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Dedicated to the Military Medical & VA Community

Special Section:

Casualty Care

Considerate Planner Dr. Jonathan Woodson Assistant Secretary of Defense for Health Affairs Director, TRICARE Management Activity Medical Informatics O Sleep Disorders O Mobile Health Dental Informatics O Patient Centered Medical Home

August 2013 Volume 17, Issue 4

Propaq—Focused on Your Data Needs Your next-generation Propaq® is here. The standard in vital signs monitoring now has advanced data communications for all levels of care.

Experience Counts ZOLL, with over 25 years of experience manufacturing resuscitation technologies for the military, understands that to meet today’s demands, you require more than the best monitoring technology available. In addition to providing the trusted and proven vital signs monitoring you have come to expect from Propaq, the ZOLL Propaq M and Propaq MD* now have significantly enhanced data communications, allowing you to capture patient care data from the point of injury through definitive care. Our new open data architecture is designed to support the military’s emerging telemedicine solutions, EHR systems, and custom reporting needs (TCCC, AF3899).

*With integrated defibrillation and pacing

For more information, call 1-800-804-4356 or visit us at

© 2013 ZOLL Medical Corporation, Chelmsford, MA, USA. ZOLL is a registered trademark of ZOLL Medical Corporation. Propaq is a trademark of Welch Allyn.

Military medical & Veterans Affairs Forum

Cover / Q&A

Features Special Section:

Casualty Care

Trauma in the Battlespace The long wars in Iraq and Afghanistan have led to major breakthroughs in combat casualty care. Today’s servicemembers stand a better chance of surviving injuries than those of any period in history. By Peter Buxbaum

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Medical Informatics Medical and nursing schools are offering advanced degrees in informatics. The career prospects for those students look good and the military is hiring. Several academic informatics programs are profiled in this feature. By Chris McCoy

August 2013 Volume 17, Issue 4

Filling the Void In Army Dentistry U.S. Army Dental Command recently created the new position of chief dental informatics officer. This is tied to the promise of a future DoD electronic dental health record. By Colonel Daniel P. Lavin

25 8

Short Sleep Duration and Shift Work The effects of sleep deprivation are akin to the effects of alcohol on our servicemembers, and a servicemember’s work schedule can contribute to considerable sleep debt. By Lieutenant Colonel (P) (Dr.) Vincent Mysliwiec and Major (Dr.) Kevin A. Carter

Departments 2 Editor’s Perspective 3 Program NotesPeople 4 PEOPLE 14 Vital Signs 27 Resource Center




The wave of new mobile heath applications and miniaturized computer devices is allowing greater tracking of personal wellness in addition to fostering more interaction between patients and their health care providers. By Chris McCoy

The patient centered medical home model has been on the rise within DoD ever since its introduction in 2008. This model of care differs from traditional primary care in a number of ways. By Regina Julian, M.H.A., M.B.A., FACHE

Miniaturizing Health Care

Adopting A new Model of Care

Industry Interview Rob Lamb



Dr. Jonathan Woodson

Assistant Secretary of Defense for Health Affairs Director TRICARE Management Activity

“The mental health of all who served, and their families, is of immense importance to me and to those in the MHS. We have to continue to strengthen our ties with the Department of Veterans Affairs.” - Dr. Jonathan Woodson


Military Medical & Veterans Affairs Forum Volume 17, Issue 4 • August 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

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

Advertising Account Executive Casandra Jones

KMI Media Group Publisher Kirk Brown Chief Executive Officer Jack Kerrigan Chief Financial Officer Constance Kerrigan Executive Vice President David Leaf Editor-In-Chief Jeff McKaughan Controller Gigi Castro Trade Show Coordinator Holly Foster Receptionist Vania’ Jones Operations, Circulation & Production Operations Administrator Bob Lesser Circulation & Marketing Administrator Duane Ebanks Circulation Barbara Gill Data Specialists Raymer Villanueva Summer Walker

The Government Accountability Office recently filed a report concerning rogue Internet pharmacies. This is an important issue to bring up for two reasons. First, a number of veterans suffer from addiction to pain medications. Second, many servicemembers purchase testosterone products online so that they can become stronger and larger prior to deployment. Chief among the problems with rogue Internet pharmacies is that the medications they offer are of subpar efficacy or plain fakes. The pharmaceutical products may also be laced and cut with poisonous substances. Often, what appear to be legitimate online pharmacies are in fact pharmacies without any official Christopher McCoy oversight. Editor There is a near impossible challenge that federal agencies face when tackling these fraudulent pharmacies: Most often, these pharmacies are located overseas and are outside the jurisdiction of federal and state laws. As a result of this challenge, the FDA has launched the national BeSafeRx campaign in order to protect American consumers. It is important to keep this information in mind since an FDA survey found that nearly one in four adult U.S. Internet consumers have purchased prescription drugs online. The FDA lists five guidelines in their campaign to help identify illegitimate pharmacies: 1. 2. 3. 4. 5.

Beware pharmacies that allow you to buy drugs without a prescription from your doctor. Beware pharmacies that offer deep discounts or cheap prices that seem too good to be true. Beware pharmacies that send spam or unsolicited email offering cheap drugs. Beware pharmacies that are located outside of the United States. Beware pharmacies that are not licensed in the United States.

The FDA also lists four guidelines to aid in recognizing a safe online pharmacy: 1. 2. 3. 4.

Safe pharmacies always require a doctor’s prescription. Safe pharmacies always provide a physical address and telephone number in the United States. Safe pharmacies offer a pharmacist to answer your questions. Safe pharmacies have a license with your state board of pharmacy.

As usual, feel free to contact me with any questions or comments for Military Medical & Veterans Affairs Forum.

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PROGRAM NOTES A Military Monitor Zoll’s Propaq M vital signs monitor was developed through a collaborative effort with the U.S. Army. The traditional requirements of reduced size, weight and cube were implemented. Moreover, unique requirements identified from the lessons learned in recent conflicts dictated the need for improved clinical parameters, a third integrated invasive pressure, and advanced data communications for electronic health records and future telemedicine solutions. “Both the Propaq M monitor and Propaq MD monitor with an integrated defibrillator originated from the Welch Allyn Propaq 206 Encore—the trusted and proven standard of care vital signs monitor for the U.S. military for the last 20 years,” said Brenda Butler, vice president of government sales at Zoll Medical Corporation. “The Propaq has enhanced clinical parameters and advanced data communications.” The complete Masimo rainbow Pulse CO-Oximetry technology is integrated into the Propaq M. “The Propaq M also has a dedicated communications processor,” said Butler. “As data communications and electronic patient care records become more important, Zoll’s open data architecture allows the patient data to flow from our device into a number of different EHR systems or telemedicine solutions.” A key design criterion of the Propaq M was to maintain backwards compatibility. The monitor can utilize a number of the Propaq 206 Encore accessories currently in theater. This reduces costs and improves logistical efficiencies. Zoll recently signed an agreement with Reflectance Medical Inc. to incorporate a ruggedized version of the Mobile CareGuide sensor into the Propaq M and Propaq MD. Mobile CareGuide has the ability to simultaneously and continuously measure muscle oxygen saturation and pH. Both the Propaq M and Propaq MD have already received air worthiness certification. “Zoll has been a trusted partner with the military for many years providing defibrillator/monitors through Defense Logistics Agency’s electronic catalog and corporate exigency contracts,” said Butler. “The Propaq M has been selected and procured by several defense agencies as the new vital signs monitor standard.” By Chris McCoy, M2VA Editor

Compiled by KMI Media Group staff

DoD Establishes Tissue Bank to Study Brain Injuries The Defense Department has established the world’s first brain tissue repository to help researchers understand the underlying mechanisms of traumatic brain injury in servicemembers, Pentagon officials announced earlier this year. The announcement follows a symposium that Defense Secretary Chuck Hagel convened, in which a group of senior defense officials and experts in the medical field and from outside organizations discussed advancements and areas of collaboration regarding traumatic brain injury. “We have been at war for more than a decade, and our men and women have sacrificed,” said Dr. Jonathan Woodson, assistant secretary of defense for health affairs. “The MHS is bringing all the resources it can to better understand how to prevent, diagnose and treat traumatic brain injuries and to ensure that servicemembers have productive and long, quality lives. Our research efforts and treatment protocols are all geared toward improving care for these victims,” Woodson continued. “And that will have benefits to the American public at large.” The Center for Neuroscience and Regenerative Medicine Brain Tissue Repository for Traumatic Brain Injury was established at the Uniformed Services University of the Health Sciences in Bethesda, Md., with a multiyear grant from the U.S. Army Medical Research and Materiel Command to advance the understanding and treatment of TBI in servicemembers. “Little is known about the long-term effects of traumatic brain injury on military servicemembers,” said Dr. Daniel Perl, a neuropathologist and director of the brain tissue repository. “By studying these tissues, along with access to clinical information associated with them, we hope to more rapidly address the biologic mechanisms by which head trauma leads to chronic traumatic encephalopathy [CTE].” CTE is a neurodegenerative disorder that involves the progressive accumulation of the tau protein in nerve cells within certain regions of the brain. As the tau protein accumulates, it disturbs function and appears to lead to symptoms seen in affected patients such as boxers and, more recently, football players with multiple head trauma injuries. Defense Department researchers will look at the brain tissue samples to characterize the neuropathologic features of TBI in servicemembers. Important questions to be addressed include “What does blast exposure do to the brain?” and “Do the different forms of brain injury experienced in the military lead to CTE?” Servicemembers exposed to blasts “are coming home with troubling, persistent problems and we don’t know the nature of this, whether it’s related to psychiatric responses from engagement in warfare or related to actual damage to the brain, as seen in football players,” Perl said. “We hope to address these findings and develop approaches to detecting accumulated tau in the living individual as a means of diagnosing CTE during life—and, ultimately, create better therapies or ways to prevent the injury in the first place.” “We are learning though the process of discovery the effects of repetitive mild traumatic brain injury, and also how to prevent this issue of chronic traumatic encephalopathy,” Woodson said. “The brain tissue repository will enable us to learn even more about how we can treat injuries and prevent future calamity for servicemembers.” M2VA  17.4 | 3


