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Dedicated to the Military Medical & VA Community

IT Integrator David Bowen Chief Information Officer Military Health System

July 2013 Volume 17, Issue 3

Leadership Insight: Rear Adm. Raquel Bono Command Surgeon PACOM

Veterinary Medicine O Vital Signs Monitors Medical Staffing O EHR O Avian Influenza

More Than Just A Monitor - Now FDA 510k Cleared TM


The smallest, lightest and most rugged fully-featured pre-hospital vital signs monitor that is FDA 510k cleared to market. More than just a monitor, Tempus Pro is small enough to hold in one hand yet sophisticated enough to use throughout the enroute care system, from transportation to the ICU. It has all the integrated features and capabilities expected in a market-leading vital signs monitor including: 3/5 Lead ECG; 12-Lead diagnostic ECG; impedance respiration; Masimo Set® SpO2; NIBP; integrated capnometry; contact temperature and invasive pressure. Tempus Pro is over 2 lbs lighter than similar transport monitors, offers a multi-mode display, 10-hour battery life, is NVG-friendly and has a dedicated tactical switch.

A combination of interface elements including a glove-friendly touch screen and dedicated function keys mean Tempus Pro is uniquely intuitive and easy to use, enabling you to input data, manage settings and reconfigure the display easily. Tempus Pro leverages over 10 years of data collection and sharing expertise. Changing outcomes is achievable through RDT’s unique, rich trauma record interface, perfected to build from far forward transportation use back to the CSH and into the long term record of care.

Call us now for more information: Tel: (843) 766 7829 / (757) 383 8401 or e-mail: TP A 0613 Tempus Pro and More Than Just a Monitor are trademarks of Remote Diagnostic Technologies Ltd © Remote Diagnostic Technologies Ltd 2013.

Military medical & Veterans Affairs Forum

Cover / Q&A

Features DoD Veterinary Medicine Veterinary medicine within the Army Public Health Command is not limited to bomb-sniffing dogs. Maintaining food safety is another focus of DoD’s veterinary branch. By Peter Buxbaum


leadership Insight

Rear Admiral Raquel C. Bono, Command Surgeon, U.S. Pacific Command, discusses advanced sustainable capacity building with interagency collaboration, focused on building relationships with allies and partners in East Asia, in an exclusive interview.







Rear Admiral Raquel C. Bono discusses Pacific Command’s surveilling efforts and work with regard to this nascent public health threat.

VA maintains the electronic health record VistA while DoD maintains the electronic health system AHLTA. Enhancing the interoperability of these two systems is a focus of military medicine. By Peter Buxbaum

Northern Regional Medical Command issued a solicitation for the standardization of vital signs monitors. In this feature we examine what is on the market today. By Chris McCoy

Much like in the civilian sphere, it is common for the VA and DoD to seek auxiliary manpower within the health care sector for a wide range of workers. By Henry Canaday

Avian Influenza H7N9

July 2013 Volume 17, Issue 3

Electronic Health Records


The Perfect Monitor

Contracting for Medical Staff

Industry Interview

2 Editor’s Perspective 3 People/Program Notes 14 Vital Signs 27 Resource Center

Jason Santamaria President Stanley Healthcare


David Bowen

Chief Information Officer Military Health System

“Despite the turbulent nature of change and the everevolving technologies we work on, it is critical that we have the right policies and frameworks in place, and we are working on those issues now.” - David Bowen


Military Medical & Veterans Affairs Forum Volume 17, Issue 3 • July 2013

Dedicated to the Military Medical & VA Community Editorial

Editor Chris McCoy Managing Editor Harrison Donnelly Online Editorial Manager Laura Davis Copy Editors Sean Carmichael Laural Hobbes Correspondents JB Bissell • Peter Buxbaum • Henry Canaday Hank Hogan • Kenya McCullum

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The Centers for Disease Control and Prevention have released information pertaining to the sporadic number of human cases of H7N9 Avian Influenza Virus infection. CDC reported that most of the persons infected with the virus had contact with poultry. A minority of cases allegedly had no contact with poultry; however, this does not necessarily discount that these persons might have had contact with areas contaminated by poultry. All reported cases of the H7N9 strain have been limited to the Chinese mainland. Several Americans returning from trips in China and suffering from flu-like symptoms have tested positive for other more common forms Christopher McCoy of influenza. Editor By May 8, 131 cases of H7N9 had been reported and 32 of the cases proved fatal. The pace of infection has diminished now, however. Some have attributed this to the containment efforts of the Chinese government. More draconian methods of containment, such as massive poultry culling, have been advocated by some groups, but such actions have not taken place. The CDC posits that this decline in transmission of H7N9 might be a result of the decline in human interaction with poultry that is typical at the end of winter. It is possible that the rate of H7N9 transmission could increase again next winter. This type of behavior would follow the path of previous outbreaks of avian influenza like H5N1. Although H7N9 has the potential to become a pandemic disease, it does not appear to be easily communicable between human hosts. Nonetheless, the CDC believes that the facts indicate that the disease does have the potential to evolve into a greater public health threat. As a result of the risk of an H7N9 pandemic, the virus is being closely surveilled by the WHO, the CDC and their Chinese counterparts. As is typical with outbreaks of exotic diseases such as H7N9, this disease is highly visible in the media. In this issue we reached out to PACOM to discuss creating sustainable health ventures in East Asia. PACOM was also generous enough to answer some of our questions on the H7N9 virus and the efforts taken to surveill it. Feel free to contact me with any questions or comments for Military Medical & Veterans Affairs Forum.

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FDA Clears Vital Signs Monitor RDT is pleased to announce that its latest product Tempus Pro has been 510k cleared to market by the U.S. Food and Drug Administration. Tempus Pro is a new concept in vital signs monitoring that places the needs of the military medic and pre-hospital care professional at the heart of its design. The monitor is light enough to carry to the patient, small enough to hold in one hand and rugged enough to deploy in any situation. Tempus Pro provides all the integrated features and capabilities expected in a vital signs monitor with unmatched durability, daylight readable display, long battery life, intuitive interface and a glove-friendly touchscreen

that enables ease of use for both advanced and basic life support paramedics and emergency practitioners. The additional ability to document and share all patient data electronically ensures that all care providers have accurate information on patient injuries, therapies, trending vital signs, drugs and fluids that can be handed over, or sent via ReachBAK, ahead of the patient arriving at hospital or next level of care. The platform is designed to be scalable to accommodate immediate and evolving needs and budgets, with the ability to add advanced capabilities post purchase. This will enable users to perform a new range of diagnostic processes on patients using the same battery

and display already being carried. This flexibility and scalability enables users to leverage the most from their pre-hospital/ transport monitor investment. RDT’s Program and Regulatory Affairs Director Chris Hannan commented, “We are proud that Tempus Pro has been cleared to market by the FDA. RDT is excited to offer a 21st-century approach to vital signs monitoring with solutions that meet the needs as described by the modern warfighter and the pre-hospital care professional. I believe it represents a new benchmark in vital signs monitoring and feel this is validated by the overwhelming commercial response we have had already.”


Compiled by KMI Media Group staff

of major general, deputy chief of staff for support, U.S. Army Medical Command, Falls Church, Va., has been assigned to be Joint Staff surgeon, Joint Staff, Washington, D.C.

Forces-Afghanistan/medical advisor, International Security Assistance Force Joint Command, Operation Enduring Freedom, Afghanistan, has been assigned to be assistant surgeon general for force projection, Office of the Surgeon General, U.S. Army, Washington, D.C.

Rear Adm. Thomas E. Beeman

Navy Reserve Rear Admiral (lower half) Thomas E. Beeman has been nominated for appointment to the rank of rear admiral. Beeman is currently serving as deputy commander, Navy Medicine National Capital Area, Bethesda, Md.

Brig. Gen. Jeffrey B. Clark

Brig. Gen. John L. Poppe

Major General Dean G. Sienko, U.S. Army Reserve, commander, 3rd Medical Command, Forest Park, Ga., has been assigned to be commanding general, U.S. Army Public Health Command, Aberdeen Proving Ground, Md.

Brigadier General John L. Poppe, assistant surgeon general for force projection, Office of the Surgeon General, U.S. Army, Washington, D.C., has been assigned to be deputy chief of staff for support, U.S. Army Medical Command, Joint Base San Antonio, Texas.

Brigadier General Nadja Y. West, who has been selected for the rank

Brigadier General Norvell V. Coots, surgeon general, U.S.

Colonel Barbara R. Holcomb, who has been selected for the rank of brigadier general, commander, Landstuhl Regional Medical Center, U.S. Army Europe and Seventh Army, Germany, has been assigned to be command surgeon, U.S. Army Forces Command, Fort Bragg, N.C.

Brigadier General Jeffrey B. Clark, commanding general, Europe Regional Medical Command/command surgeon, U.S. Army Europe and Seventh Army, Germany, has been assigned to be commander, Walter Reed National Military Medical Center, Bethesda, Md.

Brigadier General John M. Cho, deputy chief of staff for operations, U.S. Army Medical Command, Falls Church, Va., has been assigned to be commanding general, Europe Regional Medical Command/ command surgeon, U.S. Army Europe and Seventh Army, Germany.

Brigadier General Patrick D. Sargent has been assigned to be deputy chief of staff for operations, U.S. Army Medical Command, Falls Church, Va. He most recently served as commander, Carl R. Darnell Army Medical Center, Fort Hood, Texas.

M2VA  17.3 | 3

PROGRAM NOTES VA Mandates Overtime to Increase Production of Compensation Claims Decisions As part of its ongoing effort to accelerate the elimination of the disability compensation claims backlog, the Department of Veterans Affairs announced recently that it is mandating overtime for claims processors in its 56 regional benefits offices. This surge, which will be implemented through the end of fiscal year 2013, will be targeted at eliminating the backlogged status of claims. The additional overtime hours that will be worked during this period will be used to help eliminate the backlog, with continued emphasis on high-priority claims for homeless veterans and those claiming financial hardship, the terminally ill, former prisoners of war, Medal of Honor recipients, and veterans filing fully developed claims. “VA is dedicated to providing veterans with the care and benefits they have earned and deserve,” said VA Secretary Eric K. Shinseki. “This increased overtime initiative will provide more veterans with decisions on their claims and will help us achieve our goal of eliminating the claims backlog.” This is the latest effort in support of the Shinseki’s plan to reduce the backlog. This spring, the VA announced an initiative to expedite compensation claims decisions for veterans who have waited one year or longer. On April 19, VA began prioritizing claims decisions for veterans who have been waiting the longest by providing provisional decisions that allow eligible veterans to begin collecting compensation benefits quickly. With a provisional decision, a veteran has a year to submit additional information to support a claim before the decision becomes final. “We’re committed to getting veterans decisions on their claims as quickly and accurately as possible,” said Undersecretary for Benefits Allison A. Hickey. “We need to surge our resources now to help those who have waited the longest and end the backlog.” Claims for wounded warriors separating from the military for medical reasons will continue to be handled separately and on a priority basis with the Department of Defense through the Integrated Disability Evaluation System (IDES). On average, wounded warriors separating through IDES currently receive VA compensation benefits in two months following their separation from service.

