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Dedicated to the Military Medical & VA Community

Innovative Leader Maj. Gen. (Dr.) Byron C. Hepburn Commander 59th Medical Wing Director San Antonio Military Health System

November 2012 Volume 16, Issue 7

Featuring rear adm. Thomas J. mcginnis: On the new TRICARE eRx Initiative

DCoE Command Profile O Soldier Performance O PTSD Millenium Cohort Study O Promoting Wellness

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Military Medical & Veterans Affairs Forum


Soldier Performance

November 2012 Volume 16 • Issue 7

Cover / Q&A

Developing physical training programs focused on maximizing physical functional performance. By Colonel Peter J. Benson

6 Command Profile Defense Centers of Excellence Exclusive Interview with:

Paul S. Hammer Captain


A Defense Centers of Excellence interview concerning the integration of psychological health and traumatic brain injury knowledge across the military.


Promoting Wellness

Major General (Dr.) Byron C. Hepburn Commander, 59th Medical Wing Director San Antonio Military Health System

Placing an emphasis on population health activities to positively influence the health and well-being of the military. By Ginnean Quisenberry

21 The Millennium Cohort Study The largest DoD population-based military health study launched next survey cycle, hopes to enroll military members and spouses.

Departments 2 Editor’s Perspective 3 MC4


4 Program Notes/People PTSD The dreaded four letters you don’t have to fear. Recognizing, preventing and seeking treatment for this common disorder and overcoming the stigma. By Kelly L. Forys-Donahue

24 eRx Initiative E-Prescribing or eRx, is a major priority for the TRICARE Management Activity Pharmaceutical Operations Directorate. By Rear Admiral Thomas J. McGinnis


14 Vital Signs 27 Resource Center

Industry Interview

28 Mike Coughlin President and CEO ScriptPro

Military Medical & Veterans Affairs Forum Volume 16, Issue 7 • November 2012

Dedicated to the Military Medical & VA Community Editorial Editor Chris McCoy Managing Editor Harrison Donnelly Online Editorial Manager Laura Davis Correspondents Peter Buxbaum • Henry Canaday Kenya McCullum

Art & Design Art Director Jennifer Owers Senior Graphic Designer Jittima Saiwongnuan Graphic Designers Amanda Kirsch Scott Morris Eden Papineau Kailey Waring

Advertising Associate Publisher Charles Weimer

KMI Media Group Publisher Kirk Brown Chief Executive Officer Jack Kerrigan Chief Financial Officer Constance Kerrigan Executive Vice President David Leaf Editor-In-Chief Jeff McKaughan Controller Gigi Castro Operations Assistant Casandra Jones Trade Show Coordinator Holly Foster

EDITOR’S PERSPECTIVE My name is Christopher P. McCoy and I recently became the editor of Military Medical & Veterans Affairs Forum. Brian O’Shea has taken the lead of KMI Media Group’s newest publication, Border & CBRNE Defense. I look forward to aiding the military’s medical community and our nation’s veterans through this publication. A number of publications have recently reported on the extent of PTSD and traumatic brain injury among veterans of Iraq and Afghanistan. The figures are startling: 244,000 cases of traumatic brain injury since 2000 is commonly cited. The number of cases of Christopher McCoy Editor PTSD is probably similar since many times PTSD is undiagnosed. Alarmingly, these two diagnoses continue to rise within the veteran population. What further focused my attention on the mental health of our veterans was the Army’s vigorous response to the increasing number of suicides within its ranks: the full Army stand-down for mandatory suicide awareness training that took place on September 27. I applaud the Army for that decisive action. Over here it was impossible not to reflect on the many veterans I’ve known throughout the years. They are and were close friends, family, colleagues and acquaintances. I interviewed many of them both formally and informally. There were three interviews that stood closest in mind. Two were now-dead veterans of WWII. They were a Navy Pearl Harbor and Leyte Gulf survivor and an Army POW who escaped four times after his capture during the Battle of the Bulge. The third is still young and living; a veteran of two tours in Iraq. He expressed to me how life back home is so drab and dull in comparison to life on the ground, in the experience of combat in cities like Fallujah and Ramadi. Words like his are often a subtle sign that someone is depressed. Often they aren’t even aware they are. Feel free to contact me with any questions or comments for Military Medical & Veterans Affairs Forum.

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Medical Communications For Combat Casualty Care Immersed in EMR Training Lieutenant Colonel Christopher Moon, division west surgeon with First Army, is a physician who trains deploying medical units on the electronic medical record (EMR) system. He has used the Medical Communications for Combat Casualty Care (MC4) system while deployed downrange twice before and attributes the EMR technology for helping the U.S. military achieve the highest casualty survival rate since Vietnam: “We as providers in the medical community couldn’t have done that without the information linkage provided through MC4.” Q: What is the purpose of pre-deployment training and what is the value added in incorporating MC4 into the mix? A: The First Army mission statement basically boils down to ensuring that Reserve component soldiers and units are ready for deployment worldwide. How a medical unit prepares itself with the MC4 system is part of their overall predeployment training requirement. When a unit is notified of a deployment mission, we get involved at Division West by working with the unit to produce a single integrated training plan. In that training plan we detail how the unit will be supported during pre-mobilization and how Division West will support the unit during mobilization. Ultimately, the unit is responsible for becoming familiar with MC4. MC4 training can consist of several days of classroom training and live, hands-on practical exercises, such as using the EMR system with mock patients. The goal of the culminating training event is to verify that the unit is fully prepared to conduct its medical mission. Q: What has to be accomplished in order for a unit be validated? A: Validation simply means that the unit is ready to conduct its mission.

A validation board consisting of several members, chaired by the Division West commanding general or brigade commander, agrees that the unit has the necessary personnel, equipment and training to conduct its mission. Last year [2011], Division West and its collaborative partners, such as the 75th Training Division, trained 28 medical units, consisting of 1,524 medical personnel. Last year marked the first time an active component theater medical command was trained by Division West. Every medical unit received MC4 training, ranging from the smallest medical detachments to CSHs and medical deployment support commands. Q: How did the training evolve into what it is today? A: The training is really unit driven. The Army saw the need to formally incorporate MC4 training because of feedback from theater. Ten years ago when we first initiated operations in Afghanistan, the first medical units tried to do what they could with MC4 as it existed. The units saw the need for streamlining EMR and procuring medical supplies for better patient care. The Forces Command [FORSCOM] and Medical Command [MEDCOM] agreed, so over the years we’ve incorporated MC4 training for every mobilizing reserve medical unit. With each deployment, we collect valuable lessons learned and inject them back into training for the next deploying unit. Q: Can you elaborate on the scenarios provided to medical units during training? A: The exercise scenarios are an integral part of training. They give substance to the training event by replicating the deployed theater environment for our training units. We do this by creating storylines to address areas which theater

commanders, MEDCOM, FORSCOM and unit commanders identify as being operationally important. Each storyline has events governed by the Master Scenario of Events List [MSEL] that target the commander’s training objectives and allow unit personnel to play out their roles. Feedback or lessons learned from currently deployed medical units is incorporated into each training event and is critical for the storylines to be believable and realistic. We take real-world situations from theater and prepare our upcoming units to deploy by using those real-world scenarios. For example, a storyline for a CSH exercise may support a commander’s training objective of providing health services. MSEL injects could involve a soldier who gets bit by a dog in an austere environment and arrives at a medical facility. How does it progress from there? Well, that all depends on the unit. There are multiple ways a unit can react and we script for the most commonly anticipated branches and sequels. MC4 is part of the many battlefield operating systems we use to replicate the deployed theater’s medical system in a closed-loop exercise network system. We use MC4 to augment situational awareness to develop the medical common operating picture. By providing simulated patient records, we’re able to see how well the unit medically regulates casualties. By providing a simulated medical logistical environment, we’re able to see how well the unit orders and replenishes medical supplies. Tie it all together and we’re able to see how the command teams develop an operational plan to fit in with the surrounding warfighters. Every unit’s training is custom tailored because the theater environment is always changing. We want to provide them with the most realistic and most challenging situations. Immersion training—that’s what we call it. O M2VA  16.7 | 3

Program Notes Online Toolkit Aims to Support Mental Health Providers Serving Veterans in the Community The Department of Veterans Affairs has developed a new online Community Provider Toolkit ( communityproviders) aimed at delivering support, therapeutic tools and resources to community providers treating veterans for mental health concerns. “Many veterans seek mental health care at VA, yet many also choose to go to providers in their community,” said Secretary of Veterans Affairs Eric K. Shinseki. “VA is committed to helping veterans wherever they may seek care. This toolkit will enable those community providers who treat veterans to better understand the specific issues veterans face and help them access VA resources.” The goal of the Community Provider Toolkit is to further enhance the delivery of mental health services to veterans through increased communication and coordination of care between community providers and VA. It not only provides information about accessing, communicating with, and, if needed, making referrals to VA, but also provides effective tools to assist veterans who are dealing with a variety of mental health challenges. The Community Provider Toolkit also includes sections intended to increase providers’ knowledge about military culture. On August 31, President Obama issued a historic executive order to improve mental health services for veterans, servicemembers and military families. As directed in the executive order, VA is hiring 1,600 new mental health professionals and 300 support staff. The executive order also directed a 50 percent increase in the staff of the veterans crisis line. Last year, VA provided quality, specialty mental health services to 1.3 million veterans. Since 2009, VA has increased the mental health care budget by 39 percent. Since 2007, VA has seen a 35 percent increase in the number of veterans receiving mental health services, and a 41 percent increase in mental health staff.

4 | M2VA 16.7

VA Leads Nation in Breast Cancer Screening Rates The Department of Veterans Affairs leads the nation in breast cancer screening rates and has outperformed non-VA health care systems in breast cancer screenings for more than 15 years, with 87 percent of eligible women receiving mammograms in the VA health care system in fiscal year 2010. In comparison, in 2010, the private sector screened 71 percent of eligible women, Medicare screened 69 percent and Medicaid screened 51 percent, according to the Healthcare Effectiveness Data and Information Set, a tool used by more than 90 percent of U.S. health plans to measure performance on important dimensions of care and service.

Surgical and Medical Supply Contract Awarded GeoMed LLC was awarded a fixed-price with economic price adjustment, indefinite delivery/indefinite quantity contract with a maximum $36,550,740 for various medical and surgical supplies. Locations of performance are Tennessee, Georgia, North Carolina, Pennsylvania and Massachusetts. Using military services are Army, Navy, Air Force, Marine Corps and federal civilian agencies. There were 86 responses to the web solicitation. Type of appropriation is fiscal 2012 Defense Working Capital Funds. The date of performance completion is September 6, 2017.


Compiled by KMI Media Group staff

currently serving as executive assistant to the surgeon general, Bureau of Medicine and Surgery, Falls Church.