Compiled by KMI Media Group staff

VA Acquires More Than 247 Acres to Continue Memorial Benefits for Veterans The Department of Veterans Affairs recently acquired 247.4 acres of land in Morovis, Puerto Rico, to prevent the loss of burial benefits to Puerto Rico’s veterans when the Puerto Rico National Cemetery, located in Bayamón, closes to new casketed interments sometime in 2022. “Veterans in Puerto Rico have earned the right to burial in a national shrine,” said Secretary of Veterans Affairs Eric K. Shinseki. “We are committed to replacing Puerto Rico National Cemetery so that veterans will continue to have a final resting place and lasting tribute to their service and sacrifice for years to come.” VA closed on the Morovis property, located off PR Route 137, in March for approximately $7.6 million. The replacement site is located about 28 miles from the existing cemetery.

There is no possibility for expansion adjacent to the original cemetery because the property is surrounded by commercial and residential development. Puerto Rico National Cemetery became a national cemetery on July 12, 1948. The cemetery serves approximately 107,480 veterans in Puerto Rico and the U.S. Virgin Islands. Situated on 108.2 acres, of which 99 have been developed, the cemetery accommodates casketed and cremated remains. More than 1,700 burials were conducted in fiscal year 2012. Puerto Rico National Cemetery is the only national cemetery located outside of the United States. More than 56,000 veterans and family members are interred there. Veterans with a discharge issued under conditions other than dishonorable, their

Health Centers to Help Uninsured Americans Gain Affordable Health Coverage On July 10, Health and Human Services Secretary Kathleen Sebelius announced $150 million in grant awards to 1,159 health centers across the nation to enroll uninsured Americans in new health coverage options made available by the Affordable Care Act. Speaking at the Mountain Park Health Center in Phoenix, Secretary Sebelius highlighted that with these funds, health centers are expected to hire an additional 2,900 outreach and eligibility assistance workers to assist millions of people nationwide with enrollment into affordable health coverage. Secretary Sebelius said, “Investing in health centers means that people in neighborhoods and towns across the country have one more resource to help them understand their insurance options and enroll in affordable coverage.” Health centers have a long history of providing eligibility assistance to patients along with delivering high-quality, primary health care services in communities across the nation. Health centers serve more than 21 million patients annually. 4 | M2VA 17.4

With these awards, which health centers in all 50 states have received, consumers will get help understanding their coverage options through the new health insurance marketplace, Medicaid and the Children’s Health Insurance Program; determine their eligibility and what financial help they can get; and enroll in new affordable health coverage options. These awards, issued by the Health Resources and Services Administration (HRSA), complement and align with other federal efforts, such as the Centers for Medicare & Medicaid Services-funded Navigator program. Secretary Sebelius’ announcement is part of the administration’s broader effort to make applying for health coverage as easy as possible. The new, consumer-focused website and the 24-hour-a-day consumer call center help Americans prepare for open enrollment and ultimately sign up for health coverage. These new tools will help Americans understand their coverage options and select the plan that best suits their needs when open enrollment in the new health insurance marketplace begins October 1, 2013.

spouses and eligible dependent children can be buried in a VA national cemetery. Also eligible are military personnel who die on active duty, their spouses and eligible dependents. Other burial benefits available for all eligible veterans, regardless of whether they are buried in a national cemetery or a private cemetery, include a burial flag, a presidential memorial certificate and a government headstone or marker. Families of eligible decedents may also order a memorial headstone or marker when remains are not available for interment. In the midst of the largest expansion since the Civil War, VA operates 131 national cemeteries in 39 states and Puerto Rico and 33 soldiers’ lots and monument sites. More than 3.8 million Americans, including veterans of every war and conflict, are buried in VA’s national cemeteries.


Rear Adm. Colin G. Chinn

Navy Rear Admiral (lower half) Colin G. Chinn has been nominated for appointment to the rank of rear admiral. Chinn is currently serving as director, Medical Resources, Plans and Policy Division, N0931, Office of the Chief of Naval Operations, and Chief of the Medical Corps, Washington, D.C.

Rear Adm. Elaine C. Wagner

Navy Rear Admiral (lower half ) Elaine C. Wagner has been nominated for appointment to the rank of rear admiral. Wagner is currently serving as commander, Navy Medicine East; commander, Naval Medical Center; and chief of the Navy Dental Corps, Portsmouth, Va.

How health IT is creating a new breed of health care worker at A merica ’ s universities . By Chris McCoy, M2VA Editor The field of medical informatics is expected to continue growing over the next five years in both the military and civilian sectors. The 2009 Health Information Technology for Economic and Clinical Health Act and associated stimulus funding to support the adoption of health care technology has greatly expanded educational opportunities in the informatics arena. As the greater health care community focuses on adoption of health care IT and Office of the National Coordinator meaningful use requirements, there has been greater attention paid to these areas in the Department of Defense as well. “Nursing informatics specialists are critical in the Army to ensure the maximal use of health care information technology in support of safe, quality patient care,” said Richard H. Breen Jr., APR director, Office of Strategic Communications, Office of

the Assistant Secretary of Defense for Health Affairs. “Nursing informatics specialists are utilized at every level of Army Medicine, including in the operational environment.” A number of universities offer programs in nursing informatics and other related health and medical informatics tracks. Representatives of Nova Southeastern University, Walden University, the University of Missouri and the University of Pittsburgh offered insight into their informatics programs.

Focusing on the Application and Evaluation of Health IT The biomedical informatics program at Nova Southeastern University’s College of Osteopathic Medicine was established in M2VA  17.4 | 5

“Our Department of Health Management and Informatics, a 2006. The degrees and certifications offered include a Master part of the School of Medicine, leverages this history,” said David of Science in biomedical informatics, a graduate certificate in Moxley, associate director, Executive Program medical informatics, a graduate certificate in for Health Management and Informatics. “Our public health informatics, an American Medical dual expertise in informatics and health services Informatics Association 10x10 certificate, and a management creates organizational leaders preMaster of Science in Nursing (MSN) in nursing pared to transform and integrate health systems informatics. in the 21st century. Through partnership with “Being offered both onsite and online, our MU’s Informatics Institute, we also offer Ph.D.s programs allow working professionals the opporin informatics and train the next generation of tunity to obtain their degree without career health informatics faculty and researchers.” disruption,” said Christine Nelson, program manMoreover, MU provides graduate education ager of the biomedical informatics program. “Our such as a Master of Science in health informatics, skills-based curriculum offers courses leading to Christine Nelson a graduate certificate in health informatics and Lean Six Sigma Green Belt, Certified Professional dual degrees with Master of Health Administrain Healthcare Information Management Systems tion in both traditional and distance formats. and NextGen certifications.” “The curriculum provides an applied orientaThe program’s curriculum focuses on application drawing on the best evidence, to develop an tion and evaluation of health IT and the business/ in-depth understanding of how health organizamanagement of health IT. Students can apply for tions and systems are structured and function,” and begin their studies in winter, summer and said Moxley. “[The curriculum also teaches] how fall. information technology can be applied to improve “Students who study biomedical informatics the integration, quality and safety of clinical serat Nova Southeastern University have a number vices as well as the efficiency and overall business of different options when it comes to both career function.” setting and job title,” said Nelson. David Moxley The average age of MU’s executive students is Examples of settings in which a biomedical 38. However, the university has students ranging informatics student might work include hospitals from their 20s into their 60s. and health care systems; clinics, community health centers, or “Our executive cohort consists of students from all kinds of private medical practices; federal and state governmental health backgrounds, including nurses, physicians, etc.,” said Moxley. care agencies; health IT systems vendors or eHealth companies; “Each class is diverse both in ethnicity as well as professional consulting services; and academic institutions. Potential posibackgrounds.” tions include C-level administrators (i.e. CMIO, CMO, CIO, CNIO) or informatics department directors; consultants; systems analysts; project managers or designers; implementation Translating Knowledge into Practice specialists; template writers; educators and trainers; researchers; and programmers. Walden University, an online university with its academic The students of the biomedical informatics program are headquarters located in Minneapolis, Minn., offers an MSN with a diverse group. The students hail from a multitude of career a specialization in nursing informatics that is accredited by the fields including health care, information technology, business, Commission on Collegiate Nursing Education. The university education and others. Due to the field being relatively new, provides a nursing education through faculty and opportunities and few people previously being trained in both health care in the field that prepare students for the role of nurse informatiand information technology, students with a number of differcists. ent backgrounds are working to enter this field of study. “Our Walden University also maintains an extensive library and students range in age from 22 to 64, originate from 17 different offers a writing center for students to prepare them to be scholar countries, and currently reside in 21 different U.S. states and five practitioners. After graduation, the students are prepared to countries,” said Nelson. “More than half of Nova Southeastern apply for the American Nurses Credentialing Center Nursing University students are female. In addition, our students identify Informatics Exam. with a number of different races/ethnicities.” “Our MSN graduates are well prepared to enter the nursing informatics field as new master’s prepared specialists or as experienced nurse informaticists ready to contribute to the applicaLeveraging a History of Informatics Research tion of evidence in practice,” said Dr. Tracy Scott, Walden’s MSN nursing informatics program coordinator. The University of Missouri (MU), home to the world’s first The Walden University CCNE-accredited Doctor of Nursing computerized laboratory system, has been a leader in health and Practice (DNP) degree provides advanced practice nurses with biomedical informatics research since the 1960s. The university the opportunity to build on their knowledge and expertise to began offering training in health and biomedical informatics augment health care delivery and improve patient outcomes. in the 1970s and counts among its alumni some of the leading The DNP program’s coursework covers a range of topics, figures in the field. 6 | M2VA 17.4