4 | M2VA 17.3

Compiled by KMI Media Group staff

The United Kingdom’s Energy Institute Adds a New Member Onsite Occupational Health and Safety Inc. (Onsite OHS) is now a member of the Energy Institute, joining other energy industry leaders supporting a safe, environmentally responsible and efficient supply and use of energy. The Energy Institute, based in London, serves as the “professional body for the energy industry” and is considered the main professional organization for the energy industry within the United Kingdom. “Our membership in the Energy Institute, the industry's leading professional organization, represents an important milestone for Onsite OHS,” said Kyle G. Johnson, president and chief executive officer of Onsite OHS. “As we continue to grow and expand our already strong presence within the energy industry, it's vital we are well connected to our energy industry peers and leaders, and are aligned with industry standards. Our new membership in the Energy Institute will greatly assist with those objectives.” The Energy Institutes company members include organizations spanning energy industry sectors—including oil, gas, solid fuel, renewables, nuclear and more. As a

company member, Onsite OHS benefits from access to discussions on emerging energy policy; networking events on a regional, national and international level; and training and professional development. Onsite OHS recently made its debut in the energy industry at the Society of Petroleum Engineers European Health, Safety, Environment and Social Responsibility Conference and Exhibition held in April in London. Johnson and Michelle Prinzing, chief of staff, attended the three-day conference and made several business connections within the industry, including the Society of Petroleum Engineers and the Energy Institute. The Society of Petroleum Engineers is a not-for-profit professional association whose members are engaged in energy resources, development and production. It serves more than 110,000 members in 141 countries worldwide and is a key resource for technical knowledge related to the oil and gas exploration and production, events and training courses. “It’s an exciting time for Onsite OHS as we continue to be a global player in the energy industry,” Johnson said.

Contract for Noise Robust Speech Interface for Mobile Medical Tactical Environments Think-A-Move Ltd. (TAM) announced that it was selected to develop a speech and connectivity interface for mobile medical tactical environments (SCIMMITAR) by the U.S. Army’s Telemedicine and Advanced Technical Research Center under a Phase II Small Business Innovation Research contract. Designed to run on an Android OS-based device, such as a smartphone, SCIMMITAR uses a noise robust speech recognition system developed by TAM that will process the medic’s speech locally on the device, enabling a medic to interact with the system hands-free and complete an electronic version of the Tactical Combat Casualty Care (TCCC) card using speech. The interface will allow the transcription of a medic’s spoken progress notes, in addition to completing the other fields on the TCCC card. SCIMMITAR does not need a network connection to perform its speech-processing function. In addition, when there is a network connection, it will allow a medic to use speech to interact with remote data sources, permitting the medic to access important information needed to treat a casualty. Currently, the TCCC card is not always completed, because it requires the medic to stop treatment of the casualty in order to do so. Having increased documentation will give Army medical researchers more information upon which to make recommendations for best practices.

leadership insight

Compiled by KMI Media Group staff

U.S. Pacific Command Medicine How U.S. Pacific Command is establishing medical ties with partner nations in E ast A sia . Rear Admiral Raquel C. Bono Medical Corps, U.S. Navy Command Surgeon, U.S. Pacific Command

Commissioned in June 1979, Rear Admiral Raquel C. Bono obtained her baccalaureate degree from the University of Texas at Austin and attended medical school at Texas Tech University. She completed a surgical internship and a general surgery residency at Naval Medical Center Portsmouth, and a trauma and critical care fellowship at the Eastern Virginia Graduate School of Medicine in Norfolk, Va. Shortly after training, Bono saw duty in Operations Desert Shield and Desert Storm as head, casualty receiving, Fleet Hospital Five in Saudi Arabia from August 1990 to March 1991. Upon returning, she was stationed at Naval Medical Center Portsmouth as a surgeon in the General Surgery department; surgical intensivist in the Medical/ Surgical Intensive Care Unit, and attending surgeon at the Burn Trauma Unit at Sentara Norfolk General Hospital. Her various appointed duties included division head of Trauma; head of the Ambulatory Procedures Department; chair of the Laboratory Animal Care and Use Committee; assistant head of the Clinical Investigations and Research department; chair of the Medical Records Committee; and command intern coordinator. She has also served as the specialty leader for Intern Matters to the Surgeon General of the Navy. In September 1999, she was assigned as the director of Restorative Care at the National Naval Medical Center in Bethesda, Md., followed by assignment to the Bureau of Medicine and Surgery from September 2001 to December 2002 as the medical corps career planning officer for the Chief of the Medical Corps. She returned to the National Naval Medical Center in

January 2003 as director for medicalsurgical services. From August 2004 through August 2005 she served as the executive assistant to the 35th Navy Surgeon General of the Navy and chief, Bureau of Medicine and Surgery. Following that, she reported to Naval Hospital Jacksonville, Fla., as the commanding officer from August 2005 to August 2008. She then served as the chief of staff, deputy director Tricare Management Activity of the Office of the Assistant Secretary of Defense, Health Affairs from September 2008 to June 2010. Bono later served as deputy director, Medical Resources, Plans and Policy, Chief of Naval Operations prior to assuming her current duties as the command surgeon, U.S. Pacific Command, Camp H.M. Smith, Hawaii, in November 2011. In addition to being a diplomat of the American Board of Surgery, Bono is a Fellow of the American College of Surgeons and a member of the Eastern Association for the Surgery of Trauma. Her personal decorations include Defense Superior Service Medal, Legion of Merit Medal (four awards), Meritorious Service Medal (two), and the Navy and Marine Corps Commendation medal (two). Q: Could you tell our readers how your command fits into PACOM and also the larger context of the U.S. national security strategy? A: The PACOM commander aligns our COCOM strategic objectives with the national security strategy. In support, the U.S. PACOM Surgeon’s office shapes health engagements responsive to the

interests and needs of host countries. Cooperative health engagement [CHE] efforts build sustainable capabilities and capacities through the coordinated efforts of the PACOM components and within the command. This advances COCOM and national security while utilizing health as a strategic enabler and a strategic effect. Health engagements can also set the tone for other theater interactions. What is novel about the PACOM CHE is the shift from stand-alone service delivery to capacity building that is sustainable and coordinated with U.S. government agencies and host nations. Q: How do you advance that agenda of sustainable capacity building? A: We assess a host country’s disease burden, the population health status and their medical infrastructure. We also consider what percent of GDP is directed towards health improvement as an indicator of country interest. The second step is evaluating incountry initiatives conducted by U.S. government agencies and determining whether an opportunity exists for military medicine to complement their efforts. The third aspect is whether a regional framework such as the Lower Mekong Initiative, the Millennium Development Goals or International Health Regulations is available to the country. From these areas we assess the types of capabilities that U.S. military medicine can provide through exercises and engagements which complement and support the host nation’s objectives. Through this approach and in collaboration with others, we hope to create sustainability. M2VA  17.3 | 5

A specific example is the blood bank center in Laos Peoples Democratic Republic [PDR]. Through a combination of efforts that involved donations of equipment, subject matter expert exchanges, and training with the military and other organizations, a blood bank center was established in Ventiane, Laos PDR. Technicians were trained to collect, screen and store blood, and the center is approaching a donation rate that will support the needs of the community. As a self-sustaining entity, the blood donation center is planning to add blood component therapy. This involves collecting whole blood and separating it into platelets, red blood cells and plasma. An additional marker of success is that a second blood donation center is being opened in Luang Prabang, one of the northern provinces. Q: Could you tell us about some of the other countries that PACOM is developing such deep ties with? A: We’re working with Vietnam in several areas. Vietnam is developing their undersea medicine capability in support of their submarine crews. We’ve assisted their military medical department’s efforts by demonstrating various undersea medicine functions and providing demonstrations of different training platforms. With the Vietnamese military, the U.S. Pacific Fleet Submarine Force and Navy Medicine, a five-year plan to support technical acquisition and capability development is in the early planning phase. Another aspect we’re working on in Vietnam is through the PEPFAR [President’s Emergency Plan for AIDS Relief] program. This is a program sponsored by the U.S. government to assist diagnosing and treating HIV/AIDS in developing countries. DDHAP [Defense Health HIV/AIDS Program], a military-to-military program, was started in Vietnam and has advanced their HIV/AIDS screening efficacy. This has also been used as an adjunct to the treatment and research of other infectious diseases such as malaria and TB. Finally, we would like to expand working with the state partnership program and the National Guard Bureau. One of the areas that the Vietnamese Ministry of Defense, Ministry of Health and Ministry of Transportation are very keen to address is their emergency response system. With the National Guard Bureau and additional military support from the component services, we are assessing the areas where PACOM 6 | M2VA 17.3

Rear Adm. Raquel Bono and other distinguished visitors stop for a discussion with Indonesian health care providers while visiting East Java, Indonesia. [Photo courtesy of U.S. Army/by Master Sergeant Rodney Jackson]

can contribute to Vietnam’s existing efforts to enhance their ability to provide emergency care to accident victims. Another country is the PRC [People’s Republic of China]. We are looking at areas of shared interests such as humanitarian assistance and disaster relief [HA/ DR]. As part of the military medical group, we are working through the ADMM+EWG [ASEAN Defence Ministers Meeting Plus Expert Working Group] and participating in an HA/DR exercise with other ASEAN [Association of South East Asian Nations] countries in which the PRC is also a participant. We are one of the supporting medical elements in this exercise that will contribute to the regional HA/DR effort to build resiliency for expeditious recovery from a disaster event. Q: Where do you see this effort going and how do you see it maturing? A: Sustainability by partnering broadly with different organizations is the key. Partnering should occur at the country level, the U.S. government level and then at the regional level. The next opportunities to be pursued are public-private partnerships and developing relationships with academic and university centers. Q: Are you involved in any infrastructure projects? Have you had any partnerships with the Word Bank or Asian Development Bank? A: Health is an infrastructure sector that is often compromised after natural disasters,

flooding and earthquakes. Strengthening medical systems allows a country to recover much more quickly. Our participation in sector strengthening efforts supported by the World Bank or ADB is usually indirectly through other agencies that they sponsor. Q: Could you tell us more about diseases or other health issues that you are confronting? A: Malaria affects our forces especially when forward deployed. This is an area of shared interest with other militaries, so we closely monitor malaria outbreaks and the development of resistant strains. Dengue Fever is another vector-borne disease for which we don’t have a cure and can significantly affect a community. Another challenge is TB, particularly, multi-drug-resistant TB. When we talk about transnational threats to health security, the primary risk is the ease with which diseases can cross borders. Humans and animals can become reservoirs, and in some cases vectors, for an infectious disease. In the face of loosely monitored borders, cross-border traffic allows the movement of disease into densely populated areas where diseases can easily spread. Threats to health security potentially de-stabilize a country’s economy and their ability to participate in regional security. O

For more information, contact M2VA Editor Chris McCoy at or search our online archives for related stories at

Pacific command surgeon, rear admiral racquel bono, discusses the recent outbreak of avian influenza . Q: Are any measures being taken to protect against the bird flu within PACOM? A: Measures taken to prevent against any type of respiratory disease, including influenza, would follow the routine preventive medicine/force health protection guidance for servicemembers and their families. With the exception of an available vaccine, respiratory hygiene and potentially some social distancing would be utilized as needed or as the disease dynamics dictate. Q: How do you test for presence of this influenza strain? What type of hardware and diagnostics systems are you using? A: Over the past 10 years, DoD has worked closely with CDC and FDA and has committed to only utilizing FDA-approved tests and diagnostic platforms for influenza surveillance. This helps DoD to standardize surveillance efforts around the globe and also provides a clinical diagnosis for the patient being tested. This capability aligns these global DoD efforts with the standards and practices of the state and reference labs in the U.S. Q: Could you tell us anything about the surveilling process with this disease? A: There are a number of surveillance efforts among both civilians and military servicemembers throughout the region. The DoD overseas laboratories in Thailand, Cambodia, the Lao People’s Democratic Republic, Nepal and the Philippines are some examples. Additionally, there are military health facility-based surveillance programs in place in Japan, Korea, Okinawa, Singapore and Guam. These efforts include both electronic and lab-based surveillance for a variety of respiratory diseases. To date there have been no efforts to enhance existing surveillance systems, but this is always a capability that can be enhanced as the situation evolves and potentially affects health security in the region. Q: Could you elaborate on your surveilling methods? How do things work on the ground?