Capt. Terry J. Moulton

Captain Terry J. Moulton, who has been selected for the rank of rear admiral (lower half), will be assigned as deputy chief, medical operations, M3/5, Bureau of Medicine and Surgery, and director of the Medical Service Corps, Falls Church, Va. Moulton is

Maj. Gen. Kelly K. McKeague

Major General Kelly K. McKeague, special assistant to the chief, National Guard

Bureau has been assigned to commander, Joint Prisoner of War/Missing in Action Accounting Command, U.S. Pacific Command, Joint Base Pearl Harbor-Hickam, Hawaii. Brigadier General Lewis M. Boone has been assigned to director, U.S. Army Physical Disability Agency, Arlington, Va. He most recently served as director, public affairs office, International Security Assistance Force, Operation Enduring Freedom, Afghanistan.

Compiled by KMI Media Group staff

DoD and VA to Fund $100 Million PTSD and TBI Study The Department of Defense and the Department of Veterans Affairs are investing more than $100 million in research to improve diagnosis and treatment of mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD). “At VA, ensuring that our veterans receive quality care is our highest priority,” said Secretary of Veterans Affairs Eric K. Shinseki. “Investing in innovative research that will lead to treatments for PTSD and TBI is critical to providing the care our veterans have earned and deserve.” The two groups, the Chronic Effects of Neurotrauma Consortium (CENC) and the Consortium to Alleviate PTSD (CAP) will be jointly managed by DoD and VA. A primary goal of CENC is to establish an understanding of the aftereffects of an mTBI. Potential comorbidities also will be studied; that is, conditions associated with and worsened because of a neurotrauma. “PTSD and mTBI are two of the most prevalent injuries suffered by our warfighters in Iraq and Afghanistan, and identifying better treatments for those impacted is critical,” said Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson. “These consortia will

bring together leading scientists and researchers devoted to the health and welfare of our nation’s servicemembers and veterans.” More than 15 percent of servicemembers and veterans suffer impaired functioning as a result of PTSD. CAP will study potential indicators of the trauma, as well as prevention strategies, possible interventions and improved treatments. Biomarker-based researched will be a key factor for CAP’s studies. On August 31, the president signed an executive order to improve access to mental health services for veterans, servicemembers and military families. As part of that executive order, the president directed the Department of Defense, the Department of Veterans Affairs, the Department of Health and Human Services and the Department of Education to develop a National Research Action Plan that will include strategies to improve early diagnosis and treatment effectiveness for TBI and PTSD. He further directed the Department of Defense and Department of Health and Human Services to conduct a comprehensive mental health study with an emphasis on PTSD, TBI, and related injuries to develop better prevention, diagnosis and treatment options.

Specific information on the consortia, including the full description of each award, eligibility, and submission deadlines, and general application instructions, are posted on www.grants .gov and

TRICARE South Region Pharmaceutical Contract Modification Amerisource Bergen was issued a modification on a contract. The modification is a firm fixed-price, prime vendor contract for a maximum $1,771,500,000 to meet pharmaceutical requirements for TRICARE South Region. Locations of performance are Texas, North Carolina, Mississippi and Alabama. Using military services are Army, Navy, Air Force, Marine Corps and Coast Guard. There were five responses to the FedBizOpps solicitation.

VA Offers a New Tool to Help Veterans Prevent Diabetes The Department of Veterans Affairs announced the implementation of a pilot version of the Diabetes Prevention Program (DPP), a program being promoted nationally by the Centers for Disease Control and Prevention, aimed at reducing the number of veterans who develop diabetes. “The Diabetes Prevention Program will provide veterans with another tool to help them lead healthier, fuller lives, reducing their risk for diabetes,” said Secretary of Veterans Affairs Eric K. Shinseki. The DPP was a major multi-center clinical research study aimed at discovering whether modest weight loss through dietary change and increased physical activity or treatment with the oral diabetes drug metformin could prevent or delay the onset of Type 2 diabetes. The study enrolled participants who were prediabetic— overweight and with blood glucose (blood sugar) levels higher than normal, but not high enough for a diagnosis of diabetes. Results showed those who lost a modest amount of weight through dietary changes and increased physical activity sharply reduced their chances of developing diabetes. “Approximately 24 percent of veterans have Type 2 diabetes,” said Dr. Linda Kinsinger, VA’s chief consultant for preventive

medicine. “We’ve monitored the DPP’s results and we feel that it could be another tool to make a difference for veterans.” Through VA’s pilot DPP, which will be offered on a strictly voluntary basis, some veterans who are at risk for, but not diagnosed with, diabetes will attend a series of group sessions and will be given predetermined weight loss and physical activity goals. Research has shown that while many veterans benefit by establishing their own health goals, others show positive improvement working towards goals determined by the program. Other veterans at risk for diabetes will receive weight management care through MOVE!—VA’s current weight management program. The program targets a broad range of patients who are obese or overweight with obesity-related conditions, whereas the DPP specifically targets those obese individuals who have laboratory evidence of prediabetes. Because VA is eager to try new approaches to promoting health and preventing disease, it is implementing a pilot VA version of the DPP. A limited number of veterans with prediabetes will be able to participate in this pilot clinical program at the medical centers in Minneapolis, Baltimore and greater Los Angeles, with VA Ann Arbor serving as the coordinating center.

M2VA  16.7 | 5

Soldier Performance

Maximizing strength and longevity– the human performance program . By Colonel Peter J. Benson performance—and some can even be injuriAlmost any servicemember or veteran of ous. For centuries, the physical training any military around the world will be able of soldiers was focused only strength and to describe some incident of sweat, exer“toughness.” But in the process, physical tion and probably exhaustion during their over-stress and unnecessary injuries were training. The U.S. military has always put an the result. The overemphasis on physical conditionemphasis put on physiing and endurance. Yet, the basis cal toughness, to the behind the exercise physiology exclusion of maximized and human performance aspects functional perforof the time-honored exercises that mance, surely resulted soldiers, Marines, sailors and airin preventable orthopemen have endured for generations dic injuries and shorthas remained largely speculaened career span. An tive. Militaries around the world example is having solhave failed to keep pace with the diers run while carrying expanding science of athletic perCol. Peter J. Benson heavy rucksacks. While formance physiology and athletic this event may arguably strength training. Many of the contribute to mental endurance for tolerattraining methods and the exercises pering such an event, the cost is lumbar spine formed even today within the U.S. military injuries, early degenerative spinal changes remain largely unchanged since World War and shortened careers. Certainly within I. Many of these physical training exercises the priorities of a military force, physical are not geared toward maximizing functional 6 | M2VA 16.7

training is important, but it has historically not achieved the necessary emphasis for informed development with respect to other major procurement programs. Percolating up from the ranks in the last few decades however, has been a progressive interest to develop physical training programs that are more focused on maximizing physical functional performance. Modern culture has produced a sizable community of interest in multi-mode training (cross training), extreme athleticism, tri-athletes and athletic performance nutrition. The Iron Man competitions, the Tour de France bicycle races, cross-country obstacle events like “Spartan Races,” and “endurathon” extreme distance races are now commonplace. In comparison to the current standards in Olympic-style and professional athletic training methods, it is clear that most military forces’ physical training goals and programs are wholly misguided and inappropriate for training a modern force.

Within U.S. special operations forces, interested men and women enlisted their commands to develop internal initiatives to pursue novel training methods and strategies. Harvesting the best practices of Olympic and professional athletic training, these forces developed unique internal programs. The U.S. Navy’s Special Warfare Command (NAVSPECWARCOM) and the U.S. Army 75th Ranger Regiment were two of the first to sponsor a commandwide effort to modernize physical training and maximize operationally related functional performance. NAVSPECWARCOM’s Tactical Athlete Program and the Rangers’ Ranger Athlete Warrior programs were not only effective in enhancing the physical operational performance in the units—they were popular with the unit’s members. Commanders could easily see the intrinsic mission-related benefit from a more functionally fit force, but also gained from reduced losses of training time to injury and increased wellbeing. The units’ members eagerly took part in the programs, which were seen as a benefit of membership in an elite unit, and as a quest for excellence. As these programs became more established, the benefits of increased functional fitness, injury resistance, improved stamina and mental wellness were cited as the results. In 2009, U.S. Special Operations Command (USSOCOM) saw the benefits of this new training strategy and mandated that each of the subordinate service special operations commands develop a human performance program (HPP). The U.S. Army Special Operations Command’s (USASOC) component of the Human Performance Program is the Tactical Human Optimization, Rapid Rehabilitation and Reconditioning (THOR3) program. THOR3 is a proactive SOF-specific training program for Army special operations (ARSOF) soldiers. Enhanced human performance increases combat effectiveness, personal resiliency and wellness, and career longevity. Focused and individualized assessment and conditioning strategies reduce SOF manpower lost to injury and disease. Optimizing injury recovery and reconditioning maximizes return to duty times. Thus, the THOR3 program is designed to achieve the following four goals: increase combat performance and effectiveness, prevent injuries, improve health and longevity, and facilitate rapid return to duty. THOR3 is implemented in an headquarters USASOC centrally funded and managed, unit franchise model. Professional staff is

hired and the equipment is resourced by the THOR3 program management team in the USASOC deputy chief of staff surgeon’s office and provided to each unit. The unit THOR3 staff in concert with the unit command, medical and training representatives then develop and coordinate a unit-focused HPP. The THOR3 goals are accomplished through services and education provided by human performance professionals. Each unit currently has a team consisting of five types of professionals: human performance program coordinators, rehabilitation program coordinators, performance and sport dietitians, strength and conditioning specialists, and physical therapists. HPP coordinators are certified strength and conditioning specialists with a master’s degree and a minimum of five years of experience training elite athletes. Rehab program coordinators are licensed physical therapists with a master’s or doctorate degree and advanced clinical certifications as well as a minimum of five years of experience in sports medicine. Performance dietitians are registered or licensed dietitians and certified specialists in sports dietetics with a minimum of two years experience in performance/sport nutrition. Strength and conditioning specialists are certified strength and conditioning specialists with a minimum of two years of experience training elite athletes. Physical therapists are licensed practitioners with additional certifications and experience in sports medicine. Crucial to the success of the THOR3 program is hiring the best-qualified human performance professionals. High standards have been set for these professionals in order to maximize on a “franchise” concept for the quality of services provided to USASOC personnel. Unit commanders have provided feedback stating that this methodology has proved highly successful in meeting the needs of their units. The collective expertise of the THOR3 team has served as a force multiplier. Train-the-trainer programs within each unit have disseminated knowledge and skills to each ARSOF warrior down to the team, squad and crew level. This also ensures continuation of the program while away from home station. USASOC units were assigned the THOR3 personnel and were issued with equipment and assigned training facilities. As building and facilities funds were not originally part of the HPP funding, THOR3 is continuing to develop as training facilities are built or modified. Each unit’s staff is allowed to build