development of skills in precepting, mentoring and including health care policy and advocacy, quality coaching and can be applied in educational as well improvement, evidence-based practice, information as clinical settings.” systems/technology, advanced nursing practice and For academic year 2012-2013, the Pittsburgh organizational and systems leadership. Students School of Nursing had a total of 1,101 students may work with preceptors and faculty experts to enrolled. Of those, approximately 14 percent were enhance their skills in informatics and focus their male, 11 percent represented minority or underserved practicum and project work. populations and 24 percent were from out of state. “Students in our School of Nursing come from Many of the students graduating from these unidiverse backgrounds, and typically have several versities’ informatics programs will face a welcoming years of nursing experiences,” said Scott. “Many job market due to their unique skill-sets, and the MSN students specializing in nursing informatics Tracy Scott military is hiring. work in an informatics role and want to expand “Career prospects for nursing informatics professionals in the their knowledge. Students in our virtual classroom are not only U.S. Army are good,” Breen said. from the United States but other countries around the world, so The Army Nurse Corps has assignment opportunities for civilian the cultural experience is rich at Walden.” nursing informatics professionals at the military treatment facility, regional medical command and Medical Command Office of The Combining Academic Work, Research Surgeon General levels. Ultimately, a move into medical informatics and Experience can seriously advance one’s career in medicine in both the civilian and military spheres. O The University of Pittsburgh School of Nursing educates students for the field of nursing informatics through a curriculum For more information, contact M2VA Editor Chris McCoy that combines academic work with varied and intensive clinical at or search our experiences and a growing involvement in research. Completing online archives for related stories at the required coursework leads them to an MSN with a concentration in nursing informatics. “The nursing informatics curriculum includes coursework such as introduction to informatics, clinical information systems and project management for technology. There are also two practicum opportunities designed to enhance the students’ knowledge and skill set through active participation in a selected informatics role,” said Elizabeth M. LaRue, Ph.D., coordinator of nursing informatics. The University of Pittsburgh School of Nursing also offers nursing administration (NA) and clinical nurse leader (CNL) concentrations that complement informatics coursework. The NA concentration is designed to prepare nurses to work in leadership and management positions at the department and director level. “The curriculum builds on students’ experiences in direct-care nursing roles and provides the knowledge base needed to develop the conceptual, interpersonal and technical skills required to function in health care management and administration,” said LaRue. “In addition, it is designed for individuals who wish to make a positive contribution to patient outcomes and service delivery in ways that support and complement direct patient care.” The NA concentration is offered at both the MSN and DNP level. According to LaRue, the core courses build a foundation in research for evidence-based practice, nursing outcomes, use of technology, leadership development and organizational theory. This training is then enhanced with coursework in economics, health policy and health promotion. LaRue explained that the CNL concentration is focused toward nurses who want to make a difference in the clinical setting or provide leadership in educating others to gain these skills. “The CNL assumes responsibility for patient care outcomes by coordinating and supervising the care provided by interdisciplinary team members,” said LaRue. “The CNL role includes

M2VA  17.4 | 7

The relevance, prevalence and consequences of short sleep duration and shift work in military personnel . By Lieutenant Colonel (P) (Dr.) Vincent Mysliwiec and Major (Dr.) Kevin A. Carter

times, such as between 2:00 a.m. and 5:00 Command, control, communication and a.m., which is the time period of minimum intelligence are vital for any successful mishuman alertness. It is well established that sion. There is often a fine line between the majority of industrial and motor vehicle success and failure, and the importance of accidents occur during this time period. fatigue-related errors must be considered Contributing to the increased potential for in preparing for military operations. For accidents is sleep deprivation; the majority of purposes of this article, fatigue and sleepimilitary personnel average less than six hours ness will be used interchangeably and are of sleep each night, which is substantially defined as mental and/or physical exhausless than the inherent requirement of eight tion. Common causes of fatigue include hours. For military personnel to perform lack of adequate sleep, fragmented sleep— optimally, they require regular sleep of an where an individual has frequent awakenings adequate duration. Maximum alertness and while sleeping—and night shift work, which performance occurs when results in circadian misalignindividuals consistently ment and sleeping during achieve eight hours of normal periods of wakefulquality, non-interrupted ness. Fatigue ultimately sleep during the nighttime leads to impaired mental and period. Adopting good sleep physical performance. Overpractices during training all, fatigue can cause highly periods will lessen the impact trained individuals to perform of the extended periods of at a substandard level and wakefulness that are required potentially result in failed for critical missions. missions or catastrophic Notably, humans do not accidents. Understanding the Lt. Col. (P) (Dr.) Vincent Mysliwiec adapt to sleep deprivation; implications of fatigue on however, some tolerate it bethuman performance can help ter than others. There are individuals who leaders adapt to the challenges of continuare more sensitive to sleep loss, meaning ous operations and improve their ability to they manifest sleepiness sooner than others achieve mission success. and thus may not perform well in the rigorA military member is the quintessential ous military environment. Yet, even those sleep-deprived individual. It is not uncommon who perceive themselves as tolerant of sleep for military missions to require alertness for deprivation often lack insight into the level of periods greater than 24 hours. In addition, their sleepiness. It can take as many as two or operations may initiate at unpredictable 8 | M2VA 17.4

three days of “normal” sleep for them to correct their sleep debt and return to their usual performance levels. Fatigue has been implicated in several high-profile accidents, such as Three Mile Island, Chernobyl and the Challenger Space Shuttle. Through either the acute effects of one night’s sleep deprivation or chronic sleep restriction, where even one or two hours of sleep loss per night result in a chronic sleep debt, mental processes start to decline with degradations in accuracy and timing and unconscious acceptance of lower performance standards. Further, social interactions decline, multitasking becomes difficult, the ability to reason is impaired, situational awareness declines and the ability to integrate information is lost. Notably, the effects of sleep deprivation are remarkably similar to the effects of alcohol. Studies demonstrate that four hours of sleep loss impairs reaction times to a similar degree of a legally intoxicated blood alcohol level of 0.095 percent. While the mental effects of sleep deprivation occur relatively acutely, the physical strain of sleep deprivation is more of a chronic process that also cannot be ignored. Short sleep causes elevations in the body’s inflammatory markers, elevates blood pressure, increases blood glucose levels equivalent to pre-diabetes and results in dysregulation in metabolism and appetite. On a chronic basis, short sleep duration is associated with increased risks of obesity, cardiovascular disease and even death.

There is a growing awareness in the range from sleepiness and impaired functionmilitary about the importance of sleep. Shift ing upon awakening to sleepwalking and workers, especially those who work during complex behaviors without conscious awarethe late evening and early morning hours, ness of them. Side effects can have detrimenare especially prone to accidents as they are tal consequences for both the servicemember required to remain alert during the period and their unit’s mission. of time when the biologic Sleep is a limited resource clock is most prone to staythat military leaders need to ing asleep. During succesappropriately account for. sive night shifts the risk of Inadequate sleep and sleep an accident or injury nearly deprivation are well-estabdoubles, cumulating in a 36 lished causes of fatigue-related percent increase during the accidents and chronic medifourth night shift. While most cal conditions. The nature of military personnel do not fit combat missions requires prothe prototypical definition of longed operations and judia shift worker, they frequently cious use of countermeasures, Maj. (Dr.) Kevin A. Carter work long days, have 24-hour which can help maintain duty and, during deployvigilance during these critiments, conduct sustained operations. All of cal time periods. The best countermeasure this contributes to an irregular sleep schedule for successful military operations is getting and short sleep duration. adequate sleep and having an established unit Military leaders are well versed on the sleep regimen. Just as poor sleep and insomrequirement for adequate water intake to nia become learned maladaptive behaviors, prevent heat casualties. Sleep is a similar military personnel can train to have approand essential biologic requirement which priate sleep patterns. This will help ensure requires the same level of attention to preoptimal readiness and an ability to conduct vent fatigue-related accidents. An appropriate sustained operations. O sleep period that ensures eight hours of quality sleep should be addressed in all military Lieutenant Colonel (P) (Dr.) Vincent personnel. This is even more relevant in those Mysliwiec is chief, Pulmonary/Critical Care/ who perform shift work as they are required Sleep Medicine at Madigan Army Medical to sleep at times which do not align with their Center. He has practiced sleep medicine for biologic clock, i.e., during daytime hours. A 11 years and is one of the foremost experts quiet and dark environment that is comfortin military sleep medicine, having authored able, with temperature regulated as close as multiple peer-reviewed medical articles on possible to 68 degrees Fahrenheit and free of sleep and sleep disorders in military personsignificant noise and disruptions, is imperanel. tive to quality sleep. This is especially the case Major (Dr.) Kevin A. Carter graduated during daylight hours. from Ohio University Heritage College of Appropriate countermeasures to combat Osteopathic Medicine in 2006. He completed sleepiness and fatigue during shift work and a family medicine residency at DeWitt Army prolonged operations include judicious use of Community Hospital (Fort Belvoir, Va.) in caffeinated products, bright light and appro2009 and a sleep medicine fellowship at priate sleep prior to sustained operations. In Walter Reed Army Medical Center, Washingan attempt to compensate for the long hours ton, D.C., in 2010. Carter is board-certified and rotating shifts required during combat in family and sleep medicine. He currently deployments, military personnel frequently serves as the director of the Sleep Medicine consume coffee and energy drinks in excess. Center at Martin Army Community Hospital, There is data showing that military personnel Fort Benning, Ga. with excessive caffeine intake are more likely The opinions and assertions in this artito take prescription sleep medications; howcle are those of the authors and do not necesever, it is unknown if excess caffeine results sarily represent those of the Department of in difficulties sleeping and thus the need for the Army, the Department of Defense, or the a sleep aid, or if the use of a sleep aid results U.S. government. in residual sleepiness and thus the perceived need for caffeine. In either case, both preFor more information, contact M2VA Editor Chris McCoy at or search our scription and non-prescription sleep aids are online archives for related stories at associated with side effects. These side effects