A: Surveillance partnerships have been established over decades with host country military and civilian health organizations. The overseas labs are often embedded within either the Ministry of Defense or the Ministry of Health and are often primarily staffed by host country scientists and public health personnel with a small U.S. contingent of uniformed staff. This cooperation and support of the host country capacity is vital. For influenza specifically, the cooperative surveillance activities are all part of the larger WHO Global Influenza Surveillance and Response System.

U.S. Pacific Command, the issue of transnational threats to health security continues to be a heightened area of interest. A better understanding of regional migration patterns, cross-border movements and disease detection capability at the borders requires technologies and material solutions for monitoring and will require extensive engagement and input from industry, academia and international NGOs.

Q: Could you tell us more about your reporting methods and how you share information between departments and organizations?

A: The vaccine development pipeline takes place through a number of channels. DoD plays a role in identifying seed viruses for influenza vaccines every year and has historically provided seed viruses for a number of vaccines, including the 2009 H1N1 monovalent pandemic influenza vaccine. The vaccine development enterprise takes place primarily in the Department of Health and Human Services with HHS/Biomedical Advanced Research and Development Authority, FDA and CDC. They have begun the production of a vaccine for this specific strain and are on target for vaccine safety trails in the coming months. This process is enhanced to its capacity right now and this timeline reflects the most expedient development capability we currently have for egg-based vaccines.

A: Reporting for routine activities takes place through multiple methods. Routine surveillance findings are reported through surveillance reports and DoD publications and can be easily accessed through the web. For novel influenza strains such as the H7N9 strain, once the WHO designates the virus as a potential public health emergency of international concern under the 2005 International Health Regulations [IHRs], all new cases are required to be reported through each country’s national focal point for IHRs. The IHRs are the single international framework for health security (signed on by all 194 states parties) and PACOM J07 has put significant emphasis on assisting host countries to build this reporting capacity across sectors in their country. Q: Ideally, what tools or systems could the private industry provide to aid in your surveilling and detection of the virus and treatment of the virus? A: The public/private partnerships established around influenza over the past decade have been vital, not only in preventing and detecting disease but also for research, treatment and infection control. While the solutions required to better understand and react to these aspects of the disease should not all be considered “advanced” technology, the unique capabilities private industry brings to the fight are often unparalleled. For the

Q: Is there any work being done with the FDA or other organizations to devise a vaccine?

Q: Given the outbreak, is there anything else that we should be aware of or keep in mind? A: DoD continues to play an important role in the larger U.S. government effort to better understand the evolution of this severe but isolated public health concern. A number of processes developed for a pandemic from Influenza H5N1 and the 2009 H1N1 pandemic are being utilized for this new virus. While influenza continues to be a challenge to the larger global health community, we feel DoD throughout the PACOM region is prepared and ready to respond in any potential scenario this new virus may present. O For more information, contact M2VA Editor Chris McCoy at or search our online archives for related stories at

M2VA  17.3 | 7

Enhancing interoperability between the VA and DoD. By Peter Buxbaum M2VA Correspondent In February, the Secretaries of Defense and Veterans Affairs jointly announced that the plan to create a new joint electronic health record system, one that would serve both military personnel and veterans, was finished. The reason given was that they wanted to save money. Instead, the two departments would continue efforts to integrate their existing EHR systems. The VA has made it clear that it is sticking with existing system, known as VistA, as its core technology. DoD, meanwhile, appears to be abandoning its existing AHLTA EHR. The department has issued a request for information which suggests that it will be looking to implement an existing commercial or government solution, the latter referring to the possibility that DoD may actually adopt VistA. The VA is pushing DoD to go with VistA, even going so far as to post a response to DoD’s request for information online. The proposed joint DoD-VA system was put in place for a reason. The idea was to facilitate the smooth flow of information between the two systems as military personnel transitioned to veteran status. There has also been a trend in recent years to combine military and veterans health facilities and to outsource increasing proportions of health services for both military personnel and veterans to the private sector. This highlights the 8 | M2VA 17.3

necessity for interoperability, not only among the two government systems, but with private-sector networks as well. Industry experts are divided over whether a VistA implementation is right for DoD, or, for that matter, for the VA. Some say VistA provides the perfect vehicle for integrating the two systems. Others argue that both departments should rip out and replace what they have with a commercial package, at least for core functions, the better to interoperate with private networks. But as things stand now, unless DoD adopts VistA, the cancellation of the joint EHR means that the two departments will have reverted to their older strategy of integrating and interfacing two disparate systems to allow data to flow between them. Lawmakers were none too pleased by the joint departmental decision, expressing frustration that the departments had spent $1 billion of the $4 billion allocated for the joint record without producing any results. “The decision by DoD and VA to turn their backs on a truly integrated electronic health record system is deeply troubling,” said Rep. Jeff Miller (R-Fla.), chairman of the House Committee on Veterans’ Affairs. “The need for a record system integrated across all DoD and VA components has been universally accepted for years, and ... both agencies have given us nothing but assurances they were working toward that goal.

officer at Medsphere. “Although it is not well known, VistA has Previous attempts by DoD and VA to use disparate computer actually been taken commercial.” systems to produce universal electronic health records have Several companies have packaged commercial versions of failed, and unfortunately it appears they are repeating past VistA, allowing its functionality to be implemented in privatemistakes.” sector hospitals, according to Sullivan. Medsphere’s Miller’s committee demanded explanations product, OpenVistA, is a derivative of the VA system from both departments about why the joint proto which additional components have been added, gram was scrapped and what their plans are for such as modules for behavioral health, surgery and the future. Roger Baker, the VA chief information pharmacy. “There are over 27 commercial customofficer who resigned after the decision to scrap the ers that have installed our certified OpenVistA prodjoint program was announced, delivered a vision uct,” said Sullivan. for an open source strategy that would kick-start “There are some in the military health environinnovation in VistA by having private-sector techment looking for a commercial solution,” Sullivan nology providers integrate their offerings on the added, “but if we continue with an educational VistA platform. campaign they will realize that VistA is also a COTS “While the current VistA EHR system meets or Richard Sullivan product and that it would a good core technology to exceeds the capabilities currently available from be implemented by DoD. Its costs to acquire would commercial EHR vendors, low investment in VistA be less than starting from scratch with a non-VistA over the last decade has eroded its standing from product with all the customization and database the once-clear market leader to [it] being merely work that would have to be done to get to where competitive,” Baker said. “While VA clinicians VistA is now.” express strong support and preference for VistA as But Leslie Karls, customer and sales account a clinical tool, they are also vocal and unanimous manager at Epic Systems, believes that the VA’s open in calling for us to reinvigorate the innovation that source strategy for VistA leaves much to be desired. made VistA the best EHR system available.” “Our philosophy is that health care organizations Baker estimated is would take $16 billion to should implement a core suite in one database and replace VistA with a commercial EHR package. “To not carve it up among lots of different vendors,” she avoid those costs, and to find a way to involve the said. “Ancillary systems such as scheduling, regisprivate sector in modernizing VistA, the VA is turnDon Mestas tration, billing, radiology and others can then be ing to open source,” he said. “VA expects that the interfaced with the core suite.” rate of innovation and improvement in VistA can Part of the problem for VistA detractors is that be increased without increasing our current budget VistA itself is actually a federation of many systems. by better involving the private sector in both the “Many people don’t realize that VistA is not one governance and development of the VistA system system,” said Don Mestas, vice president for fedthrough open source.” eral healthcare solutions at Harris Corp. “In VistA, Jonathan Woodson, the assistant secretary of there are in the neighborhood of 150 subsystems, defense for health affairs, appearing at the same all of which talk to each other to varying degrees,” congressional hearing, explained DoD’s new stratexplained Stu Rabinowitz, chief technology officer egy as follows: “Instead of designing, building at CCSi. CCSi provides design and engineering work and implementing a new system from scratch, we to the VA around the secure transmission of data would use a core set of applications from existing Mitch Mitchell among VistA subsystems. EHR technology, to which could be added addiFor Karls, there is a difference between integrational modules or applications … DoD is reviewing tion and interfacing of systems. Integrated functions operate off available commercial and governmental options.” the same database. Interfacing refers to the ability of one system The DoD RFI stated that it is seeking an open, modto send a message to another. For that to work, the data elements ular electronic health record system “utilizing standardsbased/non-proprietary interfaces.” The department is must be mapped from one system to the next through some sort of intermediary to make sure they are referring to the same thing. interested in implementing a technology core, which is refers “Lots of things can happen when interfaces don’t work right to as “a Best of Suite application,” which would be followed by or if the VA or its vendors don’t get the mapping right,” said Karls. “the addition of Best of Breed applications until full capability is “That is when medical errors get made. You don’t get the same deployed.” In other words, DoD is envisioning installing a packquality, efficiency and improved productivity with interfacing as aged solution as its core technology with the possibility graftyou do with integration.” ing additional modules onto the core to increase capabilities as That’s why Karls advocates that functions impacting patient needed. DoD outlined a minimum of eight capabilities it requires welfare be implemented as a single integrated suite. “What the in the core system. physician sees and says, what the pharmacist sees and says, what Woodson’s reference to “governmental options” means that nurses are doing, all of these pieces should be part of one system,” DoD is considering VistA as an option. A DoD decision to install said Karls. “We believe that the quality of care is reduced when you VistA is not as far-fetched as it might sound. start to define pieces of data. Our database has between 100,000 “VistA has been around for decades and has proven to be a and 180,000 elements.” leader in the EHR space,” said Richard Sullivan, chief government