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unique training programs based on the unit’s collective missions, sub-unit operations or individual’s unique requirements. The functional, operational performance needs for a 20-year-old Ranger will differ from a 35-year-old special operations pilot. The training strategy for a long-distance infiltration surface swim will be different from that for mountain operations on skis. By utilizing the best practices from Olympic and professional athletic training, USASOC is An inside look at a THOR3 facility with a human performance coordinator. [Photo now able to train more intelli- courtesy of USASOC] gently and specifically for each unit, each operation and each soldier. The The training excellence elite professionalism result is a healthier, more functional and of the training staff, informed by individual more injury-resistant force. knowledge of the servicemember and the THOR3 has achieved unparalleled sucunit and the mission is truly unable to be cess across USASOC. Unit commanders and repeated in any other venue or program. soldiers across the command are enthusiastic Elite warriors, who are expected to be the in support. The critical mass of the program sharp edge of the nation’s forces, deserve the is the stellar quality of the professional staff. elite of the athletic strength, conditioning By maintaining rigorous hiring standards, and nutritional professional community. the HPP coordinators, rehabilitation coorAlthough THOR3 is not yet at full impledinators, strength and conditioning coaches mentation, it has already achieved resoundand performance dieticians have the training, ing support from soldiers and commanders. skills and experience needed to deal with their In special operations the human, the “operaelite soldier population. As a program without tor,” is the most weapons system and the preprecedent, there is not an existing Office of cious asset. In USSOCOM’s “SOF Truths” is Personnel Management job series code for the statement: “Humans are more important athletic trainers or strength and conditioning than hardware.” To make that truly a reality, specialists, which engendered the master’ssupport for all the HPPs by commanders and level education and professional athletics/ staff must be unquestioned. An investment Division 1 college level experience required in THOR3 and the HPPs is a visible comfor the THOR3 staff. The soldier program mitment to the well-being and functional participants would surely dismiss less skilled maximization of the force. Service men and professional staff as irrelevant. The skills women believe in the HPPs and experience needed to deal with special forces soldiers, the benefits in increased strength, speed, Rangers and elite aircrew are far beyond the agility and sense of wellness. By embedding experience of a neighborhood gym staffer. modern Olympic and professional athletic Only by maintaining very rigorous hiring was training methods into U.S. SOF and convenUSASOC able to engender the staff, which tional force training programs, the benefit was the critical mass around with THOR3, of a more effective, proficient and resilient to flourish. force is the certain result. Our SOF service “The more you sweat in peace, the less men and women have led the way out from you bleed in war,” was a pearl of wisdom of outdated physical training methods; it’s up to Sun Tzu in the 6th century B.C. THOR3 the leadership to ensure that such a valuable and USSOCOM’s HPPs bear that out. At and novel initiative is fostered. O almost any part of the duty day, a Green Beret, SEAL, MARSOC Marine or any other Colonel Peter J. Benson is Deputy Chief of USSOCOM’s SOF warriors can be found of Staff Command Surgeon, USASOC. upgrading their performance. The incredible synergistic effect between the HPP staff For more information, contact M2VA Editor Chris McCoy at or search our professionals, the individual and unit are online archives for related stories at hard to describe and nowhere replicated. 8 | M2VA 16.7

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Command Profile

Defense Centers of Excellence

Promoting psychological health,

preventing injury and providing care .

10 | M2VA 16.7

Compiled by KMI Media Group staff

Captain Paul S. Hammer MC, USN

Director Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury

Captain Paul S. Hammer is responsible for the work of DCoE headquarters and centers, the Defense and Veterans Brain Injury Center, the Deployment Health Clinical Center and the National Center for Telehealth and Technology, and a combined mission to improve the lives of our nation’s servicemembers, families and veterans by advancing excellence in psychological health and traumatic brain injury (TBI) prevention and care. He leads a groundbreaking collaborative effort that includes the Department of Veterans Affairs, civilian agencies, community leaders, advocacy groups, clinical experts and academic institutions dedicated to expanding the psychological health and TBI state of knowledge. Hammer received his Bachelor of Science degree in chemistry from the University of San Francisco and his medical doctorate from the Uniformed Services University of the Health Sciences. He completed his psychiatry residency at Naval Medical Center in San Diego and is board certified in psychiatry. His career has largely focused on psychological trauma following a disaster. He led the Navy’s west coast special psychiatric rapid intervention team providing numerous interventions to deliver immediate, on-the-ground psychological health support following

Q: Please explain the mission of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury [DCoE] and your impact on the mental health of the force. A: DCoE’s mission is to improve the lives of our nation’s servicemembers, families and

suicides, training accidents and natural and man-made disasters. Hammer led international and highprofile disaster response, most notably in the Korean Air Lines crash in Guam in 1997 and the Joint Task Force Mental Health interventions following Hurricane Mitch in 1998. In his various assignments, he has educated thousands of servicemembers on operational stress control, psychological health and traumatic brain injury care. He has deployed to Iraq twice, spending a total of 18 months in the combat theater. As the combat stress control team psychiatrist at Camp Fallujah and Camp Taqqadum, he provided direct care to Marines, sailors and soldiers suffering from acute combat stress reactions during some of the most intense fighting of the war as part of Operation Al Fajr (also known as Operation New Dawn). He also directed the psychological health care activities of more than two dozen caregivers for 33,000 service members in Al Anbar Province. His awards include the Meritorious Service Medal (four awards), Joint Service Commendation Medal, Navy-Marine Corps Commendation Medal (two awards), Joint Service Achievement Medal, Sears Award for Excellence in Navy Psychiatry, Marine Corps Good Conduct Medal, and Expert Rifle and Pistol ribbons.

veterans by advancing excellence in psychological health and traumatic brain injury prevention and care. We are a headquarters and three centers, which include the Defense and Veterans Brain Injury Center [DVBIC], the Deployment Health Clinical Center [DHCC] and the National Center for Telehealth and Technology [T2]. M2VA  16.7 | 11

Command Profile Our goal is to be the integrator of psychological health and TBI knowledge across the military system of care from the corpsman or medic on the battlefield to the level 2 or 3 trauma centers in theater to our stateside military treatment facilities and to the Department of Veterans Affairs for chronic rehabilitation. Our role is to extract data from the military health care system, work with our extensive network of government and academic partners and professional organizations to identify, analyze and evaluate that data, and then turn it into knowledge we can put back into the system to improve care. It’s helpful to imagine DCoE as the hub of a bicycle wheel; it’s in conjunction with all of the spokes in the wheel that we’re able to accomplish our mission. Q: Can you tell us about some of your key psychological health and traumatic brain injury clinical resources? A: In DCoE’s short history, we’ve already made a positive impact on the system of care by providing significant clinical practice guidelines, clinical tools and clinical recommendations that are helping providers in the field and in our military and civilian treatment facilities. As a member of the VA/DoD clinical practice guidelines workgroup, we’re part of the team that develops the guidelines and we also take these large documents and break them down into user-friendly, bite-sized pieces for clinicians. We’ve provided support tools relating to PTSD, depression, substance use disorder, acute treatment of concussive symptoms and, most recently, a revision of the guidelines for dealing with concussion in the deployed setting. Q: Can you tell us more about your centers? A: DVBIC is our TBI center. It’s been doing important work in the field of TBI for more than 20 years and has grown into a network of 17 centers, operating out of 10 military treatment facilities, five VA polytrauma hospitals and two civilian rehabilitation centers, which carry out their primary mission to educate, treat and track servicemembers, veterans and their families with TBI. DHHC is our psychological health center, which provides hands-on medical and psychological health care to servicemembers and veterans while also serving as a resource center for deployment health care. It was originally created to address Gulf War syndrome and has grown to focus on all aspects of psychological health, particularly addressing PTSD and depression in the primary care environment. DHCC manages the Re-engineering Systems of Primary Care Treatment in the Military [RESPECT-Mil] program, which promotes psychological and behavioral health screening in the military primary care setting. T2 improves care by advancing innovations in technology that support clinicians and patients in achieving better outcomes. It focuses on expanding telehealth opportunities and improving the interface between the patient and technology in a scientific, evidence-based way. Q: Can you describe how some of the emerging technologies from T2 are improving the psychological health of the military? 12 | M2VA 16.7

A: T2 develops technical solutions to support clinicians and patients in the delivery of effective psychological health care. One key area is the promotion of telehealth. T2 is helping to overcome technical barriers in terms of equipment and infrastructure as well as legal and policy issues. It works with entities throughout the health care system to help engage patients and providers in the new technology. T2 is also on the cutting edge in the development of innovative smartphone applications, which include self-help apps for patients like Tactical Breather and Breathe2Relax. The recently released LifeArmor app allows servicemembers to access real-time psychological self-assessments, relaxation exercises and resources on topics including sleep problems, depression and PTSD that are part of a web resource called The mTBI Co-occuring Conditions Toolkit app took DCoE’s 132-page product and brought it to providers’ smartphones to help them assess and treat a wide range of co-occurring conditions. The PE Coach app helps providers by putting the manualized prolonged exposure therapy into an easily accessible app that fosters a patient’s adherence to therapy. Typically manualized therapy involves recording the sessions, making appointments and creating lists of events, places and things that cause individuals distress. The app does all the work in a way that is efficient, safe and secure. Finally, it’s important to note T2’s work in the development of virtual worlds and gaming technology as a therapeutic tool and an effective way to help family members, civilian health care providers and the general public understand what PTSD is like for those who struggle with it. Using an avatar in a virtual environment can be quite useful for patients in treatment. One of the hallmark symptoms of PTSD is avoidance and virtual therapy can be a means to overcome that hurdle. Q: How far has the military come in its understanding of TBI? A: Sometimes we are so focused on solving the immediate needs relating to TBI, we don’t stop to realize how far we’ve come. When I look back to just six or seven years ago, it’s clear we’ve made significant strides. Back then we knew what concussion was but not the extent of how often servicemembers were getting them. IEDs were just emerging as the enemy’s weapon of choice and we started seeing the effects of blasts in the form of amputations and TBI. We didn’t have criteria for assessing concussion, didn’t know how long to keep warriors off the battlefield and didn’t know the most effective treatments. Fast forward to today. A recently published DoD Instruction mandates an evaluation following a potentially concussive event and provides basic assessment criteria. There are now 11 concussion care centers in theater providing prolonged care to those who need it. DVBIC recently released the revised fourth edition of the Military Acute Concussion Evaluation tool, which provides a score that providers in the field can use to determine if a person is concussed and the level of impairment. DCoE recently released revised guidelines with algorithms to further support proper TBI assessment. All of these advancements have occurred in the last several years and the future is equally bright. The Defense Department is placing significant emphasis on research into TBI epidemiology, prevention and education, diagnostics and treatment. Starting in 2007, more than $630 million has been allocated for more than 470

Compiled by KMI Media Group staff

TBI-related research studies that will provide us with a better understanding of blast exposure and how to care for those affected. Q: What can you tell me about the latest advancements in PTSD screening and treatment?

aren’t effective and expanding those that are so that others can benefit. Q: Can you describe the Real Warriors Campaign and its impact on servicemembers struggling with psychological health concerns?