M2VA  17.4 | 9

Special Section:

Cas ua lt y Ca r e

Modern medical

technologies have drastically improved the lot of the wounded warrior . By Peter Buxbaum M2VA Correspondent

Wartime brings innovations to war fighting, and the same can be said of combat casualty care. With the United States at war for well over a decade, front-line attention to casualties has changed dramatically since U.S. forces first arrived in Afghanistan. The changes take place on several levels. Cultural changes since the country’s last protracted conflict have meant that combat deaths have become less acceptable, to the political leadership, to military commanders and to citizens at large. This has led to an emphasis on developing practices and products that will keep wounded warfighters alive long enough to get them to a hospital. Changes in how simple products such as tourniquets and gauze are made and used have transformed combat casualty care in the 2000s, as have the packing of innovative medical kits, developments in foldable stretchers and high-tech electronic gear. Military medical organizations, medical personnel in theater and private companies have all made their contributions. Military medical bureaucracies have studied requirements and conducted research on products, protocols and practices. Military 10 | M2VA 17.4

medics have shared feedback on what works and what doesn’t work on the front lines. And industry has responded by developing and marketing new products and tweaking old ones. The DoD’s Joint Trauma System Committee on Tactical Combat Casualty Care (TCCC) makes recommendations regarding changes in practices and procedures for combat casualty care. The committee recently recommended changes to the TCCC Card, a document that records data at the pre-hospital level of care. The committee also recently approved protocols for warm blood transfusions, in which warfighters can transfer their own blood to a casualty in the most extreme of situations. “From the beginning of the conflict in Afghanistan we have seen changes, and the changes that have occurred have been dramatic,” said Colonel Dallas Hack, director of the U.S. Army’s Combat Casualty Care Research Program (CCCRP). “Just about everything we do is different than what we used to do.” Warfighters die from trauma primarily from blood loss, so stopping bleeding on the

battlefield became the number one priority. “Bleeding causes 80 percent of preventable deaths before patients get to the hospital,” said Hack. “Prior to 9/11, the conventional wisdom held that you can’t cut off the blood supply to an extremity. We set about to prove that wasn’t true and we saved many lives as a result.” “Civil War doctors said that every soldier should carry a tourniquet,” said Matt Westra, vice president for sales at North American Rescue. “That didn’t happen until 2005.” “What we figured out in Iraq and Afghanistan is that stopping bleeding and starting interventions in the first few minutes saves lives,” said Ken Mullins, medical products application specialist at ADS Inc. “The medevac system is so efficient that casualties now arrive in the hospital within 45 minutes. The tourniquet is the first thing out of the kit to stop bleeding. The core of the body is usually protected by armor. The tourniquet helps to prevent bleeding out from the extremities.” There are hundreds of kits available to medics to suit different mission purposes. The Army and Air Force refer to these as kit sets, each of which is reviewed and

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Casualt y Ca re

authorized by the respective service, while the Navy, Marine Corps and Coast Guard refer to these as AMOLs, which stands for Authorized Medical Allowance List. “There are kits and AMOLs for combat casualty care, for battalion aid stations and for naval vessels,” said Peggy Leighton, military account manager at Chinook Medical Gear Inc. “Products included in the kits are changed as a result of guidelines issued by the Joint Trauma System Committee on Tactical Combat Casualty Care and feedback from the services. We have already included the new triage card in our kits. We also were the first to release a kit for warm blood transfusion, which is a skill set that was just recently recognized for members of the special operations community.” “Significant enhancements in medical care have evolved from the lessons learned in Iraq and Afghanistan,” said Andrew Fleischacker, senior director of marketing for military products at Zoll. A flight medic checks to ensure IV fluid is flowing properly to a wounded Afghan National Army soldier during a patient transfer mission in Kapisa province, Afghanistan. [Photo courtesy of U.S. Army/by Sergeant Duncan Brennan] “The need for improved clinical parameters to more accurately assess a patient’s condition is critical. Equally important is this reduces the time [it takes for] bleedmilitary, but some medics prefer the SOF the ability to capture and share clinical data ing to be stopped,” said Scott Garrett, vice Tactical (SOF-T) tourniquet, according to from the point of injury through definitive president for military and tactical programs Mullins. “The CAT includes plastic and Velcare.” at Z-Medica. cro components which don’t “Patient data is often lost Z-Medica produces a line of kaolin-based always perform well in the completely or written on products called QuikClot. Combat Gauze is desert,” he said. “I have seen paper or frequently on the the QuikClot product made for the military. the SOF-T in action and it body, but not incorporated Combat Gauze represents a third generation is a good piece of gear. You into the patient’s record of of hemostatic gauze for Z-Medica. The first get more bang for the buck care,” said Barnie Howell, two generations relied on zeolite, a different from the SOF-T.” The SOF-T U.S. military director of busikind of mineral agent. handle is made of aluminum ness development at RDT. Kaolin-based QuikClot gauze has been and its fastening system per“When the patient arrives subjected to studies at the U.S. Army Instiforms when soiled, muddy, at the battalion aid station, tute of Surgical Research and the Naval frozen or wet. combat support hospital, or Peggy Leighton Medical Research Center, according to GarOther products carried back in the U.S., there is often ret. “The Tactical Combat Casualty Care by warfighters in their basic no record of the patient’s vital committee guidelines state that Combat first aid kits include needles and tubes to signs data, encounters, or interventions. If Gauze is the first line of treatment for relieve chest cavity pressure and to keep the full patient data could be transmitted to life-threatening hemorrhage on external airways open, as well as new generations of the receiving facility, prior to patient arrival, wounds that are not amenable to tourniquet gauze. “Many of these products have been patient outcomes could be improved.” placement,” he said. “The TCCC guideline developed or modified since the beginning “Early on we set out to disprove the concerning Combat Gauze was based on the of the current conflict,” said Westra. “In the conventional wisdom about tourniquets,” test results from the USAISR study.” case of gauze, a medic can pull gauze from a said Hack. “We lost some troops early on in In the studies, QuikClot caused hemopackage that is folded like an accordion. This the current war before changes took place stasis, or a stoppage of bleeding, typically in makes packing a gunshot wound easier and in the development and use of tourniquets. five minutes, according to Garrett. DoD and faster because he doesn’t have to unroll or Stopping the bleeding has become the first the National Institutes of Health are fundunfold the gauze.” mantra. The Combat Application Tourniquet ing research to explore other applications of Gauze impregnated with kaolin, an inert has saved more than 3,000 lives in Iraq and QuikClot in the health care markets. mineral substance, has been available to the Afghanistan.” Other interventions performed by U.S. military since 2008. “Kaolin activates The Combat Application Tourniquet military medics on bleeding patients have two of the clotting factors in the blood, and (CAT) remains standard issue for the U.S.