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In recent months, Karls noted, several large private-sector health care organizations, including Kaiser Permanente and Intermountain Healthcare, have closed their EHR development shops and have implemented, or are seeking, commercial solutions. Another argument for the implementation of a commercial solution is the fact that commercial EHRs have made strides in recent years to facilitate the exchange of information. “Data about the whole military history is required in order to determine VA benefits,” said Mitch Mitchell, vice president of federal solutions at Relay Health. “Providing a level of continuity across the VA and DoD care settings is vitally important in managing these populations more effectively. The two A U.S. Air Force staff sergeant and dental technician with the 509th Medical Operations Squadron updates a patient’s record as the institutions need to exchange informa- captain, a dentist with the squadron, performs an exam, at Whiteman Air Force Base, Mo. [Photo courtesy of U.S. Air Force/by Staff Sergeant Nick Wilson] tion more seamlessly.” “That way patients don’t have to features in our Soarian offering which has been in the market for go through the same testing and the same diagnostics they have the last three to four years and has achieved good traction there. already have gone through,” added Rabinowitz. We have incorporated some advanced features and functions into Beyond that, there is a growing proportion of the health care that platform.” being provided to veterans and military personnel outside the strict “Industry has put in place some excellent examples of how confines of veterans and military health facilities. “More and more to facilitate more seamless health information with technology,” of the health care that the VA and DoD deliver outside of the battlesaid Mitchell. “They are not as large as DoD or VA, but the departfield is becoming a networked activity,” said David Hamilton, senior ments can learn from these examples.” vice president for enterprise services at Siemens Health Care. Some commercial EHR providers are cooperating with one “There are fewer military clinics and VA hospitals and more use of another to enable information to be exchanged across their platthe capacity in community and academic delivery systems. That is forms. Relay Health recently announced it was joining with just a smart move, but it also means that DoD and VA have to be McKesson, Cerner, Allscripts, Greenway and athenahealth to form an integrated with the rest of the health care delivery community.” initiative called the CommonWealth Alliance. “We will continue to The required integration has not occurred to date, according compete,” said Mitchell, “but there is general agreeto Hamilton, because both departments have purment among many large providers of health informasued homegrown development efforts with VistA tion technology that there needs to be a common way and AHLTA. “Their technologies have been around for information like patient identity and consent to be for 25 years or more,” he said, “and that creates a exchanged across platforms more seamlessly. Relay certain inertia. With a greater proportion of health Health plays an important role in this regard with our care being contracted out, implementing a commerconnectivity. I believe the same kind of technology cial solution means the warfighter or the veteran can be leveraged to facilitate information exchanges becomes the center of gravity of the system and not between DoD and VA.” DoD or the VA.” Engineering and technology firms like CCSi are Siemens has taken the approach of creating working to identify new technologies that can make work and data processes that are able to flow across David Hamilton EHR systems better. “We work with a VA center of departmental and institutional lines thanks to a serexcellence, to evaluate up-and-coming vendors with vice-oriented technology architecture, an enterprise new technologies that mine and analyze data to provide diagnostics service bus, and business process management functionalities. research and clinical support capabilities,” said Rabinowitz. Service-oriented architectures (SOA) develop software capaSince both DoD and VA ended a program to adopt a common bilities through the integration of loosely coupled, reusable comtechnology platform in February, what the departments are left with ponents, as opposed to the point-to-point integration between is to continue with interoperability efforts that have been going on stand-alone systems. An enterprise service bus or service broker, for quite some time. In essence, the departments have reverted to which is able to extract data from one application and present it in their earlier strategy. another, is key to creating this interoperability. The effort to share electronic patient data between DoD and “We have been making these investments for the last decade VA began in the late 1990s with the Government Computer-based because we thought that would be the future of health informaPatient Record system, which evolved into the Bi-directional Health tion technology,” said Hamilton. “We now incorporate these 10 | M2VA 17.3

Information Exchange (BHIE). BHIE, first implemented in 2004, provides a real-time interface between DoD’s AHLTA Clinical Data Repository and VistA. The Clinical Data Repository/ Health Data Repository software synchronizes data between DoD and VA repositories to enable the exchange of information for shared patients. There have also been other more narrowly focused efforts for interoperability like the Defense and Veterans Eye Injury and Vision Registry. The registry enables comprehensive and coordinated vision care from prevention and diagnosis through treatment and rehabilitation. The registry allows both agencies to focus research, analyze long-term outcomes, assess intervention strategies, and establish guidelines for optimal care. In March 2012, the departments awarded Harris Corporation a multi-year, $80 million contract for a SOA suite. “The SOA suite is the key critical infrastructure needed by both DoD and VA to transport the data between and among the various DoD and VA information systems in a secure, reliable, reusable and standardsbased manner,” said Mestas. “The SOA will enable new types of clinical collaboration and integration of legacy data in standard interfaces that help users to exchange information in real time, without needing to change source data or displays.” The decision to go with a SOA dates back to November 2008, after DoD and VA accepted the recommendations made by government consultancy Booz Allen Hamilton. In the year since the contract award, Harris created developer toolkits for future application development and established a test environment at DoD’s Development Test Center in Richmond, Va., where the company demonstrated its solution and the government accepted it. Harris then deployed the solution to the Defense Enterprise Computing Center in Montgomery, Ala., and DoD medical centers in San Antonio, Texas, and Hampton Roads, Va. “The rollout approach helps to optimize the capability before deploying it more broadly to VA and DoD facilities worldwide,” said Mestas. “The VA and DoD have a complex suite of health care information systems, as well as 200 local data centers. The SOA suite will integrate existing and future systems, applications and medical data utilizing commercial off-the-shelf and open source technologies to provide secure, reliable and high-performance implementation for health record data exchange across the DoD and VA health care systems.” Over the next year, Harris plans to deploy the solution to additional sites. “We will also enhance the current capability by providing more sophisticated orchestration of the electronic messages between the systems that contain active duty and veteran records,” said Mestas. “The departments have stated that over the rest of this calendar year, they expect to evaluate a common graphical user interface, establish their identity management requirements, and extend the VA’s blue button functionality to DoD.” Blue button refers to a capability that produces text and PDF documents based on DoD and VA health data that can be read by multiple programs. Finally, said Mestas, DoD and VA “have stated they will have full operating capability no later than 2017.” O

For more information, contact M2VA Editor Chris McCoy at or search our online archives for related stories at

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M2VA explores the market for vital signs monitors. By Chris McCoy M2VA Editor

On June 14, 2013, Northern Regional Medical Command issued a solicitation for the standardization of vital signs monitors and other clinical products. This solicitation calls attention to the many vital signs monitoring systems on the market and some of the concerns the military might have when it comes to purchasing such products.

Building a Robust System According to Remote Diagnostic Technologies (RDT), some fundamental concerns for the military are that their mobile vital signs monitors must be small enough, light enough and durable enough to sustain the rigors of combat. Monitors must also be easy to use by clinicians with differing skill levels. Easy collection and sharing of vital signs and other data, without the need for additional equipment, is also of tremendous value. With technology changing rapidly amidst an often slow procurement process, medical equipment obsolescence shortly after deployment is sometimes problematic for the military. “Tempus Pro is the smallest, lightest and most robust fully configured monitor available,” said Barnie Howell, director of U.S. military business development at RDT. 12 | M2VA 17.3

“At approximately 6 pounds, Tempus Pro can be held in one hand.” Tempus Pro also automatically collects and stores all patient vital signs data for multiple patients, with the capability to easily add additional information, all compiled into a TCCC card. Each populated patient record can be handed off throughout the continuum of care and into the permanent patient record. Tempus Pro can transmit all data, photos and video to another location over standard military radios and satcom for telementoring. Data, including voice, is encrypted to NSA FIPS 140-2 compliant cryptography. All wireless communications can be permanently disabled without any impact on the functionality of the monitor and can be activated later should wireless technologies become approved for military use. “Along with the ability to easily collect and share patient data without the need for additional equipment, Tempus Pro is the first and only transport monitor able to evolve as customer requirements, budgets and protocols change over the life of the product,” said Howell. RDT’s Tempus IC Professional was selected as the monitor of choice for Special Operations Command’s Tactical Combat Casualty Care kits in 2011.

Not All Oximeters Perform Alike Yvonne Leonard, group marketing manager for Nonin Medical Inc., brought up another good point that those involved in acquisitions should keep in mind when choosing a vital signs monitoring system. “It’s important that they understand the manufacturers that they’re purchasing through,” said Leonard. “If manufacturers are making claims about accuracy or performance, they need to be able to back them up with appropriate testing. There are a lot of imports on the market that claim that they have FDA clearances when they don’t have them.” Nonin has a wide range of Americanmade monitors for various conditions and combat missions. Both the U.S. Army and the U.S. Air Force make use of airworthiness-certified Nonin pulse oximeters. The Nonin Onyx Model 9550 fingertip oximeter is the standard oximeter for combat medics and special forces medics. “It is very easy to get a good reading on a healthy person,” said Leonard. “It is not so easy to get a good reading on somebody who is in trouble. We build our monitors to get accurate readings so that someone can act on those readings appropriately in difficult situations.”

Accuracy in a Timely Manner

drips, leaks and spills. Battery life on the Carescape V100 is up to 11 hours after being fully charged—perfect for highvolume environments.” Welch Allyn has its own simple verAccording to Bilkovski, the algorithms sion of what makes a good vital signs used by the Carescape V100 are of central monitor. Bill Quartier, a solution archiimportance. “The monitor makes use of tect with the company, explained that a blood pressure algorithms good vital signs monitor that have been validated to captures accurate vitals in meet or exceed the requirea timely manner, allows ments of the AAMI SP10 nurses to completely docustandard,” he said. “Spement patients’ vitals signs, cifically, they demonstrate along with other important a mean error of no more data modifiers, and is easy to than 5 mmHg and a standard use and upgradeable. deviation of no more than 8 “Our Connex Vital Signs mmHg. An optional ausculMonitor [CVSM] and Connex tatory-referenced algorithm Integrated Wall System meet Bill Quartier is also available.” the criteria for a good monitor,” said Quartier. “They incorporate the latest in vital signs technolAdvanced Technologies ogy. The blood pressure algorithms meet from an Old Tradition the highest accuracy standards, but also are significantly faster than other devices.” “Philips Healthcare has a long history Quartier emphasized that the Sureof developing products to help improve Temp oral and Braun tympanic thermomepatient outcomes,” said Ben Bayder, martry are the industry standards—measuring ket manager, Patient Care and Clinical temperature in about four seconds or less. Informatics, Philips Healthcare. “The SureBoth devices were integrated into CVSM. Signs VS monitors provide several feaQuartier explained that Welch Allyn has tures that help improve workflow efficiency the lead in the industry for making devices and assist with the clinical decision ready for the world of electronic medical making process.” records (EMR). The SureSigns VS monitors Quick Cap“Our devices allow nurses and techniture feature allows for the entry of up to 20 cians to completely document the vital customizable observations and assessments signs process into the EMR at the pointand four basic measurements at the bedside, of-care on the monitor itself. And because which can be exported with the patient’s we’ve designed our products with a platvital signs record. The Quick Check feature form mentality, our devices are uniquely provides interoperability and flexibility at able to be upgraded. In the three years the bedside based on EHR charting and since we launched them, we’ve added many patient validation requirements. features beyond the standard blood pres“All of our SureSigns VS series monisure, temperature, and SpO2. We now can tors can export data via LAN or wirelessly capture height and weight through convia 802.11 a/b/g. In addition, the Surenected scales, measure new parameters like Signs VS4 is available with FIPS 140-2 blood hemoglobin and can have integrated encryption to meet government security diagnostic equipment like the ophthalmorequirements,” said Bayder. “Finally, the scope and otoscope.” SureSigns VS4 takes vital signs monitoring to the next level with its ‘Quick’ features.” Ultimately, as demonstrated by RDT, Quality Algorithms Welch Allyn, Nonin, GE Healthcare and Philips Healthcare, the military has a lot of “Hospital settings are demanding choices when it comes to purchasing vital and require monitors that can hold up to signs monitors. O intense use and frequent cleaning,” said Dr. Bob Bilkovski, chief medical officer of Life Care Solutions at GE Healthcare. “Carescape V100 has an IPX1 water penFor more information, contact M2VA Editor Chris McCoy at or search our etration rating—meaning it has a higher online archives for related stories at than ordinary level of protection from

M2VA  17.3 | 13

VITAL SIGNS Advanced Mobile Medical Shelters for the U.S. Army Smiths Detection has delivered the first chemical biological protective shelters (CBPS) to the U.S. Army as part of a $40 million award from the Department of Defense’s Joint Program Executive Office for Chemical and Biological Defense. The self-contained mobile shelters with 400 square feet of working space will be used for preventative and emergency care to troops in the field. Three CBPS units have now been delivered, the first of 111 systems due over the next two years. Bob Bohn, vice president of sales at Smiths Detection, said: “These CBPS units offer the U.S. Army a critical dual-use capability. They are a highly mobile protected environment for soldiers operating under threat of chemical and biological agents or the harsh conditions of a natural disaster response.” The CBPS protects against potential chemical and biological threats, allowing surgeons to operate in a sterile environment without having to wear protective clothing. The systems are manufactured at Smiths Detection’s recently expanded U.S. headquarters in Edgewood, Md. Dana Knox-Gower;

Family Health App Wins Mobile App Challenge Health and Human Services assistant secretary for health, Howard K. Koh, M.D., MPH, announced on April 30, 2013, that Lyfechannel is the winner of the Mobile app challenge. The winning app, called myfamily, will help individuals manage their family’s health through customized prevention information for each family member. The app, which focuses on the preventive care benefits and services covered by the Affordable Care Act, will empower individuals to take greater action to improve and maintain their family’s health. Users can find

14 | M2VA 17.3

customized prevention information and tips for each member of their family, create personal health alerts and keep track of medical check-ups and vaccinations. Research shows that patients who are better engaged in their own health care have better health outcomes and electronic tools can help them be better health consumers. “This app helps put the power of prevention at the fingertips of Americans,” said Koh. “Families can now use preventive care information to make informed, personalized health care decisions right from their smartphone.”