A: The Real Warriors Campaign is a multimedia public A: Screening for PTSD is education initiative aimed at difficult because the sympreducing stigma and encourtoms don’t always manifest aging help-seeking behavior. directly following a deployThe campaign features video ment or exposure to a trauprofiles of Real Warriors— matic event. The better male and female, enlisted approach is screening in a DCoE is an integrator in the system of care [Photo courtesy of DoD] and officer, high ranking and primary care setting and it’s low ranking, single and marbeen proven effective in the ried with kids—all of whom had the strength to seek help and are RESPECT-Mil program. The program uses sound empirical evidence now doing well. We can exhort and cajole servicemembers to get help and requires that servicemembers be screened for PTSD and depresall we want, but nothing is more powerful than hearing first-hand sion in the primary care setting. It’s especially effective given the fact accounts from warriors just like them about what they went through that close to 95 percent of servicemembers seek care by a military and how they made it to the other side. The campaign provides primary care provider. It also helps to alleviate the stigma associated resources, tools and live chat access to confidential information in with mental health care. real time for servicemembers, veterans and family members. As difficult and debilitating as PTSD can be, the good news is that when people seek help and stick with treatment, they get betQ: How does DCoE help overcome the logistical challenge of mainter. Treatment works, but the challenge is getting people there and taining mental health care in military life? overcoming the high drop-out rate. We must continue our work to reduce mental health stigma both within the military and society A: We know that it’s the transition points which create the largest at large. It’s equally important to help servicemembers overcome hurdles for servicemembers receiving mental health care, whether their internal reluctance to get help and the notion that they’re it is transitioning from one duty station to another or from active ok and they can do it on their own. I look at the way we dealt with duty to veteran status. DCoE’s inTransition program provides onecancer or heart disease 40 or 50 years ago. We didn’t talk about it on-one coaching to help servicemembers or veterans connect with a and people often denied having a problem. Today we have broken new provider and resources at a new duty station, the VA or within a down those barriers and people don’t hesitate to seek care for those civilian community. A little bit of support and coaching can go a long diseases. We are making the same progress with PTSD awareness way in ensuring that someone continues to receive the treatment he and stigma reduction. or she needs. The final step to ensuring positive PTSD outcomes is training more military and civilian providers in trauma focused therapies as Q: Is there anything else you would like to say that I have not asked? well as educating civilian providers about military culture so they can better relate to their patients and patients are more likely to A: We often hear about the invisible wounds of war because these are complete their therapy. injuries people can’t see. At a glance, it’s not apparent if someone has chronic effects of concussion or PTSD. The person has all four limbs, Q: Can you tell me about a new program or initiative you plan to is not bleeding and has no visible scars, but the scars are there. These implement over the next 12 months? injuries are not invisible to family members or close friends or coworkers and they’re certainly not invisible to the individual suffering A: Given today’s tight fiscal environment and focusing on what works from them. These are important issues to address and there’s a lot and what doesn’t, I’ll highlight DCoE’s program evaluation efforts. of work yet to do, but we are making progress and we have a plan to Several years ago, a significant amount of money was allocated get there. O for psychological health and hundreds of programs were created throughout the military. Over the course of the next year, DCoE will conduct a thorough examination of all these programs and determine For more information, contact M2VA Editor Chris McCoy at or search our which are effective through scientific, evidence-based outcome meaonline archives for related stories at surements. The end result will be winding down the programs which

M2VA  16.7 | 13

VITAL SIGNS Diabetes Monitoring Kit Proves Aid to Diagnosing Diabetes Expanded claim gives clinicians a streamlined solution that delivers fast, actionable results to identify patients at risk for diabetes The Siemens Healthcare Diagnostics DCA HbA1c test kit, already used to monitor diabetes patients’ HbA1c levels, has achieved the CE mark as an aid to diagnose diabetes and identify patients at risk for developing the disease. Available for use on the company’s DCA systems, including the DCA Vantage Analyzer, the test kit now provides clinicians with a streamlined solution that delivers fast, actionable results for the diagnosis and management of diabetes in environments ranging from physicians offices to hospitals and clinics. The benefits of using hemoglobin A1c (HbA1c) testing to measure average blood glucose levels in the management and treatment of patients with confirmed diabetes is well established. More recently, the medical community has recognized the clinical utility of HbA1c testing in the disease’s diagnosis. Notably, in 2009, several major diabetes associations, including the International Diabetes Federation, American Diabetes Association (ADA) and the European Association for the Study of Diabetes, were part of an international expert committee that accepted the HbA1c test for diabetes diagnosis based on several advantages when compared

with the traditional method of measuring blood glucose levels. Convenience was cited as a significant advantage of HbA1c testing since it can be conducted at any time and requires no preparation by the patient, unlike fasting plasma glucose measurements, where fasting must occur at least eight hours prior to testing. Also, HbA1c testing only requires a single measurement as opposed to blood glucose testing that involves serial blood draws over several hours. With the Siemens DCA HbA1c test, only a small (1 mL) whole blood finger stick sample is needed, enabling clinicians to identify at-risk patients within minutes, review test results and discuss early intervention and disease management options during the same office visit. By reducing the need for follow-up visits,

in-office testing of HbA1c with the Siemens DCA HbA1c kit not only helps consolidate operations, but also contributes to improved patient care through a simple-to-use tool. “When not diagnosed or managed properly, diabetes can have devastating health consequences,” said David Stein, Ph.D., CEO, Point of Care Business Unit, Siemens Healthcare Diagnostics. “Siemens is committed to equipping clinicians with a highly precise and accurate method to aid in diagnosing diabetes to help them intervene early in the management of at-risk patients.” Diabetes should be diagnosed when HbA1c values are greater than or equal to 6.5 percent, per guidelines from the International Expert Committee. Also, according to the 2012 “Standards of Medical Care in Diabetes,” the ADA reports that HbA1c values between 5.7 and 6.4 percent may identify individuals with high risk for future diabetes, a state that may be referred to as prediabetes. Since 1991, the Siemens DCA HbA1c test has been used for monitoring diabetes patients’ HbA1c levels, and its effectiveness is documented in over 140 publications. Siemens plans to make its dual-purpose DCA HbA1c test kit available in Europe for the diagnosis and monitoring of diabetes during the second quarter of 2013.

Preventing Hypothermia: The ARCtc Thermal Wrap BA Combating hypothermia in casualties throughout all levels of casualty care, North American Rescue has developed the next generation of innovative hypothermia prevention equipment, the ARCtc Thermal Wrap BA. This stateof-the art heating solution overcomes the limitations of chemical, selfheating devices by providing the capability to quickly produce constant heat for a long duration, even in high altitudes (low oxygen) and in moist environments (water resistant), such as rain or patient fluids. Once activated, the ARCtc Thermal Wrap BA rapidly and evenly delivers radiant heat, while operating on a standard BA-5590 battery or equivalent (not included). This battery-activated, heat-generating wrap provides radiant heat directly to the casualty’s back and chest 14 | M2VA 16.7

simultaneously through heating surfaces built into the device. By moving the chest flaps to the side during examination, the ARCtc Radiant Thermal Heating panels continue to provide effective radiant heat as the casualty is evaluated. This lightweight, compact, portable device is vacuum-packaged in a rugged pouch and, with its size and utility, allows for effective early prevention of hypothermia at the point of injury and throughout the entire continuum of casualty care.

Compiled by KMI Media Group staff

New Department of Defense Safe Helpline Mobile App The Department of Defense announced its new DoD Safe Helpline mobile application. With this new app, servicemembers transitioning to civilian life will have access to critical resources that assist in managing the short- and long-term effects of sexual assault. This new app is the latest in a string of technological innovations designed to support sexual assault victims in the military. The app contains the option for users to record their current emotional state and create tailored self-care plans to address sadness, hopelessness and disconnection. These self-care plans include suggested resources and exercises, and can be stored for future reference. This includes a list of breathing, stretching and visualization techniques that can reduce anxiety, depression and symptoms of posttraumatic stress. “Victims want to choose when and where they get support, so we are using technology to provide them as many

options as possible,” said DoD Sexual Assault Prevention and Response Office Director Major General Gary S. Patton. “This new app tied into the Safe Helpline is another tool to provide support to military victims of sexual assault.” Users can connect with live sexual assault response professionals via phone or anonymous online chat from their mobile devices for support. Users can also navigate resources (e.g., disability assistance, medical benefits, housing help and employment assistance), or search for resources near their base or installation. The Safe Helpline mobile app is for shortterm self-care and is not to be used as a substitute for professional medical advice or a mental health treatment plan. The app is free and available for download from the Apple and Android app stores. DoD administers Safe Helpline via a contract with the non-profit Rape, Abuse and Incest National Network, the nation’s largest anti-sexual violence organization.

Pharmacy Services Portal Pharmacy Services Portal (PSP) is an enterprisewide hardware and software application of SP Central Workflow System that provides self-service patient pharmacy services, ticket queuing, and patient/prescription integration. PSP checks patients into pharmacies, notifies pharmacy staff of the check-in, prints patient tickets, calls patients to pharmacy pickup windows and exception areas, and broadcasts pharmacy waiting room statistics to pharmacy staff. ScriptPro’s SP Kiosk, a stand-alone kiosk located in a physician clinic or pharmacy waiting area, allows the patient to get a check-in ticket for pharmacy services, select a prescription pickup time and pharmacy location, manage their profile, and request refills. SP Kiosk prints a barcoded ticket, projects the patient wait time, and sends the data to prioritize and link the ticket with the patient’s prescriptions. SP Central Workflow prioritizes tickets for processing and collates all prescriptions for the pharmacy staff to fill, verify and dispense. Using the following configurable PSP components, patients experience a flexible, organized and integrated pharmacy.