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changed in recent years. The loss of fluids during bleeding motivated the medic of the past to pump the patient with water. This provided some benefits to the casualty, primarily in keeping blood pressure up, but it also had the tendency to dilute the patient’s clotting factors. “You need to replace red blood cells to carry oxygen in the blood, but you also need the other parts of the blood, particularly where the clotting factors are in the non-red cell parts of the blood,” said Hack. “The idea is instead of putting in pure water to put in more concentrated fluid so as not to lose the clotting factor and not to add so much fluid that it might get into the lungs, which it has a tendency to do.” The CCCRP is performing research on the efficacy of dried plasma. “The plasma available now is frozen and it is hard to thaw on the battlefield,” said Hack. “Dried plasma can be reconstituted with food a soldier is carrying.” A medical evacuation helicopter flown by soldiers of the 82nd Combat Aviation Brigade lands as paratroopers from the 82nd Airborne Division’s 1st Brigade Combat Team secure the area, Ghazni province, Afghanistan. [Photo courtesy of U.S. Army/by The CCCRP is also looking into the posCaptain Thomas Cieslak] sibility of freezing blood platelets, which are also necessary for clotting. Fresh platelets company’s vice president and founder. “It suitable for medics and individual operators. last for only five hours. Hack hopes that weighs 7 pounds and with all accessories it Some of Chinook’s newest kits and modules freezing platelets will make them available weighs 9 pounds. There is a strap diagonally that have received military approval include at far forward locations. across the chest to keep the patient in if it a dental kit, a chest tube module and the Chinook Medical Gear has devised a kit gets inverted.” Ultra-Lite Gamow bag, a portable hyperbaric based on some very recent guidance from The Tactical Sked is secured across a chamber for the treatment of the TCCC for warm blood ruck and is made of rugged plastic for duraaltitude sickness. Modules are transfusions. These procebility in extreme environments. “When it is packaged in plastic, vacuum dures, to be performed pricarried or hoisted, it keeps the patient’s body sealed and placed into kits. marily by special operations straight,” said Calkin. “It will not bend in ADS is also a custom kitin those rare occasions when the middle. Because it is narrow it forms an ter which sells products to no packaged blood is availanatomical splint around the legs when the the U.S. military through able, involve one warfighter straps are pulled tight.” multiple contract vehicles. transferring blood directly to The Tactical Sked comes in a kit that “Most of the guys at ADS, another. includes 75 feet of Kevlar rope. Skedco litters like myself, are combat veter“This is a new skill set,” have been upgraded with Cobra side release ans,” said Mullins. “My team said Leighton. “This is someBud Calkin buckles that are rated at 3,000 pounds, and has 98 years of military expething that was not previously which allow patient packaging in half of the rience and multiple tours in accepted or recognized, but time of the original steel buckles. Iraq and Afghanistan. We talk to corpsmen over the last few years they have ironed out Skedco also produces specialty products in their own language to find out what they the kinks and have developed a procedure such as the Oregon Spine Splint II, which need.” that is very precise and methodical.” Chiis designed to immobilize the back to allow Military stretchers hadn’t changed in 50 nook’s Field Blood Transfusion Kit includes for safe removal of patients without doing years until new products were developed for equipment to perform a quick blood match further damage to the spine. “The OSS II the recent conflicts. “Today’s military litters between the two parties as well as the gloves, is designed to provide easy access to the can collapse and be carried in a medic’s bag, tape, tubes, packs and other paraphernalia patient’s chest or abdominal area for treatthen folded out when needed. Many of these required to execute the procedure. ment or diagnostic procedures,” said Calkin. innovations have come from military medics Chinook does not manufacture the items “It can also be used as a hip or leg splint. The themselves,” said Westra. in the kits it sells to the military but has OSS II includes a shoulder board which can Skedco’s latest stretcher, the Tactical access to over 5,000 products that can be kitbe used to prevent compression of the shoulSked, “was requested through the system ted for different units and different missions ders when using a flexible stretcher.” The from down range,” said Bud Calkin, the on a custom basis. Tactical kits include those 12 | M2VA 17.4

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OSS II folds into a small package and can be slipped inside a rolled-up Sked stretcher in its backpack bag. The Army is currently searching for a new vital signs monitor that can be easily transported to and operated in the field. “The monitors we have been using for decades are big and heavy and don’t have all the parameters we need,” said Hack. “We want monitors that can communicate information to higher levels of care and that are the size of a tablet computer instead of the 30-pound units we are carrying around now.” New software is being developed that will predict when casualties reach a critical state. “The problem we face is that young healthy people are able maintain their pulse and blood pressure even after losing a significant amount of blood, and we can’t always tell when they are getting into trouble,” said Hack. “There are new techniques that are able to indicate this a few minutes ahead of time.” Two of the contenders for the military’s new monitor come from RDT and Zoll. “The RDT Tempus Pro vital signs monitor has the ability to easily document and share all patient data electronically from the battlefield across the continuum of care back to CONUS,” said Howell. “Tempus Pro software enables the creation of an electronic version of the TCCC card that is automatically populated with vital signs, and the touch-driven display facilitates entering of drugs, fluids, interventions and notes. The patient record of care builds throughout the encounter and is then exported for handover or transmitted to the receiving clinician throughout the echelons of care and into the long-term patient record.” Tempus Pro is designed to evolve over the life of the monitor as requirements and budgets change, according to Howell. “It is a fully featured monitor that is smaller and lighter than the current military monitor,” she said. “Parameters include a 12-lead EKG, two channels of invasive pressure, with an additional two channels under development, and CO2. The unit is also ruggedized and durable.” Tempus Pro can also support the addition of advanced clinical capabilities. “Advanced capabilities that are currently under development include ultrasound to support field FAST [focused assessment with sonography for trauma] exams, pneumothorax detection, and video laryngoscopy

to help ensure and document proper tube placement,” Howell noted. “After a new capability is introduced, all Tempus monitors will be shipped from the factory with the software embedded to enable every device to interface with the new capability set.” “The new Zoll Propaq M vital signs monitor and Propaq MD monitor/defibrillator is a robust platform with a unique open data architecture,” said Fleischacker. “We have added a variety of new clinical parameters to help assess patient status. We have also partnered with several companies to provide a telemedicine solution that allows you to collect and transmit patient data from the point of injury forward.” Zoll provides a number of resuscitation technologies to the U.S. military as well as an automated external defibrillator and blood and fluid warming equipment. The new Propaqs are the latest additions to the company’s military portfolio. “The Propaq M is the next generation of the Propaq 206 Encore that has been the standard of care monitor for nearly 20 years,” said Fleischacker. “We also listened carefully to our military customers, who requested that we integrate more into a single box. The Propaq MD has all the features of the Propaq M with an integrated defibrillator/pacer.” Among the advanced clinical parameters provided by Zoll are Masimo’s E1 sensor, which measures oxygen saturation changes from an ear sensor and, once FDA clearance is achieved, several other Masimo non-invasive blood measurements. “Our open platform provides the capability to easily integrate new parameters, as developed, with a simple software upgrade,” said Fleischacker. “As data communications and electronic patient care records becomes more important, Zoll’s open data architecture allows the patient data to flow from our device into a number of different EHR systems or telemedicine solutions.” RDT’s equipment also supports telemedicine capabilities, according to Howell. “The optional ReachBak telemedicine capability enables users to transmit all medical data, waveforms, still images, TCCC cards and EKG recordings,” she said. “This can be accomplished over various communications links, including standard military radios and military and civilian SATCOM. Over the last several years, the Tempus has successfully operated over various military radios

Casualt y Ca re

with no need for a laptop or other portable computing device. RDT will be continuing to expand Tempus Pro with new software features and external peripherals that will be field upgradeable.” The telemedicine capabilities of this new generation of equipment sound like stepping stones to Hack’s vision of a virtual ICU, a system he expects to be in place within the next three to five years. “We will get to the point where front-line care will be team care,” he said. “One person up front will be backed up by a team at an entirely different location to provide almost the same level of care as an emergency room or a trauma center. This will represent a vast improvement in the ability to keep patients alive until a surgeon can take care of them.” O

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

M2VA  17.4 | 13

VITAL SIGNS Hepatitis C Genotype Detection Kit Wins FDA Approval

Point and Shoot C-Arm Surgical Imaging Device GE Healthcare recently received FDA 510(k) clearance for its latest Brivo Plus C-arm, now available in the U.S. “We’re thrilled to bring our line of Brivo C-arms to the U.S. with the new OEC Brivo Plus,” said Jim Corrigan, president and chief executive officer of GE Healthcare Surgery. “The C-arm offers an affordable solution without sacrificing the technology and innovation OEC is known for. With its compact design and easy maneuverability, the OEC Brivo Plus is a great option for our customers in surgery centers and facilities that need an easy-to-use, accurate mobile C-arm.” This point and shoot C-arm has automated features that deliver quality imaging at a clinician’s fingertips, enabling optimal image acquisition with fewer re-takes. With new advancements in steering and lightweight construction, the C-arm’s compact design makes it easier to guide into spaceconstrained operating or procedure rooms. Brivo’s data management abilities can help clinicians boost productivity. Wireless capabilities are also enabled to ensure the fast transfer and protection of data. Mirielle Ranade;

The Abbott RealTime HCV Genotype II is a laboratory test that can determine certain genetic types of the hepatitis C virus (HCV), providing results about what type of HCV a person is carrying. In order to detect the virus a patient’s blood sample is taken. The test extracts genetic material from inside the HCV virus. The test then produces multiple identical copies of specific segments of the extracted genetic material to help identify the unique genotypes. It uses fluorescence to detect the amplified signal for each genotype in the laboratory. The Abbott RealTime HCV Genotype II assay is used in individuals known to be chronically infected with HCV. It can differentiate HCV genotypes 1, 1a, 1b, 2, 3, 4 and 5 in a sample of human blood plasma or serum from an individual chronically infected with HCV. The test should not be used as a diagnostic test or as a screening test for the presence of HCV genetic material in donated blood, blood products, or tissue donors. The particular type of HCV is an important factor, together with other clinical factors, in helping determine the appropriate type of therapy for patients with chronic HCV infections. Because the various HCV genotypes respond differently to available drug therapies, knowing the type of HCV a person is infected with can result in better patient outcomes.