Veterans Affairs Selects VisualDx Mobile App for its Hospitals and Clinics Logical Images announced that the Department of Veterans Affairs chose the medical technology company’s widely used mobile app and online resource, VisualDx, for the third year in a row. The VA operates the nation’s largest integrated health care system, and VisualDx has been providing the web-based clinical decision support system to the department’s health care providers since 2010. “We are proud to serve the men and women who have served our country in our armed forces,” said Art Papier, M.D., chief executive officer of Logical Images. “With VisualDx, the VA’s health care providers can quickly and accurately diagnose disease and then educate and empower veterans and their family members by showing them images and information in an easy-to-use and easyto-understand format on a smartphone or tablet.” During appointments or at the bedside, physicians enter a patient’s symptoms, medical history and other information into VisualDx. Based on the information entered, VisualDx quickly delivers a highly accurate list of potential diagnoses, a series of photographs against which to match the patient’s current conditions, and the recommended treatments. The physician can then work through the list to arrive at the best diagnosis, explain the process to the patient and decide on the right treatment for each patient.

Personalized Health IT Product Solution LifeMed ID launched the SecureReg product solution to address the problems of patient identity accuracy and the high cost of health care due to medical errors and privacy. The platform uses smart cards and a cloud computing application to register patients, verify ID, eliminate duplicate records and overlays, and reduce fraud. It has the ability to maintain clean records on an ongoing basis. One patient is connected with one record. SecureReg is scalable and interoperates with many different health IT systems. It leverages connectivity to present patient health care data to the health care provider at the desktop computer. SecureReg is bi-directional and allows for retrieval of patient information and changes to be stored in the system. SecureReg product solutions have applications in federal, state, insurance and health care provider organizations. With this product solution, patients can move or travel across geographical locations and receive continuity of care.

Compiled by KMI Media Group staff

Wearable Defibrillator The Zoll LifeVest wearable defibrillator is worn by patients at risk for sudden cardiac arrest, providing protection before their permanent sudden cardiac arrest risk has been established. The LifeVest allows a patient’s physician time to assess their longterm arrhythmic risk and make appropriate plans. The product is lightweight and easy to wear, allowing patients to return to their activities of daily living, while having the peace of mind that they are protected from sudden cardiac arrest. The device continuously monitors the patient’s heart and, if a life-threatening heart rhythm is detected, the device delivers a treatment shock to restore normal heart rhythm. The LifeVest is used for a wide range of patient conditions or situations, including following a heart attack, before or after bypass surgery or stent placement, as well as for those with cardiomyopathy or congestive heart failure that places them at particular risk.

Customized Home Sleep Study Kit Losing sleep is more than an inconvenience. It can also become dangerous to one’s health and mental well-being. However, people don’t always recognize the signs of a sleep disorder. They can live with the side effects for years. Apnix Sleep Diagnostics’ study kit identifies underlying problems that lead to sleep loss and provides viable solutions to correct such problems. Apnix specializes in home sleep studies. They provide patients with the kit needed to record their sleeping patterns and determine if they are suffering from sleep apnea. Trained Apnix assistants then help patients set up the kit to accurately record data. In the past, sleep studies had to be completed in a hospital or in another clinical setting. While agencies make the facility as comfortable as possible, patients may still be uncomfortable doing the test in a strange place. With the home sleep study from Apnix, patients can remain in the comfort of their own home and still obtain the information that their doctor is asking for. It can be easier for a patient to fall asleep at home and a home sleep study can also fit a patient’s schedule better since they don’t have to drive to a hospital. After the study is completed, patients visit Apnix to receive a full evaluation based on the information gathered. Patients who need to have a sleep study done are often looking forward to improving their lives. Improving their sleeping habits can help them with medical and psychological challenges.

Specialized Juntional Hemorrhage Tourniquet SAM Medical Products has received 510(k) regulatory clearance from the FDA for the release for sale of the SAM Junctional Tourniquet (SJT). Building upon the SAM Pelvic Sling II, presently utilized by health care professionals around the world to immobilize pelvic fractures, the SJT is designed to also control bleeding where standard tourniquets would not be effective. Such wounds are typically junctional in nature, such as a highlevel leg amputation as a result of an IED blast injury. Time is of the essence for patients with these types of injuries, and the SJT’s simple design allows applications for hemorrhage control in less than 25 seconds in most cases. Compact and lightweight, it can easily be carried in a medical bag or attached to a backpack. Recent studies indicate that junctional hemorrhage accounts for up to 20 percent of preventable deaths in combat. The SAM Junctional Tourniquet was designed, using input from key military medical personnel, to treat these injuries by placing pressure on an artery to stop the flow of blood to a region of the body. The design utilizes a rugged target compression device (TCD) which, once targeted by the medic, is inflated to apply the necessary amount of pressure. Each SJT can utilize up to two TCDs to treat bilateral injuries. The unique combination of both a mechanical belt buckle and a pneumatic TCD allow for quick application and effective, expedient hemorrhage control. “We designed the SAM Junctional Tourniquet as an easy-to-use, multi-purpose product that can be applied quickly in life-threatening situations,” said Adrian Polliack, president of SAM Medical Products. “We worked directly with key military medical and scientific personnel along the product development and testing pathway to ensure the product met the rigid requirements associated with medical devices used in the challenging combat battlefield arena.”

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IT Integrator

Q& A

Overseeing Information Technology Within The Military Health System

David Bowen Chief Information Officer Military Health System

David Bowen currently serves as the chief information officer for the Military Health System, Office of the Assistant Secretary of Defense for Health Affairs, where he is building upon in-depth knowledge of information management and technology, as well as years of health care industry experience in this leadership position. In his previous position as assistant administrator, Information Services, and CIO at the Federal Aviation Administration, Bowen led an information technology enterprise with a budget of more than $3 billion and more than 1,000 staff members. Among his many accomplishments at FAA, Bowen developed and implemented new security policies to protect systems and data; directed, developed and implemented privacy and security improvements; and implemented a cyber defense strategy. Bowen’s extensive experience in health care comes from roles as senior vice president and CIO at Blue Shield of California, and senior vice president, Information Management, and CIO at Catholic Healthcare West. At Blue Shield of California, he developed and implemented an IT strategic plan, operated the IT department’s budget at a savings of more than 3 percent, and developed and implemented an insourcing strategy that saved the company $6 million annually. At Catholic Healthcare West, Bowen operated information management departments under budget and was responsible for CHW’s information management and telecommunications resources for this 50-hospital system located throughout California, Arizona and Nevada. Recognized as a Top 50 Public Sector CIO by Information Week in 2010 and 2011, Bowen has served in leadership roles on several boards, including as a past chairman of the Blue Cross Blue Shield Association CIO Roundtable; former board member and chairman of the Coastside Family Medical Center; and past member of the Blue Cross Blue Shield Association Interplan Technology Advisory Committee. Bowen is also a charter member of the College of Healthcare Information Management Executives. Bowen has an undergraduate degree in economics from Ursinus College and a master’s degree in business with Distinction from the Johnson Graduate School of Business at Cornell University. He is a certified public accountant. 16 | M2VA 17.3

Q: Could you tell us about your responsibilities as chief information officer for the Military Health System [MHS]? A: I have three areas of responsibility. First, I oversee IT in the MHS direct care network, including all of the 56 military hospitals and more than 360 clinics. Second, I oversee IT in the managed care side of the military network, which is TRICARE for dependents and retirees. Third, I collaborate with the DoD/ VA Interagency Program Office, which is responsible for the VA/ DoD joint integrated electronic health record [iEHR] program. My team and I are working collaboratively with the IPO and VA to implement an electronic medical record system for both organizations. Since I joined MHS in September, we’ve made significant movement forward on the EHR front with the VA. Q: Since you became CIO of MHS, what have been your priorities? A: I am initially focused on providing leadership for the organization; building relationships and establishing trust, particularly with the service CIOs and chief medical informatics officers; supporting and streamlining financial efficiencies and effectiveness by focusing on eliminating redundancies and items of low value; and supporting the development of the integrated EHR by

ensuring that both the MHS Development and Testing Center [DTC] and Joint Information Technology Center [JITC] are positioned to enable testing of its components. One of my priorities has been the promotion of the new Defense Health Agency, which is a new organization for the military health care system that has been mandated by Congress. This unified system will cut costs and create the best in health care quality and access, while still retaining the unique features that individual service cultures bring to the fight. Another priority for me is leading the organization as it faces change. Some of this change is brought on by fiscal concerns and sequestration, and other points of change are more cultural as the enterprise moves to a more integrated system. Some of these changes, such as the sequestration, bring significant challenges. It is a priority to figure out how we can continue to operate at our full potential under difficult circumstances. As we have seen recently, we can’t continue to do the same things in the same old ways. Despite the turbulent nature of change and the ever-evolving technologies we work on, it is critical that we have the right policies and frameworks in place, and we are working on those issues now. The right frameworks will allow us to guide the MHS to a better way forward in terms of protection of personal health information [PHI], conformity to standards, and interoperability across the enterprise. Q: What are some of the IT challenges you’ve confronted within the MHS? A: The biggest IT challenge is information security. The security and privacy of our beneficiaries is of the utmost importance to the MHS. The challenges are to ensure that we have trusted and secure communications across the MHS, and that we have proper encryption in place to prevent sensitive medical information from falling into the wrong hands. At MHS, we have to get the security policies and frameworks right, and we are working on a lot of these issues right now. These will allow us to guide the enterprise to a better way forward for all of our technologies. We want to ensure that any PHI or personally identifiable information that could be present on any devices, applications and software is protected. As I mentioned, there is also a great need for leading MHS through change right now. Because of sequestration, we are not able to do what we once could. We are being challenged to reduce costs while maintaining the high standards we have always strived to achieve. The question is, how do we continue to fully operate under sequestration? We can’t keep doing the same old thing the same old way. So, we are trying to find ways to do more with less, such as by reducing IT resource duplication and redundancy across the DoD medical communities. We’re working to help reduce overall costs to MHS through projects such as enabling more information sharing on care given to our servicemen and women outside of our direct care system; working with commercial providers to generate more data on our members so we won’t have to repeat tests; using clinical data to improve treatment patterns and standardize medical practice within our various care areas; and getting patients involved in their care via access to their data for improved understanding and compliance.