O2PAK – Handheld Emergency Oxygen

Combat Critical Care announced the launch of the O2PAK, a compact emergency oxygen solution for use in hostile and inaccessible environments directly at the point of injury (combat, demining activities, disaster relief and emergency preparedness situations, etc.) until casualty treatment and evacuation can be achieved. The O2PAK is a compact, lightweight, handheld unit (9 inches high for 2.8 pounds) and is small enough to be carried in a standard military backpack—it is activated within seconds, delivering 99 percent pure oxygen at a flow-rate of 4 to 8 LPM for 20-25 minutes in any position. The O2PAK is not pressurized, requires no filling or mixing, no maintenance and has an extra-long shelf-life of 4 years. Solid-state chemical oxygen is utilized to produce oxygen, thereby eliminating the risk of explosion under enemy fire or hazardous conditions (e.g., mine/IED detonation). It does not require electricity, battery connection or recharging and can be stored under severe conditions for prolonged periods, immediately ready for use as required under the direction of trained military medical personnel. The O2PAK has been specifically designed to address field requirements and is qualified for use in rugged and extreme environmental conditions (extreme high/low temperatures, pressure, humidity) as well as high altitudes (up to 40 000 feet). Extensive scientific research and development and testing have be done under a wide variety of operational conditions to prove safety and efficacy. The O2PAK has been cleared by the FDA. The O2PAK is particularly suitable for units operating in abnormal and remote environments who are exposed to a high risk of serious injury. These include special operations forces, early entry and rapidly mobile land forces, airborne forces, marines, demining/ EOD engineers, peacekeeping forces, SWAT teams, search and rescue teams, and disaster relief organizations. M2VA  16.7 | 15

Innovative Leader

Q& A

Partnering to Build a High-Performing Health System

Major General (Dr.) Byron C. Hepburn Commander 59th Medical Wing Director San Antonio Military Health System

Major General (Dr.) Byron C. Hepburn graduated from the U.S. Air Force Academy in Colorado Springs, Colo., in 1976. He received a Master of Arts equivalent in European studies from the University of Geneva, Switzerland. He is one of 15 U.S. Air Force pilot-physicians and is a command pilot with more than 3,000 flight hours on the T-37, T-38, C-9A and C-17A aircraft. In 1987, Hepburn graduated from the Uniformed Services University of Health Sciences School of Medicine and completed a residency in Family Practice. He is a graduate of Air Command and Staff College, Air War College, Interagency Institute for Federal Health Care Executives, Medical Capstone Course and the Capstone General and Flag Officer Course. He has commanded a medical squadron, group and center, and served as command surgeon, U.S. European Command. Additionally, Hepburn served as command surgeon, Air Mobility Command and had clinical oversight for the global Air Force aeromedical system. He is an honored recipient of the Mackay Trophy for his participation in the USS Cole medical evacuation mission. Hepburn deployed to Afghanistan in 2001 in support of Operation Enduring Freedom. He was assigned as commander, Air Force Medical Support Agency. Prior to his selection to serve as commander, 59th Medical Wing, Hepburn was confirmed for promotion to the rank of major general and served as the deputy surgeon general, Office of the Surgeon General, Headquarters U.S. Air Force, Washington, D.C. As chief operating officer, he directed all operations of the Air Force Medical Service, a $5.1 billion, 43,000-person integrated health care delivery system serving 2.4 million beneficiaries at 75 military treatment facilities worldwide. In 2011, he was selected as the first director of the San Antonio Military Health System, leading the way to build the framework for an integrated military medical system in San Antonio. Hepburn’s awards and decorations include the Distinguished Service Medal, Defense Superior Service Medal, Legion of Merit with oak leaf cluster, Meritorious Service Medal with four oak 16 | M2VA 16.7

leaf clusters, Air Force Commendation Medal with oak leaf cluster, Air Force Achievement Medal and National Defense Service Medal with bronze service star. For his career-long collaboration with the French Military Medical Service, he was awarded the French Legion of Honor. Hepburn is a member of the Association of Military Surgeons of the United States, American Medical Association, Aerospace Medical Association, American Academy of Family Physicians and the Interagency Institute for Federal Healthcare Executives. Q: As the commander of the 59th Medical Wing [MDW] and director of the San Antonio Military Health System [SAMHS], what are your current responsibilities? A: As commander of the 59th MDW, my mission is to ensure exceptional care is provided to our 240,000 local beneficiaries while educating and training the next generation of military medical professionals. Our wing has a strong focus on graduate medical education, allied health training and clinical research; all are designed to enhance Air Force readiness and positive outcomes for our wounded warriors. I’m grateful to have 5,775 talented military, civilian and contract employees executing our nation’s medical mission every day.

As the first director of the San Antonio Military Health System, I oversee a $1.18 billion budget, and 12,000 personnel working in nine medical treatment facilities across the San Antonio metropolitan area. Army, Air Force and Navy personnel are working side-by-side in our health system to provide worldclass, compassionate and safe health care for all of our patients. Q: What are the main challenges faced by the SAMHS and the 59th MDW? A: As a new organization, having just celebrated its one year anniversary on September 15, 2012, SAMHS continues to mature as an integrated military health care delivery system. Our initial challenge was the timely transfer of nearly 2,000 Air Force personnel to the San Antonio Military Medical Center [SAMMC], Fort Sam Houston. We successfully completed that seamless relocation as scheduled while maintaining world-class health care for all our beneficiaries. Throughout the transition, the Air Force and Army have been dedicated to this essential mission and SAMMC was recently rated ‘Outstanding’ by The Joint Commission. Perhaps the biggest challenge is in the different, and sometimes conflicting, service-specific programs and policies. Those policies work well within their respective services but at times, they impede full health system development. Our respective Surgeons General are committed to supporting us in identifying and resolving those issues as they arise. At the 59th Medical Wing, our biggest challenge was the transition from a medical center to the Wilford Hall Ambulatory Surgical Center [WHASC]. We moved all the in-patient wards such as labor and delivery and the intensive care units to SAMMC with minimal interruption in patient services. I certainly give credit to the amazing team at the WHASC who demonstrated a true commitment to complete the changes quickly and efficiently. In fact, within two months of the transition we excelled in a thorough inspection by the Accreditation Association for Ambulatory Health Care. We rose to the challenge and were awarded their highest accreditation status. Currently we are building a new state-of-the-art facility that will replace the existing 60-year old Wilford Hall Ambulatory Surgical Center. The new $476 million surgical center will include 300 exam rooms and four operating rooms next to a 1,000-car parking garage, which should be completed in 2016. With the completion of the WHASC and our newly built Air Force Post Graduate Dental School and Clinic, Lackland will have a completely new ultra-modern, patient friendly and more energy-efficient medical campus.

A medical technician performs an ultrasound on a patient at Wilford Hall Ambulatory Surgical Center. The WHASC is the Air Force’s largest outpatient facility which provides the full spectrum of primary care, specialty care and outpatient surgery. [Photo courtesy of U.S. Air Force]

Schoolchildren with a 59th Medical Wing nurse in Bocozelle, Haiti. A team of medical personnel were sent to support a population-at-risk of 300,000 people, and cared for approximately 8,000 people in a two-week period. [Photo courtesy of U.S. Air Force]

health record [iEHR]. This iEHR will enhance communication between providers and improve patient outcomes, so we’re very excited to be chosen to start that endeavor for federal medicine. Furthermore, we are collaborating with community partners to evolve from a platform of health care to one that focuses more on preventive health. We are working together with community leaders to improve the overall health status of our San Antonio community as active participants in the Mayor’s Fitness Council. Q: Can you discuss the importance of integrated operations within SAMHS?

Q: How can the private sector help alleviate those challenges? A: The local community has certainly helped us through active partnering in health care delivery, education and training, as well as clinical research and development. San Antonio hospitals have provided training environments for our specialty providers when the military patient population hasn’t sufficed for particular educational opportunities. Also, the San Antonio Audie Murphy VA Hospital has worked closely with us to enhance the quality of care for all our veterans. We are now partnering with the VA to become a test site for the new DoD/VA integrated electronic

A: In today’s resource-constrained environment, we have to eliminate redundancies and inefficiencies while meeting all the Air Force and Army operational mission requirements. We must fully coordinate and prioritize our efforts to succeed as a military health system. As commander of the 59th MDW, I realize our Air Force medics must maintain their clinical proficiency in order to achieve mission success in any worldwide contingency. They provide care and maintain their specialty and trauma skills now at SAMMC, the DoD’s only Level I trauma center here in the United M2VA  16.7 | 17

States, while at the WHASC our medics work to hone their outpatient health care skills. As our medical personnel serve side by side with their Army and Navy colleagues in the deployed environment, it makes sense for us to train and work together here at home. One of the greatest benefits is that we now better understand each other’s culture and clinical processes before we deploy. We are all proud of our respective services but we are also proud to excel as a strong SAMHS team. Q: Can you expand on the 59th Medical Wing’s operations to include health care readiness, education and training? This Air Force doctor uses a carbon dioxide fractional laser to help improve skin texture and flexibility on a wounded warrior’s arm at Wilford Hall Medical Center. A grant was recently approved for further research into the use of laser treatments. [Photo courtesy of U.S. Air Force]

The 59th Medical Wing deployed four critical care air transport teams (CCATTs) to McGuire Air Force Base, N.J., in support of the Sept. 11, 2001 tragedy at the World Trade Center and at the Pentagon. The three-member team operated an intensive care unit in an aircraft cabin during flight. CCATT is designed to support combat casualties evacuated from combat but also supports homeland defense and humanitarian missions. [Photo courtesy of U.S. Air Force]

A technician prepares a patient for a CT scan at Wilford Hall Ambulatory Surgical Center. The technician is a diagnostic imaging technologist with the 59th Medical Wing. [Photo courtesy of U.S. Air Force]

A recovering airman and mentorship program administrator speaks to an explosive ordinance disposal team leader about becoming a mentor at Wilford Hall Ambulatory Center. This program pairs wounded, ill and injured airmen with other airmen who have experienced similar situations and are in the initial stages of their recoveries. [Photo courtesy of U.S. Air Force]

18 | M2VA 16.7

A: The 59 MDW makes up the largest medical wing in the Air Force, with over 5,700 members working all over the city of San Antonio. At Lackland, we have the Air Force’s largest ambulatory surgical center and dental program as well as the DoD’s busiest blood donor center. We’re also home to the Air Force’s Centers of Excellence for Eye, Diabetes, and Hearing. Other Air Force clinics include the Randolph Clinic, which provides health care to our vital pilot instructors and students, major command headquarters personnel, their family members and many more. At Lackland, we have the Reid Clinic, which has the honor to care for and keep 86,000 basic military trainees and students capable and healthy each year. Our North Central Federal Clinic is where we’re collaborating in a joint venture with our Veterans Affairs counterparts to care for our veterans and dependents. In the past year, over 600 Air Force medics have deployed worldwide in support of global operations including humanitarian missions in Guatemala and Honduras. Right here inside the WHASC is our newest readiness mission—the aeromedical staging facility [ASF]. It is now the mid-west regional hub for our Wounded Warriors transiting the aeromedical evacuation system. Since opening the doors of the ASF, our active duty and reservists have cared for 3,000 ill and injured warriors. Under our graduate medical education program, called the San Antonio Uniformed Services Health Education Consortium [SAUSHEC], we have 35 programs with over 600 military residents in training at 32 locations around the world, with the majority training at our military treatment facilities here in San Antonio. SAUSHEC collaborates in training with the University of Texas Health Science Center, the VA, and many other local civilian hospitals. Additionally, more than 450 nursing and medical technicians graduate annually from specialty programs such as the only DoD Neonatal Intensive Care Unit nursing course, making Lackland the largest clinical training site for the Air Force. All of our graduates are immediately ready to work in the military system and deploy upon completion of their respective program. The 59 MDW is proud to provide highly-trained medical professionals in support of our military family members on the home front and our brothers and sisters in overseas operations. It is a privilege to get the call and the opportunity to put all our training to use to serve our warfighters and our country. Q: As the home to the Department of Defense’s Warfighter Refractive Surgery Center, critical care air transport team pilot unit, the DoD’s largest blood donor center, and the only extracorporeal life support capability in the DoD, why are these critical to military medicine?