Ultra-Fine Pen Needle BD Medical, a segment of Becton, Dickinson and Company has launched the BD Ultra-Fine Nano 4mm Pen Needle with EasyFlow Technology, making it easier and faster for people with diabetes to give themselves their daily insulin injections. A majority of diabetics prefer this pen needle to their current pen needle on all three of the leading insulin pen brands. In a clinical study published in Clinical Therapeutics, 61 percent of patients reported they needed less thumb force to inject it. BD Medical is able to deliver this improved performance by increasing the space inside the needle while maintaining industry leading gauge size––increasing the flow rate in controlled laboratory testing by up to 149 percent versus competitive pen needles. The launch of this technology follows BD’s recent unveiling of PentaPoint Comfort, a patented 5-bevel needle tip. EasyFlow Technology is currently available in the U.S. and Canada on all BD Ultra-Fine Nano 4mm Pen Needles

14 | M2VA 17.4

with PentaPoint Comfort and will be available in many European countries in the coming months.

Compiled by KMI Media Group staff

First Transparent Cervical Collar The North American Rescue Cervical ClearCollar is the world’s first transparent cervical collar—allowing for constant visualization of the neck for patient assessment. This cervical collar gives the care provider access to see jugular venous distention, tracheal deviation, hematomas and more without subjecting the patient to possible further injury by removing stabilization. The ability to visualize the neck and airway ensures the best patient care throughout all phases of care, from the battlefield to the hospital. The collar is constructed of a lightweight, flexible, and strong polymer that has been tested in extreme temperatures from -20 F to 150 F. It also features large posterior and anterior openings for easy palpation and access and is adjustable to fit all sizes of adults. Special features include: MRI CAT/X-ray compatibility, latex free, optimum flexibility and strength, nominal 9.7-by-6.4 cm posterior opening, exceeds torque and pressure tests against competitor collars and improves patient care while reducing liability. Lonnie Johnson;

Defibrillator Earns U.S. Army Airworthiness Certification Philips received an airworthiness release certification for its HeartStart FR3 automated external defibrillator from the U.S. Army. The U.S. Army Aeromedical Research Laboratory confirmed the completion of extensive aeromedical testing and evaluation of the FR3, both in the laboratory and aboard a U.S. Army HH-60M helicopter. The certification validates the safety of the aircraft and its subsystems, the aircraft crew, the device itself, and ultimately, the patient. The HeartStart FR3 significantly reduces deployment time by eliminating steps to help responders start delivery of the right therapy—CPR or defibrillation—on the patient faster. The FR3 automatically powers on when the rigid

system case is opened. The device also features easy to access, pre-connected peel and place pads that do not require opening a foil pouch. These unique features help speed therapy delivery. Rachel Bloom-Baglin;

Advanced Flexible Stent Graft System The Aorfix Flexible Stent Graft System is an endovascular stent graft used to repair abdominal aortic aneurysms (AAA). An AAA is a diseased, weakened and bulging section of the wall of the aorta, the body’s largest vessel. A synthetic tubelike device (a stent graft) is used within the blood vessel (endovascular) to treat the AAA by sealing it off. The graft is made of a fabric tube supported by a metal framework. This framework supports the graft and holds it open within the blood vessel. Each endovascular graft is compressed into the end of a long, thin, tube-like device called a delivery catheter. The delivery catheter containing the endovascular graft is inserted into an artery in the groin through a small skin incision. It is carefully guided by a type of X-ray (called fluoroscopy) within the artery into the abdomen to bridge the site of the aneurysm in the aorta. The endovascular graft is then released in the aorta, where it expands to the diameter of the aorta to seal off the aneurysm and relines the artery wall. This endovascular graft goes from the aorta to the arteries that supply blood to one leg. M2VA  17.4 | 15

Considerate Planner

Q& A

Focusing on Readiness, Relevance and the Long-term Health

Dr. Jonathan Woodson Assistant Secretary of Defense for Health Affairs Director TRICARE Management Activity Dr. Jonathan Woodson is the Assistant Secretary of Defense for Health Affairs and Director, TRICARE Management Activity. In this role, he administers the more than $50 billion Military Health System (MHS) budget and serves as principal adviser to the Secretary of Defense for health issues. Woodson ensures the effective execution of the Department of Defense medical mission. He oversees the development of medical policies, analyses and recommendations to the Secretary of Defense and the Undersecretary for Personnel and Readiness, and issues guidance to DoD components on medical matters. He also serves as the principal adviser to the Undersecretary for Personnel and Readiness on matters of chemical, biological, radiological and nuclear medical defense programs and deployment matters pertaining to force health. Woodson co-chairs the Armed Services Biomedical Research Evaluation and Management Committee, which facilitates oversight of DoD biomedical research. In addition, he exercises authority, direction and control over the Uniformed Services University of the Health Sciences; the Armed Forces Radiobiology Research Institute; the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury; the Armed Forces Institute of Pathology; and the Armed Services Blood Program Office. As director, TRICARE Management Activity, Woodson is responsible for managing all TRICARE health and medical resources, and supervising and administering TRICARE medical and dental programs, which serve more than 9.6 million beneficiaries. He also oversees the TRICARE budget; information technology systems; contracting process; and directs TRICARE regional offices. In addition, he manages the Defense Health Program and the DoD Unified Medical Program as TRICARE director. Prior to his appointment by President Obama, Woodson served as associate dean for diversity and multicultural affairs and professor of surgery at the Boston University School of Medicine, and senior attending vascular surgeon at Boston Medical Center. Woodson holds the rank of brigadier general in the U.S. Army Reserve, and served as assistant surgeon general for Reserve Affairs, Force Structure and Mobilization in the Office of the Surgeon General, and as deputy commander of the Army Reserve Medical Command. Woodson is a graduate of the City College of New York and the New York University School of Medicine. He received his 16 | M2VA 17.4

postgraduate medical education at the Massachusetts General Hospital, Harvard Medical School and completed residency training in internal medicine, and general and vascular surgery. He is board certified in internal medicine, general surgery, vascular surgery and critical care surgery. He also holds a master’s degree in strategic studies (concentration in strategic leadership) from the U.S. Army War College. In 1992, he was awarded a research fellowship at the Association of American Medical Colleges Health Services Research Institute. He has authored/coauthored a number of publications and book chapters on vascular trauma and outcomes in vascular limb salvage surgery. His prior military assignments include deployments to Saudi Arabia (Operation Desert Storm), Kosovo, Operation Enduring Freedom and Operation Iraqi Freedom. He has also served as a Senior Medical Officer with the National Disaster Management System, where he responded to the September 11 attack in New York City. Woodson’s military awards and decorations include the Legion of Merit, the Bronze Star Medal and the Meritorious Service Medal (with oak leaf cluster). In 2007, he was named one of the top vascular surgeons in Boston and in 2008 was listed as one of the top surgeons in the U.S. He is the recipient of the 2009 Gold Humanism in Medicine Award from the Association of American Medical Colleges.

Q: What do you consider the priorities of your office? A: My top responsibility is to ensure we are operating a health system in which our servicemembers are medically ready to deploy anywhere in the world on a moment’s notice, and that the medical forces that go with them are ready to deliver health care in these same environments. In support of that mission, we have to operate a health system that provides the highest quality care to all of our 9 million beneficiaries—servicemembers and their families, retirees and their families, and members of the Reserve component. Now, our mission support role is complex. We operate an expansive medical education and training program in the Military Health System [MHS]; we are responsible for public health—keeping our air, water and environment safe; we direct hundreds of millions of dollars in military medical research and development; we manage one of the largest health insurance plans in the country. But central to everything is our readiness mission. We are in the midst of dealing with a number of long-term issues. After 11 years of war, we have learned a great deal about saving lives on the battlefield, and succeeded in ways unimaginable to many people. But, we have long-term medical issues for veterans that require our attention. The mental health of all who served, and their families, is of immense importance to me and to those in the MHS. We have to continue to strengthen our ties with the Department of Veterans Affairs. We are also working toward a system that is focused on health—not just health care—and trying to determine how we can help individuals stay healthy. And, we also have a part to play in larger federal budget matters—and do everything we can to function even more efficiently without ever compromising our readiness or our quality. Q: In M2VA’s first issue this year, your op-ed mentioned Operation Live Well. Could you elaborate on that for our readers? A: We’re dealing with a national crisis. This country has a problem with increasingly poor health, particularly around weight management and smoking, and the many medical problems that result from poor health habits. The military community is not immune from these trends. It affects retention. It affects recruitment. It affects readiness. And, Operation Live Well is the department’s long-term initiative for helping people make healthy choices in their lives. There are a lot of moving parts to Operation Live Well. First, it’s for everyone—active-duty and Reserve servicemembers, military children, spouses, retirees and DoD civilians. Second, it’s taking a comprehensive approach to changing our behaviors—what we eat, how much we exercise, how we take care of our mental health, if we’re smoking or using tobacco products—we let people know about the broad array of resources available to them to help them quit. Third, the whole military community is engaged—commanders, health and medical experts, commissaries and dining facilities, education resources and morale, welfare and recreation programs. We’re going to give people tools to help them along the way, let them track their progress and provide encouragement to their efforts. I recommend that people check out the incredible resources we are bringing to this effort at the Military OneSource website ( As part of Operation Live Well, this past month, we kicked off a one-year pilot project called the Healthy Base Initiative in which