Some of our biggest challenges to the success of these activities involve both human and IT changes. For one, we need to figure out how to encourage physicians to change the way they do business. Secondly, we are integrating information across many, many systems, which poses IT challenges. It is a real conundrum how to do more data sharing across systems implemented with little standardization from system to system, while keeping it secure. We do the obvious like encrypting more, both at rest and in motion, and developing a single sign on methodology to be used across the MHS and VA so clinicians can gain access to the information they need, and developing secure messaging so providers can interact securely with each other and be assured of patient information confidentiality. We don’t just stop there, though; we’re constantly looking for new and better ways to securely share data. Q: What are the most pressing IT needs of MHS? A: It is critical that we get the necessary infrastructure in place to support the iEHR. By doing this we will reduce IT resource duplication and redundancy across the DoD medical communities, get greater capability to our providers at less cost, and maximize the benefit to our beneficiaries. We will also leverage the Medical Community of Interest, a network solution that is as an integrated component of the “single medical enclave.” This capability will create a logical single medical enclave that meets both departments’ security requirements, adheres to the core principle of equal access to iEHR data and resources by both departments’ users. The single medical enclave will provide unprecedented ability for collaboration on health care delivery and will form the basis of DoD’s portion of the DoD/VA single medical enclave. As in any organization, having enough resources—both financial and staff—is a pressing need. But by reducing duplication we will save resources and allow our staff’s work to be used more efficiently. Modern delivery of care now requires sophisticated technology, and duplication across the various services no longer bring the same return on investment. We have to make sure we have a shared vision, shared acquisition structure and shared logistics structure to be good stewards of taxpayers’ dollars. If we have an administrative structure that allows the services to decide which platforms they want to establish, where they want the technology, without duplicating all of that, the savings can be enormous. Q: How has your experience as CIO of the FAA and other previous positions helped you as CIO of MHS? A: As CIO at the FAA, I learned the importance of strong policies and standards across the enterprise to ensure ultimate functionality while following the organization’s strategic objectives. Certainly, as the CIO of FAA, I learned how the government operates. For example, the contracting and hiring processes were new to me, coming from the commercial sector. One project in particular stands out in my mind as an example of my lessons learned. The FAA’s air traffic control modernization program had been on the GAO “High Risk” list for the previous 14 years. I led a team of executives and staff to get this program off of that list. At the FAA, we also implemented new technologies that improved pilots’ flight experiences. We used mobile technology to improve the information that pilots have at their disposal. M2VA  17.3 | 17

Pilots are now authorized to use iPads in the cockpits, so all of their aeronautical charts and other important flight resources are easily within their reach. I have also worked in health care information technology management, both in the private and public sectors, for more than 25 years. One of the most important lessons I took from this experience was the importance of strong partnerships. I also worked at some of the nation’s largest health care organizations, and it has always been my goal to provide the best health care delivery to our beneficiaries. Q: What are some of the most exciting developments we can expect to see within the field of government health IT? A: There are so many exciting developments; it is hard to know where to begin. Off the top of my head, I can think of three key developments that are really exciting and changing the way we think about health care. The first is how we’re supporting the shift from health care to total health. MHS, as well as private health care, has started to focus on preventing illness, rather than just treating existing illness. Since we believe that a healthy and fit force is essential to the defense of the nation, we are designing systems and mobile solutions to help people manage their own health and wellness. These mobile solutions include everything from enabling electronic health records to mobile apps on nutrition and mental health. We are essentially striving to increase the amount of patient interaction in that patient’s care and general wellness. We’re doing this by giving them access to key elements of their own medical record online, and tailoring treatment and wellness plans to their individual needs. We are also developing several mobile health solutions that will allow us to be more responsive and adaptable for our health care beneficiaries around the globe. We’re using mobile technology to improve the availability of patient data to multiple providers for better, more cost-effective care. As IT evolves, I think we’ll start to see even more converging technologies with “smarter” medical devices. Genetics is another really exciting area in which we’re starting to see developments. We now have the ability to tailor medicines specifically to a patient’s genetic makeup. We’re using genomics to anticipate and treat diseases before they become life threatening. Military health is often on the cutting-edge of medicine, and our work in developing information technology to support these advances is particularly rewarding. Another really exciting area that we are exploring for diagnosis and treatment options is nanotechnology. Nanotechnology devices are small enough to access areas of the body that were previously off limits to medical technology. Through nanotechnology, medical advances have been made in cancer research and treatment, and our doctors have been looking at how nanotechnology can help us understand and better treat PTSD. Along these same lines, we’re also really excited about advances in robotics, which enable more precise surgical procedures. With all of these exciting advances in health IT, we are also supporting the sharing of clinical best practices through advances in IT. Basically, we are making advances in health IT, and using IT to support the sharing of those best clinical practices. The line between medical devices, information technology, and communications is blurring. 18 | M2VA 17.3

Q: Are there any particular MHS health IT programs or initiatives that we should be aware of? A: While the biggest initiative that most individuals are focused on is the iEHR, there are other programs that are certainly worth knowing about, and that have great utility for clinicians. AHLTA and CHCS [Composite Health Care System] are legacy applications for the DoD. AHLTA is often underestimated and it actually offers the clinician some true gems. All of our DoD/VA data sharing applications, including Federal Health Information Exchange, Bidirectional Health Information Exchange and Clinical/Health Data Repository are the mainstay of our ability to exchange data with the VA today. This is particularly true for our ability to exchange data on wounded warriors. In addition, we also continue to work on the health portion of the virtual lifetime electronic record, or VLER. Unfortunately, VLER is not as robust as originally intended because of the original software design by the Office of the National Coordinator [ONC], and also because our civilian partners do not have the ability to exchange the same level of data that the DoD and VA have been exchanging for years. We continue to work with ONC and are encouraged by recent progress in the private sector health communities. Q: Could you describe the benefits of mobile health IT systems for our readers? A: Mobile technology offers so many benefits across the board. For one, you get faster access to information from any location. For example, wireless infrastructure allows health care providers to take tablets with them on their rounds. These handheld devices can replace volumes of reference materials for doctors and nurses, allowing providers to more quickly diagnose injuries and illnesses [as well as] access lab results. We also know that our beneficiaries are interested in mobile applications that will help them manage their own care. This is now possible through mobile health IT systems, and several projects are underway at MHS. An example of this is The National Center for Telehealth and Technology [T2], a division of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, created to identify, treat, and minimize or eliminate the short- and long-term adverse effects of TBI and mental health conditions associated with military service. Right now, T2 has a suite of 10 applications that are available for free to the public on iTunes and Google Play, dealing with topics such as stress management, mood tracking and PTSD. These applications have been downloaded more than 300,000 times and used more than 1.2 million times. So by turning to a mobile solution, we have been able to offer support to those who need it, while also making it completely anonymous to access the information and reducing the stigma attached to some of these conditions. Q: If MHS had an interoperable EHR system, what would it be like? A: I’m glad you asked this question, because contrary to popular belief, MHS already has one of the most advanced interoperable EHR systems in the world. This is particularly true in terms of having a servicemember’s clinical and medical records transition with him around the world, even while in transit. Whether it is at a field

Lt. Gen. Patricia D. Horoho, 43rd surgeon general of the United States Army and commander, U.S. Army Medical Command, is briefed about the implementation of the Military Health System’s electronic health record, AHLTA, in the troop medical clinic at Rose Barracks, Germany. Implementing the EHR at the clinic allows the regiment’s medical providers to document soldier medical care, which can be viewed at any military medical treatment facility in the world. [Photo courtesy of 7th U.S. Amy Joint Multinational Training Command, Training Support Activity Europe/by Getrud Zach]

hospital in theater, or a medevac hospital in Germany, or a clinic or hospital here in the United States, we are developing systems to make the individual’s health data is available worldwide. From battlefield to the home front, there are many points of care that can touch a servicemember, and all of those points of care need to be coordinated. With our current interoperable EHR system, if a soldier is injured in Afghanistan by a roadside bomb, the field hospital that treats him have access to that soldier’s electronic health record through AHLTA-Theater. The health care team that first treats the injured soldier also uses AHLTATheater to document the injury and treatment. The information entered into AHLTA-Theater is then synced with the larger MHS EHR system. If that patient then needs to be evacuated, the medical team at their next location will have that patient’s information, and can start preparing long before the patient arrives. It also ensures that the clinician has all the information they need to recommend the best course of treatment based on the individual’s medical history. Right now, the DoD EHR system and AHLTA-Theater system does talk to the VA system in several areas. However, this interoperability is only within the active services. If that servicemember uses his or her TRICARE benefit to see a private practitioner, we don’t necessarily see that. A vision of the future would be to expand the interoperability we currently have to the private sector, to improve the workflows and clinical processes embedded in the system and to improve the information that individual servicemembers personally have access to as a patient. We need to ensure that medical information follows the patient wherever they go, not just while they are within the Military Health System. A final comment would be that we need to upgrade our automation capabilities so they can be maintained at lower cost, more rapidly enhanced and provide better response times.

Q: Is there anything I have not asked that you’d like to discuss? A: We recognize that we need to take our system to the next level. We need more integration of our clinical facilities, and we recognize that IT plays a large role in providing this support. This will likely require information integration across the services, as our treatment facilities are likely to be multi-service in the future. We are looking to see what kinds of IT organization, operating models, and metrics are going to be necessary to support the mission of a leaner, more integrated Military Health System. An example of this integration effort comes from a year ago when the services were pulled together at the new Defense Health Headquarters, in Falls Church, Va. Congress mandated the consolidation of military bases through the Base Realignment and Closure Act of 2005. This joint environment includes TMA, Army, Navy and Air Force. Part of the integration that we have been involved in lately is the formation of the Defense Health Agency. The DHA will oversee a system that creates the best quality in health care and access while preserving the unique features that individual services offer. The DHA will allow us to get maximum effort and efficiency of shared services, without having to disrupt the services as part of the reorganization. Significant savings are expected once the DHA is operating to eliminate waste and bringing new business processes to military hospitals and clinics. Without this collaborative administration structure the services would continue to operate in isolation. As current cost growth shows, that is not the best use of resources. The new administrative structure will allow us to collaboratively and effectively make decisions that are essential to making the military health care system stronger, more efficient, and better able to serve beneficiaries. As our preliminary plans are briefed and approved, we will be able to share more on specifics for our DHA IT shared services plans in the future. O M2VA  17.3 | 19

Veterinary medical services within the Army Public Health Command. By Peter Buxbaum M2VA Correspondent There is a multifaceted relationship between the health of animals and the health of human beings. That is why veterinary medical services within the Department of Defense are managed through the Army Public Health Command. Military dogs work with warfighters in theater and elsewhere to sniff out explosives and are vulnerable to the same injuries and traumas that soldiers face, including PTSD. Animals can also transmit diseases to humans; therefore, it is a public health concern to keep tabs on diseases that might be afflicting working dogs, ceremonial horses and even pets kept by military personnel. Animals are also part of the routine diet of military personnel and their families. The Army Public Health Command veterinary services branch also sees to the safety of food—as well as water—supplies. The U.S. Army, in a move to consolidate veterinary health services within DoD, was appointed executive agent for the provision of these services throughout the department. In other words, it 20 | M2VA 17.3

is the Army that provides veterinary health services for all of the branches of the armed forces. “People usually associate veterinary medicine with a focus on pets and farm animals,” said Colonel Erik Torring, deputy commander for veterinary services at the Army Public Health Command. “It is actually much wider in scope and also reflects the relationship between animal and human health. It fits in well with the public health sector.” Torring is himself a veterinarian and also holds a master’s degree in public health. “Veterinary services within the public health command focus on food and water safety and protection and the veterinary clinical medical mission,” Torring added. “We provide veterinary personnel in support of military operations, including in theater.” The U.S. military maintains 2,800 dogs and owns over 300 other animals, mostly ceremonial horses that participate in funerals and serve as unit mascots. There are a total of about 3,200 veterinary personnel working for the Army around the world.