A: Each of these capabilities is critical to the DoD’s global mission success. The refractive eye surgery center is correcting corneal imperfections of Air Force, Army, Navy and Marine members to enhance operational performance while also eliminating the dependence on corrective eyewear in austere environments. Another key mission occurs at the blood donor center, where an average of 1,300 pints is donated each month. The blood donated here is sent to Afghanistan in less than four days and there’s no doubt this blood has and will save the lives of thousands of trauma patients. One of our newest missions is the adult extracorporeal lifesupport program. This program uses a portable heart-lung bypass machine for patients suffering from heart and lung failure, thus allowing us to transport the most critically ill more expeditiously. Historically, war fighters with these types of injuries could not be flown to a higher echelon of care, but now we now can get them to definitive care within 36 hours. Additionally, our critical care air transport team pilot unit is making executive decisions, process improvements and amazing advancements in aeromedical transportation for our most seriously ill and injured patients. Q: You mentioned the CCATT [critical care air transport team] pilot unit has executive decision capabilities. Can you tell us more about what the individual CCATTs are doing to support global operations? A: Each CCATT is comprised of an intensivist physician, critical care nurse and respiratory therapist who care for the most critically wounded and ill patients moved all around the world. They are literally an intensive care unit flying 30,000 feet in the air while providing life-saving measures. When patients are placed in one of our aircraft, it’s guaranteed these teams will deliver the absolute best U.S. quality intensive care across intercontinental distances. Our Air Force CCATT teams have participated in all recent major combat operations, to include Operation Iraqi Freedom and Operation Enduring Freedom. These teams also provided support during the tragedy at the World Trade Center and Pentagon in 2001; the 2005 Hurricanes Katrina and Rita response; and patient evacuations in Chile, Georgia, Turkey, Colombia, Bangladesh and Mexico. Since the creation of our CCATTs, we have safely transported over 4,000 patients. Last year alone, our teams from the 59th MDW flew more than 1,230 critical care missions. A new extension to our critical care capabilities in the Air Force is the tactical critical care evacuation team. Research in trauma care from the early 2000s demonstrated the need for higher level care earlier in the medical evacuation process. These teams are placed in helicopters for a more capable medical response to patients at the point of injury. As a result of early, critical care intervention in the field and in the air, we are seeing our lowest-ever ‘died of wounds’ rate. We are putting the right care at the right place to save lives.

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Q: What are a few of the important research initiatives conducted at the 59th MDW? A: The 59th MDW remains on the leading edge of research thanks to an $86 million portfolio and more than 600 active protocols under investigation. One of our most exciting initiatives

M2VA  16.7 | 19

underway is at the enroute care research center, where there is significant focus on the rapid and safe transport of patients from the point of injury on the battlefield to definitive care while reducing variability. Technological advancements in the field of enroute care have helped us maintain 98 percent survivability for our wounded warriors. This is amazing when you consider the 76 percent survival rates during Vietnam. Other research is addressing the serious concerns of traumatic brain injury and post-traumatic stress disorder. The Air Force is teaming with the Army and civilian universities in multiple nationwide studies to determine best practices for neurological injuries and treatment of chronic pain. We want to make sure that not only are we getting our wounded warriors home alive but we’re ensuring quality in all aspects of their lives. However, these areas of investigation aren’t unique to our military population. Clinical practice guidelines resulting from this type of research are put to great use in civilian trauma centers and hospitals caring for all kinds of injuries and diseases faced by the general public. Q: What types of BIOMED technologies are used within the SAMHS and at the 59th MDW? A: We have many exciting technologies used here at home and in the deployed environment. One piece of technology developed out of collaboration with medical industry partners is known as an intraosseous infusion system. This is a lightweight, handheld drill used to gain access into a bone in as little as 10 seconds, allowing patients to receive life-saving resuscitative fluids and medications when typical vein access is not possible. At the 59th MDW, the work being done in the new Air Force Post Graduate Dental Clinic is astounding! In the stereolithography department, we have the ability to produce incredible lifelike prosthetics for our wounded warriors, burn and cancer patients. Prosthetics such as ears, noses and even bone can be sculpted by laser machines without ever having to have the patient set foot in the clinic. Thanks to innovative technology and highly skilled medics, these prosthetic pieces can be surgically implanted with an exact fit. Most importantly, these innovations are significantly improving the quality of life for our patients. Another BIOMED technology advancement is the use of skin laser treatments on burn patients. In the past, scars were simply resurfaced or surgically cut away for cosmetic reasons. Now, research and technology has refocused our previous treatment modality from improving the look of the scar to actually improving the structure and functionability of the surrounding tissues. What we have learned is laser treatment can modify scar tissue and now patients have increased range of motion in their extremities. In one instance, a soldier could not grasp his young daughter’s hand, but after his laser treatments he was able to hold her hand and catch her when she stumbled over a street curb. This is the perfect human example of how we’re improving the quality of life for our wounded warriors and for their family members. Q: What are the global responsibilities of the 59th MDW and how do you use your resources to meet those global demands? 20 | M2VA 16.7

The 59th Medical Wing patient decontamination team prepares to move a simulated patient during an emergency management exercise at Lackland Air Force Base, Texas. The team must set up and be ready to decontaminate patients within 20 minutes of activation in order to receive a passing rate. [Photo courtesy of U.S. Air Force]

A: Across all of the 59 MDW medical treatment facilities, we sustain a first-class global readiness capability. Our wing has the largest medical deployment commitment of any medical unit in the U.S. Air Force and our medics are carrying out the nation’s work 24/7. At any point in time, we have at least four critical care teams on standby and approximately 200 medics deployed worldwide, executing missions for all of our regional combatant commanders. SAMHS warrior medics are treating soldiers, sailors, airmen and Marines in Afghanistan as part of the global aeromedical evacuation system, and in our facilities here in San Antonio after they arrive back at home. I couldn’t be more proud of the compassion and care our medics are giving our nation’s heroes and their families. SAMHS is dedicated to executing the nation’s medical mission today and will continue to do so in a positive, professional manner in the years ahead. Q: In closing, is there anything else you would like to add? A: Before the creation of SAMHS, our Army and Air Force treatment facilities were fine, but they weren’t as efficient and synergistic as possible. With Congress’ Base Realignment and Closure mandate as the impetus, we have now transformed our San Antonio military treatment facilities from separate ‘A’ teams to an integrated ‘A+’ team. We are embracing change and innovation to achieve a win-win for not only the Army and Air Force but for our sister services and VA patients. Our SAMHS interservice teams are devoted to providing safe and compassionate health care here and abroad, and we are dedicated to becoming the premier military health system in the nation. O

From a system of health care to health . By Ginnean Quisenberry After a decade marking tremendous strides in improved battlefield care, military medicine is also focusing efforts on the future and actively revisiting solutions to emphasize population health based initiatives. As the health care needs of the defense community change, some truths remain the same. Taking advantage of available wellness programs and activities, choosing healthier food options and becoming more physically active have significant positive effects on your overall health. As a result, military medicine is placing an emphasis on population health activities to positively influence the health and well-being for all of our 9.7 million beneficiaries. To encourage this shift, the Military Health System (MHS) is moving from an environment that promotes health care to health. What does that mean? While it is common knowledge that living a healthy lifestyle will greatly enhance quality of life and overall health, the MHS’s move to embrace a culture within the medical community of promoting overall wellness is noteworthy. This simple shift in the concept of how best to serve the military community holds the potential to impact our entire population. Of course, promoting wellness is nothing new for the MHS. TRICARE continuously demonstrates its commitment to providing the best quality of care the MHS can offer to improve the health status of all beneficiaries. One way the MHS promotes these activities is through active involvement in systemwide disease management programs. In the National Defense Authorization Act for fiscal year 2007, Congress established a requirement for TRICARE Management Activity (TMA) to develop and offer a disease management (DM) benefit for members with chronic conditions with the intent to facilitate the improvement of the health status of those receiving military care, ensure the availability of effective health care for individuals with diseases and other chronic conditions, and ensure the proper allocation of resources to meet the medical needs of those individuals. TMA responded by implementing a DM program through a

tion health based approach that emphasized the improvement of a patient’s self-management skills and encouraged the patient’s active engagement in their own health care by improving understanding of their disease and how it affects their body. As a result, the DM programs worked to empower individuals to take control of both their own health and their health care experience. Encouraging and empowering people to be involved in improving their own health and well-being are pathways to enhancing systemwide population health improvement. Currently, the DM programs cover asthma, congestive heart failure, diabetes, chronic obstructive pulmonary disease, depression and anxiety. Care is managed through caregiver/patient interaction tools such as mailings, web-based education, telephone contacts and group education support. Chronic DM programs have laid a foundation for the principles and objectives for population-based initiatives throughout the MHS. Taking steps to encourage and empower individuals to actively participate in their own health through shared decision making with their provider and medical teams can help facilitate better health care outcomes. The DoD is also actively engaged with supporting the 2011 National Prevention Strategy (NPS), which identifies priorities for improving the health of Americans. Through partnerships among federal, state, tribal, local and territorial governments; business, industry and other private sector partners; philanthropic organizations; community and faith-based organizations; and everyday Americans, the strategy aims to improve the nation’s health. The four strategic directions identified within the NPS include: healthy and safe community environments, clinical and community-based preventative services, empowering people to make healthy choices and eliminating health disparities. “We know that preventing disease before it starts is critical to helping people live longer, healthier lives and keeping health care costs down,” Dr. Regina M. Benjamin, U.S. Surgeon General, said M2VA  16.7 | 21

