Ciulla, Ph.D.

Greg M. Reger, Ph.D.

Division Chief Population & Prevention Programs (P3)

Acting Division Chief Innovative Technology Applications (ITA)

Matthew C. Mishkind, Ph.D.

Robert Kayl, MSE, MHR

Acting Division Chief Clinical telehealth (cTH)

Division Chief Technology Systems (TS)

35 The National Center for Telehealth & Technology

T2 Staff

The National Center for Telehealth & Technology

National Center for Telehealth & Technology 9933 West Hayes Street Joint Base Lewis-McChord, WA 98431 253-968-1914 www.t2health.org | yourthoughts@tee2.org Project Director: Joseph Jimenez | Writer/Editor: Kevin Noschese | Graphics Design & Layout: David Sperry | Photography: Jennifer June