These include not only veterinarians, but also food safety and food inspection specialists, as well as other specially trained personnel, both uniformed and civilian. About half of these individuals are attached to the Army Public Health Command, while the remainder work in deployed units, medical research and development organizations, special operations units and other DoD components including the Army Reserve. The U.S. military sometimes provides logistical support for public health efforts overseas. “In the last year, we were called upon to provide large quantities of cattle de-wormer medications in Guam and heartworm treatments in Japan,” said Dr. James Freeman, Field Veterinary Services at Merial and a former military veterinarian. “We delivered these supplies to military bases for local distribution.” The Army’s 150 animal health clinics around the world provide a full spectrum of care for government-owned animals as well as for the pets of military personnel and their families. The Army also

maintains the Holland Veterinary Hospital at Lackland Air Force Base in Texas, where all working dogs are trained and where they go for specialized care and rehabilitation. “The Army’s working dogs provide a very valuable force protection mission,” said Torring. “They are trained in explosives detection and save countless lives each year.” Military pets are provided wellness examinations, vaccinations and other services at the clinics. “Not only do we provide veterinary care for those animals,” said Torring, “but this also enhances our ability to provide disease surveillance. By having a flow of animals through the clinics, we can identify diseases that are potentially transmittable to humans, thus keeping the military community and those pet owners healthy. This also allows our veterinary personnel to maintain their clinical skills for when they are asked to deploy in support of any military operation.” One phenomenon the veterinary service has identified in recent years is that working dogs in theater are subject to post-traumatic stress disorder, much like humans. “The treatment is similar to their human counterparts,” said Torring, “and includes conditioning through exposing them to circumstances that can trigger PTSD. There are also medications that can be provided to help alleviate the symptoms. Sometimes the animal has to be retrained.” The consolidation of military veterinary services within the Army will lead to a standardization of veterinary laboratory equipment, according to Randy Knick, director of sales and marketingPacific Rim at Abaxis. Knick expects a request for quote to be released in the near future. Most of the Army’s veterinary clinical facilities have their own in-house lab capacity, said Torring. But local facilities typically buy lab equipment on an ad hoc basis, according to Knick, often mixing and matching equipment from different vendors. The standardization effort will concentrate the purchase of all veterinary lab equipment with a single vendor. “Right now we have equipment in 50 percent of the clinics,” said Knick. “They usually have one or two pieces of Abaxis laboratory equipment.” The standardization will benefit the Army from an ordering and training standpoint, according to Knick. “The clinics often have personnel turnover every 12 to 18 months,” he said. “Standardization will require less retraining. It will also make it simpler for the Army to order equipment.” Abaxis’ keystone product is called the VetScan VS2, a portable chemistry, electrolyte, immunoassay and blood gas analyzer that delivers results from two drops of whole blood, serum or plasma. It can be used, among other things, to test for heartworm and to run a comprehensive diagnostic profile with complete chemistry and electrolyte analysis. “The system runs a quality control and calibrates for instrument accuracy every time a sample is run,” said Knick. Heska Corporation supplies the military with the gamut of veterinary supplies, from heartworm testing to allergy testing products. “Allergies can be regional and seasonal,” said Janet Kellogg, Heska’s senior director of corporate communications. “We recently received an inquiry from South Korea, where they are seeing an extraordinarily high rate of allergy cases. Allergies are very big problems for dogs all over the world and they can be exacerbated by regional allergens.” Heska’s blood serum tests can determine specific allergies, and the company’s immunotherapy product can then treat M2VA  17.3 | 21

One such technologically advanced vaccine used on military animals counters Lyme disease. “The vaccine targets a specific protein within the organism that causes Lyme disease,” said Freeman. “The result is a very targeted immune response” that mitigates the dangers of lesser engineered vaccines. The Army Public Health Command’s veterinary services unit also works to promote human health through its food safety and protection program. “That program is comprised of three major functions: food safety, food defense, and food and water risk assessment,” explained Torring. “Food safety experts perform audits of commercial establishments. Any company wishing to sell or provide food to DoD must be on list of approved vendors.” On average, the veterinary services unit conducts 3,000 audits and inspections per year of commercial food establishments in order to assess their ability to produce subsistence or provide food or bottled water for DoD components. “On military installations, the food safety mission helps prevent food and water from contamination,” said Torring. “Food inspection specialists make sure food is provided by approved sources and make sure it remains wholesome. We also work with the Food and Drug Administration and other government agencies.” The food defense mission is more focused overseas. “We work at the installation level to assess identify and mitigate potential incidents of contamination from biological, chemical or radiological agents,” said Torring. “We recommend security measures for facilities to prevent food contamination that could sicken the community.” Food and water risk assessments are performed stateside and elsewhere on commercial establishments that wish to cater food for DoD exercises or operations. “We are looking for the intentional or unintentional introduction of agents that could cause harm to personnel,” said Torring. Torring expects the Army Public Health Command’s veterinary services to continue to provide these services to the military community, but with a possible change of geographic emphasis. As the U.S. Top: Bomb sniffing dogs require veterinary care in deployed environments such as Iraq and Afghanistan. military shifts its focus to Asia, the Pacific Rim and [Photo courtesy of U.S. Marine Corp/by Lance Corporal Walter D. Marino II] Africa, the men and women of the veterinary services Above: Much like their human trainers, bomb sniffing dogs are also subject to PTSD. [Photo courtesy of U.S. Army/ will be challenged to expand their operations to other by Specialist Blair Larson] parts of the globe. “I expect veterinary services to continue to play an important patients according to the specific allergens to which they are senand possibly an expanded role in food and water risk assessment,” sitive. The company also supplies an intravenous infusion system said Torring. “We see the possibility of shifting some of our food that could be of service to dogs injured in the line of duty. safety and commercial audit personnel to other parts of the world “The infusion therapy pump is used to administer fluids for and also to participate in stability operations and agricultural and surgery and other situations and is often used during search and public health development projects. rescue operations,” said Kellogg. “Service dogs often get dehy“As DoD missions and strategies change,” he added, “we will drated. The level of fluid can be adjusted quickly and easily.” change with them and respond accordingly.” O Merial supplies its well-known Frontline, which kills fleas and ticks and prevents their recurrence, and Heartgard, which prevents heartworm disease. Merial also supplies technologically For more information, contact M2VA Editor Chris McCoy at or search our advanced vaccines. “We provide recombinant vaccines, which online archives for related stories at means that they are genetically engineered,” said Freeman. 22 | M2VA 17.3

How DoD and the VA fill the need for qualified health care professionals . By Henry Canaday M2VA Correspondent Civilian hospitals and medical facilities contract for medical professionals extensively, many outsourcing the staffing of entire emergency rooms. The U.S. military health system and Department of Veterans Affairs also contract out for medical staff of a wide variety of types. Contracting for staff, from the most specialized surgeons to the laboratory technicians and support staff, can make sense for a variety of reasons. They often fill needs while permanent hires are sought, to meet a temporary spike in workload, or to obtain scarce resources that are difficult to recruit quickly and may not be needed permanently. For example, VA’s general policy in acquiring medical professionals is to first seek to hire within VA whenever possible, explained Betty “Charlie” Benmark of the Veterans Health Administration’s Office of Procurement & Logistics. And if a particular VA medical center cannot find in-house resources, it often refers the patient to another center. But contracting for medical staff is a regular practice at VA. “We typically contract out when we have shortage in services; for example, there may be a backlog of care that the current staff cannot handle and we need additional staff to make that up,” Benmark said. “Or it may be we lost someone due to retirement or their moving on. So we just have to temporarily fill that position.” Another reason for contracting out for medical staff could be that the VA does not have enough work for a full-time employee. “Say we need them only half time; we may contract just for certain hours to help with the workload,” Benmark noted.

Typically, contracting for medical staff at VA is a short-term solution, although contractors may end up being in a facility long term if the facility cannot fund a full-time person or does not have a full-time workload. Most frequently, contracting medical staff is done to fill medical specialties that are not locally available. “For example, it could be a neurosurgeon in a rural community where the VA hospital does not have the higher specialties,” Benmark said. “They tend to have more general physicians, so may have to contract out for specialists.” VA may contract with either a provider of medical staff or with individual staff. Typically, there is a local temporary need and the VA usually goes to the Federal Supply Schedule, which offers hospital and medical services. “It is a very streamlined process,” Benmark said. “But there are some situations where a local community provider could put in an offer in response to a solicitation.” Contract medical professionals are requested by a VA network facility, but the actual procurement is handled by one of the three VA regional headquarters that support the network of VA facilities in East, West and Central regions. Benmark said contracting needs vary by facility and over time, but the demand is generally highest for specialties like radiology and anesthesiology. “It depends on the age and gender of veterans and what they need. We are seeing a lot of cardiovascular cases and also more ophthalmology cases. But I haven’t seen the need for any primary care contracting.” Benmark expects VA contracting will remains stable in policy, but will of course vary according to needs. “There has been some M2VA  17.3 | 23