in her introductory message to the strategy. “Poor diet, physical inactivity, tobacco use and alcohol misuse are just some of the challenges we face. We also know that many of the strongest predictors of health and well-being fall outside of the health care setting. This is why the National Prevention Strategy helps us understand how to weave prevention into the fabric of our everyday lives.” In direct support of the NPS, DoD has launched a broad range of campaigns aimed at making healthy living both an easy choice and a social norm. Operation Live Well directly aligns with the NPS and is the product of an interagency collaboration between the Assistant Secretary of Defense for Health Affairs, the services, the NPS committee and a growing base of partner governmental organizations. While the military community shares many health issues with the rest of the nation, servicemembers and their families also face some unique health challenges. With this in mind, the campaign provides information and resources targeted towards the top concerns of military leadership and families. Three key areas in which the MHS seeks to improve the health of its population are encouraging and enabling servicemembers, families, veterans and retirees toward tobacco-free living, healthy eating and active living. “In the case of tobacco, we exceed the national averages for tobacco use in our youngest servicemembers [age 18-25]. We have to take action with the entire military community united in our objective,” Dr. Jonathan Woodson, assistant secretary of defense for health affairs, said in a statement earlier this year. “Similarly, we must promote healthy living and reduce rates of obesity in our population. Our patients are our partners in these specific endeavors, and we will give them tools and the capability to manage their own health.” Tobacco is a dangerous addiction that is expensive, deadly and has a serious impact on readiness. Tobacco use has adverse effects on endurance, work productivity, night vision, wound healing, risk of surgical complications and other mission-impacting effects. We know that tobacco cessation services, including counseling and medications, are effective in helping people quit using tobacco. Encouraging tobacco cessation and providing the tools and support to help people quit are a top priority. The nation’s obesity epidemic is a troubling one which affects the military community as well. Like the use of tobacco, poor nutrition can have negative effects on overall health. Conversely, eating healthy can help reduce people’s risk for heart disease, high blood pressure, diabetes and several types of cancer, by helping them to maintain a healthy body weight. The DoD is committed to increasing the availability of healthy eating options in dining facilities, commissaries, exchange food courts and worksites. In addition, the military medical community is stepping forward by finding new ways to provide people with the knowledge and tools to balance their caloric intake to help them achieve and maintain a healthy weight. Of course, good nutrition works hand-in-hand with active living. Engaging in regular physical activity is one of the most important things that people of all ages can do to improve their health. Physical activity strengthens bones and muscles, reduces stress and depression, and makes it easier to maintain a healthy body weight or to reduce weight for those who are overweight or obese. Even people who do not lose weight get substantial benefits from regular physical activity, including lower rates of high blood pressure, diabetes and cancer. Tailored fitness programs appeal to individual interests and preferences, as this can be more effective in increasing physical activity. 22 | M2VA 16.7

Command fitness leader of Patrol Squadron (VP) 47, leads sailors in a run during weekly squadron physical training in preparation for the biannual Navy wide physical fitness assessment. [Photo courtesy of DoD/by Stacy Laseter]

A Lance Cpl. lifts weights inside one of three fitness rooms aboard the USS Rushmore. [Photo courtesy of DoD/by Lance Cpl. Timothy Childers]

While health care services play an important role in sustaining and restoring good health, the choices individuals make on a daily basis are the strongest predictors of lifelong health and well-being. Efforts to educate and motivate people to make healthy choices are a basic premise of the population health initiatives within DoD. When people have access to actionable and easy-to-understand information and resources, they are empowered and more likely to make healthier choices. The DoD partners, to include community-based programs, are encouraging good health, and are committed to providing servicemembers and their families with the tools and the capability to manage their own health. Everyone has the ability to actively participate in both personal and community disease prevention efforts, and this participation contributes to improvements in overall health. Supporting a culture of adopting healthy behaviors is essential to readiness and maintaining a healthy community. Leading a healthy lifestyle (physically, mentally, socially and spiritually) plays an important role in the overall preparedness of our nation’s warriors and the families that support them.O Ginnean Quisenberry is the division chief for population health and medical management in TMA’s Office of the Chief Medical Officer. For more information, contact M2VA Editor Chris McCoy at or search our online archives for related stories at

The Millennium Cohort Study

Compiled by Chris McCoy M2VA Editor

The largest DoD population-based military health study hopes to enroll military members and spouses . The Millennium Cohort Study, a DoD-wide study that is conducted at the Naval Health Research Center, began enrolling volunteers in May 2011. This year, the research team expects to add 50,000 U.S. servicemembers to reach a total goal of over 200,000 participants. Enrollment is projected to last six or more months. The study is the largest prospective military health study in the United States and captures data on servicemembers from all of the military branches. Enrollment cycles, which occur every three years, have been timed to assess occupational exposures and health outcomes that may be related to deployment. This study is in its 10th year and is scheduled to continue until 2022. “The study is poised to provide critical information toward understanding the long-term health of future generations of military members, thus contributing to force health protection, a DoD priority,” said Dr. Nancy F. Crum-Cianflone, the study’s principal investigator. “In addition to the enrollment of servicemembers in this cycle, we hope to enroll about 10,000 military spouses as part of the Millennium Cohort Family Study.” The Millennium Cohort Family Study is designed to get a better sense of how military families are coping with military life after nearly a decade of war. Spouses who enroll will be contacted every three years to complete a follow-up survey, even if their sponsor is no longer in the service. Findings from this study will go a long way in helping to understand the emerging and changing needs of military families, as well as the cumulative effect of multiple deployments. The study team is currently working on a number of research efforts to prospectively investigate military, veteran and public health

concerns possibly related to military service. Specifically, the study is designed to combine survey data with vaccination, personnel, deployment and military health system information, to evaluate the impact of military service, including deployment, on various health measures. In response to concerns about the health effects of deployments following the 1991 Gulf War, Congress and the Institute of Medicine recommended that DoD conduct prospective epidemiological research to evaluate the impact of military exposures, including deployment, on long-term health outcomes. The Millennium Cohort Study, the largest prospective health study in the military with more than 150,000 participants at present, meets this critical need. Although the original designers of the Millennium Cohort Study could not foresee the post-2001 military conflicts, the project is perfectly positioned to address health outcomes related to these operations. More than 40 percent of Millennium Cohort participants have deployed in support of the wars in Iraq and Afghanistan and their input will enable investigators to prospectively evaluate detailed data from before, during, and long after these deployments. Current areas of analyses include posttraumatic stress disorder, depression, alcohol misuse, respiratory illnesses and traumatic brain injury. O For more information visit For more information, contact M2VA Editor Chris McCoy at or search our online archives for related stories at

M2VA  16.7 | 23

 The dreaded four letters you don’t have to fear. By Kelly L. Forys-Donahue, Ph.D. PTSD. These four little letters have been the source of much confusion, misunderstanding, pain, and now, hope. Yes, you read that correctly, hope. PTSD, which stands for post-traumatic stress disorder, is a reaction to experiencing or witnessing one or more terrible events. The one, surefire way to prevent PTSD is to avoid seeing or being involved in any horrible event or scene that may cause you distress. This is easier said than done, especially for servicemembers in times of war. Although you may not be able to avoid all stressful and disastrous situations, there are things that you can do to help prevent PTSD. These things include creating a strong social support network, getting enough sleep, maintaining mental and physical health, and engaging in activities that make you feel good—physically, emotionally and mentally. Even if you make every effort to prevent PTSD, it can still occur, and that does not mean that you are weak or defective. All kinds of people can get PTSD—children, adults, men, women, civilians, servicemembers, officers, enlisted, tall, short, etc. PTSD occurs when an individual has several symptoms that impact his/her ability to function in life. These symptoms usually occur within three months of a traumatic experience; however, symptoms can occur up to one year following the event. There are three main types of symptoms that occur in PTSD: 1. Memories: Individuals with PTSD may have flashbacks, which are experiences of feeling as if the individual is back in the traumatic moment. Flashbacks are scary because they seem very real and can last for a few seconds or for hours. Flashbacks can occur at any time, with or without a trigger of the disturbing event. Another kind of memory occurs when you dream. Nightmares of the event are common and make it really tough to get a good night’s sleep. 2. Avoidance: It makes sense that an individual with PTSD would want to avoid any reminders of the horrific event, and that is exactly what happens! In addition to avoiding places, smells and conversation about the event, the avoidance can spread to avoiding pleasurable things that used to be enjoyable because of a fear that the happy experience might trigger memories of the bad event. When an individual 24 | M2VA 16.7

begins to avoid things that were once enjoyed, pleasure in life decreases, which can cause problems in relationships, difficulty concentrating, memory problems, hopeless feelings, numbness or detachment from life. 3. Anxiety: Individuals with PTSD are often on “high alert,” meaning that they cannot relax. They tend to be startled easily, and they may hear or see things that are not there. They may feel angry, irritable or guilty, and they may do things that are harmful to themselves, like drinking or reckless driving, to try to cope with these symptoms. PTSD is not fun, but the good news is that it is treatable, and the earlier that it is identified, the quicker the improvement. You wouldn’t keep walking on a broken leg, would you? No, you would see the doctor ASAP and start treatment to heal the leg. Similarly, you do not need to live with the negative symptoms of PTSD. Getting help early and often improves the outcomes, but it is never too late to get help. Even if you have been dealing with symptoms of PTSD for a long time, treatments will help you get better. Treatments often include a combination of medication (especially to help with sleep) and talk therapy or counseling. Treatments can occur in individual or in group settings. Counselors treat thousands of people for PTSD each year, and they will help to determine the best combination and course of treatment for each case. Therapists trained in the treatment of PTSD are available at behavioral health clinics on post, in the civilian community, and in Veterans Affairs clinics. If you or someone you know is showing signs of PTSD, do them a favor and get them help. Their symptoms can be relieved, and they can “be themselves” again. Do not fall into the trap of medicating with alcohol or other drugs because these will only worsen PTSD symptoms and prolong recovery in the long run. Identifying the problem is the first step, and making a call to get help is the next. Don’t let four little letters rule you! O Kelly L. Forys-Donahue, Ph.D., is a clinical psychologist at the U.S. Army Public Health Command. For more information, contact M2VA Editor Chris McCoy at or search our online archives for related stories at


By Rear Adm. Thomas J. McGinnis


Driving down

costs and reducing risks. The TRICARE Management Activity (TMA) Pharmaceutical Operations Directorate (POD) serves 9.7 million uniformed servicemembers, their family members, retirees and their family members, and meets the objectives of the Military Health System’s Quadruple Aim model of care. TMA and the services are ramping up the Rear Adm. use of currently available health Thomas J. McGinnis care technology to give the Department of Defense’s military treatment facility (MTF) pharmacies the capability to accept electronic prescriptions from civilian providers. This option is currently unavailable to beneficiaries. Electronic transmission of a prescription—also referred to as e-Prescribing or eRx—is a major priority for the TMA POD because it touches at the core of TRICARE’s mission: to improve patient outcomes and enhance the quality of the MHS pharmacy benefit so it is safe, effective and efficient for beneficiaries. This e-Prescribing initiative will utilize the DoD’s Pharmacy Data Transaction Service, which is a centralized data repository that allows us to build a common patient medication profile for all DoD beneficiaries regardless of their point of service. This endeavor offers potential benefits to TRICARE and our beneficiaries through improved patient safety, MTF pharmacy workflow efficiency and better cost management through time and fiscal savings.