we will be formally evaluating at 14 installations—what works and what doesn’t work—in getting people healthier. We’ll then expand the effective programs across DoD. And, I am practicing what I preach. I made sure that the Defense Health Headquarters is one of the 14 demonstration sites for the Healthy Base Initiative. I’m excited about Operation Live Well and when I talk to our line leaders and military spouses, they’re excited about it too. This is a long-term, strategic change in how we address health in the department. Stay tuned. Q: What are the advantages of the patient-centered medical home model? What can industry do to support this nascent movement? A: I’m not sure I would call it nascent anymore. This is getting to be pretty mature in DoD, and I am pleased with what I am seeing, and optimistic about what it portends for the future. Here are some of things we are seeing through our more mature medical homes: continuity of care is improved, patients get to know their care team, and they’re getting the access to care they need. As a result, we’re seeing fewer emergency room visits. We’re seeing higher patient satisfaction scores. We’re seeing better screening for preventive services, for quitting smoking, curbing alcohol use and treating depression. And, we are giving patients more tools to connect with their providers, such as secure patient-to-physician messaging, so they can email the physician a question rather than making an appointment for a day. I would add that having a comprehensive, worldwide electronic health record is a central and vital component to our success. As far as industry goes, we are learning from each other. There are plenty of medical homes best practices that we are adopting from the civilian community and we hope to share some of ours, as well. Q: How does DoD leverage interagency research investments within the Department of Veterans Affairs to advance health care and health services? A: Medical research within the MHS is DoD’s fundamental and sustaining institutional means to modernize the practice of military medicine. It’s absolutely incredible what has been produced through our research investments for our beneficiaries—and for all Americans—over the last year. I’m sure you saw the story a few months ago about a double arm transplant, performed at Johns Hopkins University, on one of our severely wounded servicemembers. In just less than five years, we have focused research funding on a multiinstitutional, interdisciplinary network of leading universities, hospitals and private companies working to develop advanced treatment options for our severely wounded servicemen and women. That contributed to that outcome. You asked about interagency efforts. Both DoD and the VA collaborate extensively on medical research. In fact, the DoD/VA Health Executive Council is directly responsible for overseeing our interagency medical research agenda and has chartered a research and development work group to enhance DoD/VA research initiatives. DoD and VA jointly review funded research initiatives to determine the state of science in a given area, jointly determine needs and jointly determine how we will fund new research in the near term. We recently established two joint DoD/VA research consortia. One is focused on traumatic brain injury/chronic traumatic M2VA  17.4 | 17

encephalopathy, a very serious degeneration of brain tissue over time caused by repeated concussive events; and the second is focused on PTSD. These are enormously important collaborative approaches that I think will serve as models for a broad range of research going forward. But it’s not just DoD and VA alone. We also collaborate with the National Institutes of Health on research, and our reliance on private sector and academic medical research institutions is stronger than ever. Q: Could you discuss DoD’s vision of moving post-traumatic stress treatment and research into practice? A: Maintenance of our warfighters’ psychological health and resilience is critical, both for training and in operational environments. The department invests in research in PTSD, suicide prevention, warfighter resilience, military family psychological health, alcohol and other drug use, and violence within the military. We’ve invested more than $620 million for at least 260 research projects, and PTSD is studied the most. And the research is yielding results. We now know which classes of drugs usually treat PTSD effectively and which drugs do not. DoD has funded studies that reveal the usefulness of exposure therapies and many providers are now trained to administer these therapies. In addition, DoD is using the Joint Incentive Fund [JIF] to collaboratively use approaches for early, preventive-based intervention in primary care. The JIF is also supporting the improved integration of chaplains and mental health counselors for enhanced access and care. Furthermore, exposure techniques such as trauma narratives and virtual reality have been integrated into step-down units and outpatient clinics. Health data compiled by the Armed Forces Health Surveillance Center and research on comorbidities has helped providers be attuned to co-occurring conditions, such as depression and substance abuse, in patients with PTSD. Through the Integrated Mental Health Strategies, DoD and VA have collaborated to develop pilot networks to ensure research findings that impact evidence-based treatment and can be more rapidly translated into clinical practice. These networks will be implemented within the next year, and will focus on promotion of evidence-based psychotherapy for PTSD, standardization of outcome measures and reduction of clinical implementation barriers. DoD and VA have developed and disseminated current research findings for clinicians in the form of a Post-Traumatic Stress Clinical Practice Guideline, which is updated regularly. DoD provided support for the development of a collaborative care model to move PTSD screening, assessment and treatment to the primary care level through Enhancements to (to include telephone psychotherapy, more intensive care management, and better coordination with specialty mental health services) are being tested as part of an ongoing $15 million DoD-funded trial. Q: What actions are being taken to treat the high number of returning servicemembers and veterans suffering from TBI? A: We are ensuring that every servicemember who is involved in a concussive event is provided with the care and services they need to aid in their recovery—regardless of the severity of the event. 18 | M2VA 17.4

A soldier receives information on signs and symptoms of a concussion during a consultation at the Traumatic Brain Injury clinic at Fort Belvoir Community Hospital. The Defense and Veterans Brain Injury Center team assigned to the TBI clinic assists with the evaluation of servicemembers who are suspected to have traumatic brain injuries. [Photo courtesy of the U.S. Navy/by Carlson Gray]

We are investing significant resources to understand the impact of TBI, identifying the appropriate treatment protocols and ensuring we have the resources to build and sustain world-class medical treatment and research facilities. Through the Defense & Veterans Brain Injury Center, we have been at the cutting edge of TBI clinical care, research and education for more than 20 years, including key partnerships with the VA and other federal agencies and academic partners. We are proud to have a unique public-private partnership in the National Intrepid Center of Excellence [NICoE] at the Walter Reed National Military Medical Center at Bethesda. The Intrepid Fallen Heroes Fund has been instrumental in getting this built, and DoD provides staffing. We have created one of the most cutting-edge research institutions in the country—where leading academic and military researchers collaborate on the nexus of TBI and psychological health conditions. We’re expanding the NICoE through nine additional satellite clinics at military installations, including Fort Belvoir and Camp Lejeune, which are scheduled to open this fall; as well as on Camp Pendleton, Fort Campbell, Joint Base Lewis-McChord, Fort Bragg, Fort Hood, Fort Bliss and Fort Carson. We’ve built another important partnership: the Army and the National Football League are working together on TBI-related research and improving awareness of brain injuries in both sport and military settings.

One last item. We are also establishing the first brain tissue repository at the Uniformed Services University, which is designed to address the underlying mechanisms that cause brain injury and disability stemming from TBI in servicemembers. Although our work has been underway for years, we are still in the early stages of beginning to unlock the mysteries of how the brain responds to traumatic events. But make no mistake, what we learn will benefit those who serve and every American. This is transformative work. Q: How is the military ensuring proper health care for warfighters and their families in this time of steep budget cuts? A: First things first—we will not compromise the quality of care we provide to the people we serve in any way, shape or form. Soldiers sit in the main waiting room at Monroe Health Clinic while waiting for prescriptions or appointments. The newly Reduced defense budgets following major renovated facility was designed to follow the patient centered medical home model of care and now provides many services on site including behavioral health care, X-rays, labs and pharmacy. [Photo courtesy of DoD/by Brandy Gill] conflicts is not a new phenomenon. Our job in military medicine is to be thoughtful in to include families of servicemembers who died on active duty, and how we adjust to these reduced budgets. Within the MHS, we are families of servicemembers who are medically retired. taking a number of important steps. The modest increases in retiree contributions from military Within the department, we are also in the midst of a major retirees that we propose, even when fully implemented, will still overhaul of how we are organized, and how we collaborate. Beginresult in lower out-of-pocket costs than military retirees experienced ning in October, TRICARE Management Activity and elements of in 1994 when TRICARE was first introduced, and remain far more Health Affairs will form what will be known as the Defense Health comprehensive than most Americans enjoy. Agency. This effort will result in a more integrated system of care I wish it were possible to not increase fees, ever. But that’s simply so that our clinics—across Army, Navy and Air Force medicine— not realistic. We are putting forward a balanced approach in which operate in a common way; purchase medical supplies and services we are seeking both internal efficiencies, and changes in beneficiary in a more unified manner; and work together in a manner that cost-sharing to help place us on a sustainable financial path for the helps the patient navigate the MHS. We learned to do this very long term. well in the combat theater, and we need to bring back that same approach at home. Q: How do you expect the health care needs of the military comWe need to be more efficient; we can be more efficient … but munity to change over the next five years? What types of health it’s achieved by better health and better integration, not by cutting care professionals will be in demand? back on services. In short, this transition will make the MHS better, stronger and more relevant. A: You know, I will end the interview where I started. Readiness is our core mission. Some things are constant—and the resources we Q: What role are higher TRICARE premiums playing in support need to ensure this readiness is one of them. of the MHS’s ability to finance itself and provide the best posThe drawdown of the Afghanistan conflict, however, is a major sible care? inflection point for our military and for our military medical personnel. Some of our work, in collaboration with the Department A: We have made only very modest changes in cost-sharing for of Veterans Affairs, will turn to the long-term care for returning beneficiaries since the TRICARE program was introduced in 1995. servicemembers suffering from both the physical and psychological In the president’s budget for fiscal year 2014, we did propose an wounds of war. increase in TRICARE enrollment fees and some additional fee I mentioned earlier that we are in the early stages of an overincreases. haul of how we manage this very complex system we call the Our proposals are designed to slow the growth in retiree health Military Health System. One of the things we are assessing is how benefit costs to the department over time, while keeping in place we can best provide superb access to high-quality medical care for the comprehensive medical benefits that retirees receive. The everyone in our system, while ensuring we maintain the clinical proposals will not affect most active duty military families. Active skills of our military medical team. We don’t have the answers duty families pay no fees other than pharmacy copayments—and to what our system will look like in five years, but I can be sure they only pay these fees when they obtain prescriptions outside of of this—we may look different, but we will be even better, stronger a military hospital or clinic. Additionally, our proposals exempt the and more relevant for all of American medicine when we are done. O most vulnerable within our retired population from fee increases—