cost saving nationally, summarized Joel McMains, vice president increase in certain areas like mental health, as a lot of soldiers and of operations. The company provides nurses and allied medical airmen and [sailors] require that type of service,” she noted. professionals, physical therapists, pharmacists, radiology techniBenmark acknowledges that both VA itself and many staffing cians and so forth, but not physicians. providers sometimes find the contracting process burdensome. MSN’s 30 years of experience enable it to offer private, VA and However, “accountability is always an issue,” she noted. Last year, military hospitals comprehensive services, from recruitment and VA conducted a number of industry days to discuss its needs and on-boarding to intake and case management. MSN provides mediexplain to firms how to do business with the agency. Benmark feels cal staff in nursing, pharmacy, clinical research, anesthesia, as that communication between VA and staff providers is improving. well as advanced practice and case management professionals. It Providers of contract medical staff vary widely in size, the offers these staff from more than 70 locations. staffing areas they specialize in, and the types of contracts—short MSN is now the one of the largest providers of per-diem and or long term—that they prefer. Many provide staff widely to the contract nurses in the U.S. and supports thousands of acute general civilian medical sector, but have divisions dedicated to and long-term care facilities. The company offers registered health facilities run by the federal government, including VA and nurses, licensed practical nurses, certified nursing assistants and the military services. advanced-practice nurses. The firm’s Allied Health division offers Staff Care, a division of AMN Healthcare, provides temporary health care professionals in more than 60 specialties. staffing of nurses, nurse practitioners, doctors and pharmacists. MSN’s Pharmstaff unit provides pharmacists and pharmacy Doctors are available in all medical specialties, according to Vice technicians. Its Saber-Salisbury Group provides anesthesia and President Jeff Waddill. advanced practice medical staff, including anesthesiologists, The company supports both VA and military facilities, somecertified registered nurse anesthetists, nurse practitioners and times as a prime contractor and sometimes as a subcontractor to physician assistants. MSN’s Clinical Research unit offers clinical another firm. The medical specialists provided are independent research professionals in a variety of specialties. The company can contractors, not employees of Staff Care. also provide professional, clerical, secretarial, food service, and Medical staff can be provided under a variety of terms. “It can light industrial and construction staff to medical facilities on a be three months or six months, and the contracts may be renewed temporary or project basis. if both facility and the doctor are happy,” Waddill noted. “We are To enable efficient contracting for several medical services, the matchmaker, but they are independent providers.” Staff Care’s MSN offers OneSource, which provides medical facilities with work is divided between VA and the military health system. one point of contact, one consolidated invoice and one contract For doctors, one of the attractions of working for the national with standardized rates. OneSource streamlines order processing, military and VA networks is that they do not need a local license. invoicing, quality initiatives and reporting. “For example, if they have a Texas license, they can practice in McMains said MSN has provided health care staff to the federal Georgia for the military and VA,” Waddill noted. government under a Federal Supply Schedule contract for nearly In addition, many of Staff Care’s doctors are military veterans. 10 years. Under this contract it has provided nursing and allied “When they get out, they want to give back,” Waddill explained. health care staff to both the VA and DoD. In addition to direct “This is a very special field to do work in, enabling you to help contracting with these clients, MSN also subcontracts to small other veterans.” business prime contractors working for VA and DoD. Also, the far-flung VA and military health networks often give “MSN’s staffing solutions are flexible to the needs of our doctors an opportunity to travel and to practice where they want, government customers, from daily per-diem shifts not just where they landed after medical school. on an as-needed basis to large-program full-time On the customer side, there are also advantages equivalents—we have over 200 FTEs—with on-site to the contract approach. “VA is not unique,” Wadmanagement,” McMains emphasized. He noted that dill noted. “Many hospitals use temporary staff his company was awarded the Certificate of Distincwhen they are staffing up. They want to be able to tion for Healthcare Staffing Services by the Joint provide quality care before they make permanent Commission in 2005. “We have maintained that hires. It can take six months to a year to hire a perstatus every year since.” manent doctor, depending on the specialty and the Drawing on a network of more than 55,000 part of the country you are in.” health care professionals, MSN has had more than While Staff Care offers doctors in all medical 500 government health care staffing contracts since specialties, Waddill said the highest demand now is George Tracy 1998. McMains stressed that MSN is one of the for primary care doctors, ER physicians and mental few health care staffing companies that has both a health specialists. national presence and a local delivery model. With more than 70 Waddill emphasized that Staff Care has been in this business locations and nearly 75 specialized recruiters, the company can for 20 years, has national reach and possesses the ability to find a ensure staff satisfaction and retention, which enables superior wide range of qualified health care providers. He expects there will patient care. be a continued need for Staff Care services. Although there have MSN recently launched a subsidiary, Optimal Workforce Solubeen some worries about the impact of the budget sequester, Wadtions, to help health care institutions re-evaluate procedures and dill expects continued increases in health care provision in private, enhance workforce management. government and defense segments. Spectrum Healthcare Resources, a subsidiary of TeamHealth, Medical Staffing Network (MSN) provides health care staffing serves the U.S. military, VA and the Department of Health and and workforce solutions that balance quality patient care with 24 | M2VA 17.3

Human Services (HHS). The largest portion of its staffing is done for the military, with smaller portions performed for HHS and VA, explained Spectrum President George Tracy. Parent TeamHealth serves about 800 civilian and government health care facilities with 8,600 medical professionals, and Spectrum has been working for government clients for about 25 years. “We support the military and military treatment facilities [MTFs] at about 100 locations,” Tracy said. “For example, we have been at Pearl Harbor since 1989.” The majority of staff provided for the military system is in primary care, but since 2007 there has been increased demand for behavioral health specialists, which is now number two in importance. The company provides the military with physicians, mid-level practitioners, nurses and technicians. Spectrum provides medical staff for the VA across the country, from New York to Minnesota and westward to Colorado and Long Beach, Calif. Tracy said Spectrum works less often for the VA than for the military because VA has a different model and strategy for its human capital. “The VA is able to hire more permanent physicians, so they only use temporary staffing contracts, generally. We like to focus on long-term contracts.” Distinctively, TeamHealth is a health care organization, “physician-founded and physician-led,” in Tracy’s words. “We concentrate on consistency and continuity.” For MTFs, Spectrum typically provides staff under contracts with a one-year base period and four annual renewal options. “We want to provide a patient-centered medical home, so we make sure there is consistency. Once they are in an MTF they stay there. Everyone talks about patient-centered care. We understand that and are here to support that mission.” Spectrum also seeks to make its medical staff financially sustainable for the facility over the long term. For temporary medical staff, facilities must pay commissions to the providing agencies, which make these staff more costly. “We try to make our contract work cost about as much as it would cost to hire a permanent physician,” Tracy noted. Spectrum has also been certified by the Joint Commission, the entity that certifies MTFs and civilian hospitals so they may participate in Medicare. VA continues to use Spectrum mostly for temporary contracts of three to nine months until the agency can make permanent hires. Spectrum provides staff for several VA community-based outpatient clinics. In addition, the firm has been providing ER staffing for two VA facilities, much as its parent, TeamHealth, does for civilian hospitals. “We can leverage TeamHealth physicians for that,” Tracy noted. Approximately one-third of hospitals employ ER physicians while nearly 70 percent outsource. Much of the outsourcing is to small local providers. Under this type of arrangement, a hospital can outsource its ER staffing 24/7. “That way, they do not have to have their staff physicians rotating through the ER. And they don’t have to develop their schedule every month. We do that.” Of course, VA ER demands can differ from those of most civilian hospitals. “VA ERs have less trauma and they are less exciting,” Tracy noted. So far, Spectrum has taken over ER staffing for VA facilities at Long Beach and Hampton, Va., and is discussing the approach with several other locations.

Dumfries Health Center is a family clinic of Fort Belvoir Community Hospital. [Photo courtesy of Spectrum Healthcare Resources]

Onsite Occupational Health & Safety is a full-service medical provider that offers turnkey medical solutions, both directly to the U.S. military and to private contractors that support the military. “We provide everything from simple staffing up to and including full capabilities for clinical operations of outpatient clinics around the world,” summarized Chief of Staff Michelle Prinzing. Onsite has not provided staffing for VA yet, but Prinzing said the firm seeks to support VA as well. Under one contract with medical facilities at Lackland Air Force Base, Onsite provides three laboratory technicians and two administrative personnel. It plays a much lager role in Afghanistan, providing medical staff, supplies and equipment. Onsite has more than 150 health care providers in Afghanistan, including doctors, physician assistants, nurse practitioners, registered nurses, technicians and paramedics. “We are the largest medical-care provider after DoD in the country,” Prinzing explained. “We support forward operating bases and perform medical oversight in northern Afghanistan. We work in austere and remote locations.” Onsite may be small now, but it is a rapidly growing provider. Prinzing noted the company had just three employees three years ago and now has 250. “We can do turnkey, fullservice operations and can set up anywhere, domestically and internationally,” Prinzing emphasized. Onsite also has ambulatory care accreditation from the Joint Commission. Altogether, as the need for health care professionals increases due to the needs of the expanding and aging veteran population, medical staffing agencies will most likely continue to provide auxiliary professional health care for VA centers and MTFs. O

For more information, contact M2VA Editor Chris McCoy at or search our online archives for related stories at

M2VA  17.3 | 25




The Navy’s shift to the Pacific inspires our twelfth title and website...



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Cover Q&A:

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Rear Adm. David Lewis, PEO Ships

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Military Medical & Veterans Affairs Forum

Jason Santamaria President Stanley Healthcare Jason Santamaria is the president of Stanley Healthcare. An inclusive, resultsoriented leader with a proven track record of driving growth and operational efficiency, Santamaria started his professional career as an officer in the United States Marine Corps. Q: Could you talk about Stanley Healthcare’s activities in the government market and some of the solutions being offered to the military? A: Building on our extensive government customer base through other divisions of Stanley Black & Decker, Stanley Healthcare has been active across all DoD and civilian agencies for many years. Many of our health care solutions are already broadly deployed. For example, our wander management products, including RoamAlert and WanderGuard, are in place at 52 sites across the U.S. Department of Veterans Affairs. And we are also very active in the Military Health System, such as through our Hugs Infant Protection system, with ongoing support of nearly 30 facilities worldwide. Beyond those products, we provide extensive solutions for our customers to significantly improve the safety and security of their staff and patients, facility security and efficiency, environmental monitoring, clinical workflow, and the protection and visibility of equipment and other high-value items. And we are proud that our solutions yield significant return on investment for our customers, which means we are together reducing waste and spoilage. Q: You mentioned that Stanley products improve efficiency. How does that actually happen? A: There are literally dozens of examples of improved operational efficiency that stem from the deployment of these types of solutions in health care. And given the 28 | M2VA 17.3

short supply of funding, qualified medical personnel and capacity, it is more important than ever to drive redundancies, loss and waste out of the system. At a basic level, real time location systems [RTLS] enable medical facilities to eliminate a wide variety of manual processes by providing visibility into the location of equipment, such as wheelchairs or IV pumps, to ensure that staff doesn’t spend countless hours searching for missing items. RTLS also makes it possible, using our web-based MobileView application, to monitor and assess operational challenges such as workflow bottlenecks, which can occur with patients awaiting procedures or being discharged from a medical treatment facility. MobileView is designed to be easy to use, which is even more critical in a military setting, to facilitate the quick ramp-up of personnel newly assigned to a unit or facility. Another great example of improved efficiency and reduced waste is through environmental monitoring. No longer does staff need to manually check refrigerators or other equipment. At VISN 23 in Omaha, we have deployed over 300 temperature tags, to notify personnel of power outages or other problems that could have led to the loss or spoilage of pharmaceuticals and other high-value assets. Q: What is Stanley Healthcare doing to position itself for the future?

A: The future of health care is happening right now. As we have seen in commercial health care, there is also widespread adoption of 802.11 Wi-Fi in the Military Health System and the VA, which is advancing the use of critical applications to improve quality of care, responsiveness and the patient experience. We, in turn, are proactively advancing our portfolio to enable our customers to leverage the full potential of Wi-Fi. Recently, we launched our Hugs Infant Protection Solution on Wi-Fi. This marks a significant advancement in infant protection and surpasses any other product on the market today. It works with standard Wi-Fi, so it is able to continually track the location of the infant and provides protection anywhere in a hospital where Wi-Fi coverage exists—so security is no longer confined to particular units. Q: Is there anything I haven’t asked that you’d like to discuss? A: I think it’s important to mention the profound mental health issues that our returning servicemen and women face today. An article in the “Federal Practitioner” said recently that the prevalence of PTSD following deployment to Iraq or Afghanistan is approximately 13.2 percent in personnel who were assigned to combat infantry units. This significantly impacts how we care for our soldiers and the personnel charged with their treatment. At Stanley Black & Decker, we show our support to them every day through our partnership with Wounded Warrior Project. And, having served as an active duty Marine, I consider the welfare of our returning servicemen and women of paramount importance. So we are all very proud to be a part of improving our nation’s health care capabilities to benefit our military and veterans, and it is exactly these types of challenges that will drive our innovation for decades to come. O


August 2013 Vol. 17, Issue 4

Cover and In-Depth Interview with:

Dr. Jonathan Woodson Assistant Secretary of Defense for Health Affairs

Special Section: Combat Casualty Care

Major breakthroughs in combat casualty care continue to lessen the number of fatalities on the battlefield.

Features: Sleep Disorders

Shift work sleep disorder is a prevalent sleep disorder among active duty servicemembers and veterans with work schedules that conflict with a normal sleeping period.

Patient-Centered Medical Home

Comprehensive medical care overseen by a physician or nurse practitioner can maximize health and general wellness for many of today’s veterans.

Mobile Health IT

The miniaturization of medical communications devices and mobile apps is facilitating better patient-doctor relations while efficiently communicating a wide range of health data to both doctors and patients.

Nursing Informatics

This component of clinical informatics deals with the roles and activities of individuals in the nursing profession. In this feature we examine several university nursing informatics programs.

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