Rx Dispensing in Challenging Times Since 2001, health care costs have greatly increased. A top priority for TRICARE today is to manage its portion of the DoD budget, in step with the president’s initiatives to decrease overhead and wasteful spending. Under the DoD pharmacy benefit, close to 2.6 million prescriptions are filled each week. In 2011, DoD spent close to $7 billion to fill these prescriptions. One of the higher cost outlays in the pharmacy program is the utilization of the retail pharmacy network to fill retail prescriptions. In order to control future health care costs, the TMA POD continues to work on maximizing its efficiencies and encouraging beneficiaries to make responsible choices when filling their prescriptions. Enabling electronic prescribing from civilian providers to all MTF pharmacies potentially represents significant savings to DoD and to our beneficiaries, since there would be no co-pay charged. In addition, eRx will support DoD’s long-term cost management goals.

Statistics Point the Way to Success TMA has already seen success in the utilization of electronic prescribing in the TRICARE Home Delivery program. This program is growing, with a record 1.44 million prescriptions filled in July 2012, many of these sent electronically. In the private sector, more and more civilian providers are adopting electronic prescribing. According to the Surescripts 2011 National Report on E-Prescribing and Interoperable Healthcare, more than 570 million electronic prescriptions were routed M2VA  16.7 | 25

to pharmacies in 2011, compared to 79 million in 2008. Approximately 58 percent of all office-based civilian providers are currently prescribing electronically. A catalyst for the rapid adoption electronic prescribing by civilian providers is the Medicare Improvements for Patients and Providers Act of 2008, which incentivizes civilian providers with higher reimbursements for prescribing electronically through 2013; and, beginning in this year, imposes penalties (i.e., lower reimbursement rates) for those not electronically prescribing for patients covered by Medicare. DoD recognizes the importance of electronic prescribing statistics in the civilian sector and the opportunity to manage costs more effectively by increasing the way it uses available resources, namely MTFs. With the eRx initiative in place, the opportunity to recapture retail pharmacy prescriptions improves by allowing civilian providers to electronically prescribe to MTF pharmacies. This will result in a positive financial impact on the military health system (MHS) through recapture of electronic prescriptions that go into the retail network today. For example, TMA calculates that for each 1 percent shift in non-specialty maintenance medications (~420,000 prescriptions) from retail pharmacies to MTF pharmacies, the MHS will realize approximately $5.8 million in savings annually. Implementing electronic prescribing enables DoD an opportunity to stem the tide of beneficiaries leaving MTFs for civilian retail pharmacy networks as a point of service, because of the convenience of retail pharmacies, the current low co-pays and because of electronic prescribing for MTFenrolled beneficiaries being referred out of the MTF to the purchased care network.

Game Plan for Implementation The overall goal of the TMA’s POD e-Prescribing initiative is to decrease costs to DoD and its beneficiaries. This initiative will be phased in, with an initial focus on civilian providers electronically prescribing to the MTF pharmacies. The implementation and testing of the first phase (i.e., MTF pharmacies accepting electronic prescriptions from civilian providers) of this initiative is tentatively scheduled for the summer of 2013. A single MTF will be selected for beta testing. Upon the completion and validation of the testing, this capability will be available to all MTF pharmacies located in the United States.

The Quadruple Aim The Quadruple Aim model of care represents MHS leadership’s four strategic goals: readiness, population health, experience of care and per capita cost. The e-Prescribing initiative not only gives prescribers and beneficiaries one more tool to use when meeting medication needs but it

also aligns with the MHS’s Quadruple Aim of supporting experience of care while optimizing health outcomes and responsibly managing costs.

Experience of Care We strive to see the health care experience from our beneficiaries’ perspective and always seek ways to meet their needs more efficiently and effectively through the use of existing or emergent technology. E-Prescribing fits one component of MHS’s Quad Aim by providing a care experience that is patient centered, convenient, equitable, safe and always of the highest quality.

Per Capita Cost Driving the per capita cost down by using the existing MHS infrastructure creates value by reducing the total cost of care over time and aligns with the MHS’s goal of responsibly managing costs as part of the Quad Aim. TRICARE beneficiaries have several choices when filling their prescriptions: MTF, Home Delivery and retail pharmacies. Prescriptions filled at a MTF pharmacy represent a lower cost point for DoD and no cost to the beneficiaries. Retail pharmacies are the most expensive option for beneficiaries and to DoD. However, retail pharmacies are currently the easiest and most popular point of service and most already accept electronic prescriptions. Enabling electronic prescribing at the MTF pharmacies promotes the utilization of this point of service, which will reduce costs to DoD as well as lower out-of-pocket expenses for the beneficiary.

Healthy Outcomes E-Prescribing is also essential for enhancing patient safety, improving the quality of care and increasing healthy outcomes, another aspect of the Quad Aim. This program will deliver better quality assurance for optimal health results. E-Prescribing is expected to reduce errors relating to the readability of the prescription and decrease transcription errors since the prescription information flows directly into the computer system.

Best Outcome: A Win-Win TMA POD is committed to improving the wellness of TRICARE beneficiaries while managing escalating costs. E-Prescribing promotes the use of the lowest-cost point of service, encourages the use of a cost-effective TRICARE formulary while reducing the risk of medication errors. The DoD e-Prescribing initiative is a win-win for beneficiaries and the military health system as it undergoes major changes. During a time of reduced budgets, the MHS’s longstanding culture of innovation will help us successfully accomplish our goals as we embrace medical technology advances to better serve our beneficiaries. O Rear Admiral Thomas J. McGinnis is the director, Pharmaceutical Operations Directorate, TRICARE. For more information, contact M2VA Editor Chris McCoy at or search our online archives for related stories at

26 | M2VA 16.7

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Military Medical & Veterans Affairs Forum

Mike Coughlin President and CEO ScriptPro Q: Can you tell us about your company and its history with the military? A: ScriptPro developed the first robotic prescription dispensing system for outpatient and retail pharmacies during 19941997. The focus of technology up to that time was limited to making sure prescriptions were entered properly, checking for potential drug interactions, and verifying how payment was received. Then, a printed label was the work driver to filling the prescription. There was no concept of a workflow system to organize the preparation of all prescriptions for a patient and make sure all were properly handed off to the patient. ScriptPro’s most fundamental mission is error prevention. Studies have shown that the most serious errors involved giving the wrong drug to the patient. ScriptPro focused on using robotics and barcode scanning to prevent filling errors. We also pioneered printing warning messages, or aux labels, directly on the label and displaying a file image of the drug with color and markings for verification. The VA and DoD were early adopters of these technologies. Then came the question, Can these powerful systems be expanded to provide a higher level of support for remote pharmacies operated by technicians? The military was already operating pharmacies in this manner, but did not have systematic control and oversight. The VA needed to provide pharmacy services over a wider area through their CBOC [community-based outpatient clinic] program. So ScriptPro developed an extension of its workflow system to incorporate telepharmacy. The VA was the earliest user of telepharmacy. Once it was proven, the Navy deployed it worldwide, then other branches of the military, public health services, community health centers and independent pharmacies. As our users express needs, we try to develop solutions. Many needs are first expressed by the military and the VA. Q: In your opinion, what are the current topics for military pharmacy and how do 28 | M2VA 16.7

ScriptPro automation products fit with those issues? A: Military pharmacy leaders are concerned that their patients may feel disenfranchised from health systems due to the crowding of patients at major health facilities. Another concern is the tendency to deal with crowding by dispensing larger quantities and increasing the use of mail order. Although these solutions may reduce traffic, they may cause an impediment to helping patients get the desired outcomes. The priority should be serving the patient, not just getting the patient out the door. ScriptPro’s newly released Pharmacy Services Portal [PSP] addresses crowding. Patients view the available pharmacies from a kiosk while still at the clinic and make informed choices as to where and when to get their prescriptions filled. Patients can see the current wait times, too. Once the decision is registered at the kiosk, the patient gets a ticket, and instructions are sent to the ScriptPro workflow system in the chosen pharmacy. The objective is that the order is ready when the patient enters the pharmacy and scans the ticket at the pharmacy kiosk. No more waiting in lines to present the prescription. This saves the patient’s time and is more efficient for the pharmacy. Inventory management is a priority with military financial planners since analysis shows that a significant amount of money and space are tied up in inventories. Without reliable, real-time, stock on-hand information, patient service is impaired and labor-intensive inventory ordering processes are typically employed, leading to excessive inventories for some items and

stockouts for others. ScriptPro offers inventory management system as an add-on to workflow that is a fully integrated solution that gives maximum control with minimal user input. ScriptPro also offers a variation of its telepharmacy system, which we call Health Messaging Services [HMS]. This web service is designed to organize and facilitate after-hours pharmacist support for inpatient medication verification and inspection. Verification and inspection can be provided from anywhere in the world at any time of the day. This functionality can also be extended to outpatient pharmacy services. Q: What are the top issues for Veterans Affairs pharmacies? How do ScriptPro products help the VA pharmacies? A: Robotics, workflow, telepharmacy, PSP, inventory management and HMS are all very important to the VA. ScriptPro works with both the DoD and VA to meet their complex needs in areas such as security, interfaces to other systems, and specialized patient services. This is important due to the emergence of shared facilities such as the James A. Lovell combined VA/DoD facility north of Chicago, which uses ScriptPro workflow and robotics. Q: Can you explain your vision for pharmacy over the next five years including military and VA pharmacies? A: The past five years have shown how fundamental technologies such as robotics, barcode driven workflow systems and telecommunications technologies can be coordinated to solve the problems of some of our largest and most complex organizations—DoD and VA. This has come about due to the willingness and motivation of pharmacy specialty leaders to convene and discuss their needs. DoD and VA should now deploy the next phase of integrated systems such as inventory management, PSP and HMS. We can help consolidate these solutions across combined DoD/VA platforms, maintaining and expanding the functionality and efficiencies brought about by these systems. O


Dedicated to the Military Medical & VA Community

December 2012 Vol. 16, Issue 8

Cover and In-Depth Interview with:

Col. Peter J. Benson

Command Surgeon U.S. Army Special Operations Command

Features Special Operations Protective Clothing What the military uses now, what the military has a need for today, and what the market has to offer.

Special Section Medical Simulation Training/Services

A special feature on simulations used for medical training and services from the trainer’s perspective.

Air Transport Technologies

The medical situations that require air transport, the difficulties involved, and the technologies available with the field of air transport today.

Organization Profile VA for Vets

Cold Weather Operational Medicine The hazards encountered in cold weather environments and the medical technologies used to overcome them.

SOF Medic Training

An exclusive interview with trainers of today’s special operations forces medics.

An overview of the program and the leaders of VA for Vets, the Department of Veterans Affairs program for hiring veterans.


• •


Insertion Order Deadline: November 12, 2012 • Ad Material Deadline: November 19, 2012

M2VA 16-7 (Nov. 2012)  

Miltiary Medical & Veterans Affairs Forum, Volume 16 Issue 7, November 2012