M2VA  17.4 | 19


Health Care

How mobile health

technologies are altering the medical landscape . By Chris McCoy M2VA Editor Mobile health technologies are allowing a range of new activities in modern medicine. Health applications on mobile phones are allowing doctors and patients easy remote access to electronic health records and miniaturized machines are offering care in a manner previously relegated to hospitals. Mirroring life in the civilian sphere, mobile health technologies are having a sizable impact on the military population. “Today, the Military Health System [MHS] is evaluating ways to leverage mobile health technologies to support the capturing and exchange of health care information on its more than 9.6 million patient population,” said Mark Goodge, chief technology officer of MHS. “Mobile health technologies present opportunities for health care providers to access data while roaming a hospital or standing bedside. “Our partners at The National Center for Telehealth and Technology [T2], a division of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, have been hard at work developing applications to help identify, treat and minimize the effects of TBI and other mental health conditions associated with military service.” T2 already has 10 mobile phone apps for stress management, mood tracking and PTSD, which are available for free online through iTunes and Google Play. “These applications have been downloaded more than 300,000 times and used more than 1.6 million times,” said Goodge. “Going forward, we look to leverage their experience and knowledge as we continue to explore the possibilities that exist within the mHealth arena. The MHS is always open to considering new technologies that support the needs of our patient and provider population.” Innovations in the private sector such as barcode readers for patient medication dispensation also can aid the military. Speaking of future military medicine, Goodge said, “I think we are seeing 20 | M2VA 17.4

more of how smartphones can be adapted to capture, store and transfer data on a person by turning a phone into a portable medical device, or allowing the phone operator to manually input their latest glucose ratings, [which then] can automatically be sent to their physician. Though some aspects of health care tend to differ between the private sector and the military, in terms of delivery of health care, both areas strive to provide the highest quality of service through cutting-edge technology.” An example of private sector mobile health work that could aid the military is the company Surescripts, which operates the nation’s largest clinical health information network. Pharmacies, payers, pharmacy benefit managers, physicians, hospitals, health information exchanges and health technology firms rely on Surescripts to share health information. “The Surescripts network enables the timely and secure electronic exchange of clinical information to support real care collaboration,” said David Yakimischak, executive vice president and general manager of E-Prescribing for Surescripts. “The network allows health care providers to send electronic clinical information to other care providers, regardless of the provider’s connectivity status or EHR partner.” Yakimischak added, “We are the only national network enabling comprehensive clinical information exchange––including e-prescriptions, clinical messages, immunization summaries, referrals, discharge summaries and lab results––between pharmacists, doctors, practices and health systems, locally and nationally, across all

installed on DoD networks. The recently-issued authorization to technology platforms. Our network eliminates the need for multiple operate letter allows AirStrip solutions to be deployed at any Air connections between care organizations and disparate systems and Force military treatment facility. has the potential to reach more than 500,000 providers over an “DIACAP certification is further independent validation of the established, proven and secure network.” trustworthiness of AirStrip’s patent-protected technology, which With regards to e-prescribing specifically, employs the most stringent security standards,” said Patterson. Yakismischak continued, “Surescripts has lead “This certification will enable a wide variety of collaborative mobility the shift to a paperless and more informed way efforts with the federal government.” for prescribers, payers and pharPatterson, a former U.S. Navy physician who macists to make better clinical deciserved as the medical director of the Naval Special sions and improve workflows related Warfare Center in San Diego, added that mobility fits to medication management. Surescripts well into the U.S. military’s record of using cuttingallows physicians to electronically send edge health technologies. prescriptions from their offices to more “Communication throughout the continuum of than 62,000 retail pharmacies and seven of care is a persistent challenge for the military,” Patthe largest mail-order pharmacies. In addition, terson noted. “Mobility solutions such as those develSurescripts provides physicians with electronic oped by AirStrip ensure military medical personnel access to their patients’ prescription benefits and can capture patient information much more quickly, medication history, which helps to improve safety put the right data into the right hands at the right and enables doctors to prescribe medications at the Dr. Matt Patterson time, and ultimately improve outcomes for our serlowest cost to the patient.” vicemembers and their families.” Surescripts works with both the U.S. Department of Health Large defense contractor Northrop Grumman is also involved in and Human Services and the Office of the National Coordinator the mobile health market and has developed its own mobile health for Health Information Technology. Moreover, the company is colapplication known as the Clinician app, which is designed for use laborating with the HHS, CDC and the Centers for Medicare and with a 7-inch Samsung Galaxy tablet. Medicaid Services on a public health initiative called Million Hearts. According to Karen Chapman, project manager, veterans The goal of this initiative is to prevent 1 million heart attacks and and military technology health IT at Northrop Grumman, “The strokes by 2017. clinician using the tablet can access the patient’s history. They can “Through the Million Hearts Initiative, Surescripts is leveraging access medications, lab results and radiology results—anything our technology to help people find the most conveniently located they need to treat that patient right then and there.” pharmacy care center through integration with mobile applicaThe device allows the doctor to access information through the tions,” said Yakimischak. “Surescripts believes that achieving a susclinician app as they talk to the patient, which helps to facilitate a tainable, high-quality health care system cannot occur if we do not more positive interaction. succeed in preventing disease and illness and maintaining wellness.” “It is now a collaborative session. It facilitates that commuMHealth developer AirStrip of San Antonio has created an enternication and that trust relationship between the patient and that prisewide, data-agnostic mobility solution to securely deliver patient provider. But it also gives the provider the data that they need,” data from medical devices, EHRs and patient monitors to mobile said Chapman. “They may have reviewed that patient’s charts back devices. This enables the rapid and secure exchange of vital clinical in their office four hours ago. Now they can pull it up when they’re information across the continuum of care. talking to the patient and [say]: ‘Now I have a question about this Using smartphones and tablets, clinicians can access all live relmedication that it says you’re on. Why are you still taking it? What evant data via AirStrip One to get a more complete picture of patient are the side effects?’ Essentially the providers now have a focal point. health. This includes live waveforms, near real-time ECGs and vital They don’t have to recall every little detail about the patient since signs, and EHR data. Mobility solutions developed by AirStrip are it is right there.” now in use by more than 350 hospitals and health systems across Currently, Northrop Grumman is working with the prototype the U.S. of the Clinician app. The next stage is to put the Clinician app in “Mobility in health care is more critical now than ever before,” a pilot setting. “We’re also working on making the Clinician app Dr. Matt Patterson, AirStrip’s chief transformation officer. “Airplatform-agnostic so it can run on Android, Windows or iOS operatStrip has created an advanced mobility solution that provides true ing systems,” said Morgan Crafts, director of technology, health IT. interoperability, putting diagnostic-quality data in the hands of “That way we can prepare to meet the needs of any clients running physicians anywhere to support faster, more informed decisionone of those three operating systems.” making.” The company Reka Health has also carved out its niche in AirStrip solutions are cleared by the FDA as a diagnostic aid. mobile health technology. Reka Health focuses primarily on devices AirStrip recently became the first and only mHealth solution used by cardiologists and internists aiding patients experiencing for medical device mobility certified to comply with the security cardiac events. Reka Health’s E100 Cardiac Event monitor was requirements by the Department of Defense Information Assurance designed in response to the rising costs of health care, and initiaCertification and Accreditation Process (DIACAP) by the U.S. Air tives by organizations, such as the VA, that have placed a high preForce. mium on telemedicine and telehealth over the past years. The DIACAP certification ensures that AirStrip applications “We offer the clinicians easy access to their patients reports incorporate the levels of authentication and encryption necesvia our hosted cloud platform,” said Ron Richards, chief executive sary for use in government organizations, and allows them to be

M2VA  17.4 | 21

channels that people may have operated on traditionally, whether officer of the Americas division of Reka. “The E100 is also capable of snail mail, email or the telephone. I think the other key thing is sending data from the product via iOS and Android operating systhat apps, HTML 5 and mobile web tend to get the limelight, but tems as well as directly through the Internet. This approach enables text, which has been around for a while, is still a great use for a patients and clinicians more options in terms of getting data from mobile device.” the E100 to the clinic for review of the raw data.” “Text is very important because it is the number one way that When asked how the E100 can best aid the warfighter in a batpeople in the United States and around the world communicate; tlespace like Afghanistan, Richards said, “Our technology can be it outstrips any other form of communication,” said Jed Alpert, easily deployed in rural settings and collect, then transmit, patient co-founder and chief executive officer of Mobile Commons. “Text information within minutes after taking a reading. The device has is the most universal and ubiquitous medium known. It has the a generous hard drive storage component that can take up to 2,000 highest response rate. People respond to text more than any other readings in 30-second events and transmit this information to a form of communication. They respond to it almost immediately, physician through a smartphone or an internet connection.” usually within 15 minutes instead of days. It is relatively spamAetna is another company that has entered the mobile health free.” market, with several applications such as Aetna Mobile, iTriage and Mobile Commons offers a staff software service-based platform CarePass. that enables organizations, businesses and large “Aetna Mobile is a core servicing application. It institutions to communicate using mobile messagprovides members with access to the provider direcing at scale and on a one-to-one basis with autotory and variety of different sources of information mated and customized message flows. The software related to their health,” said Dan Brostek, head of utilizes text, voice, mobile, web, video and pictures. member and consumer engagement for Aetna. “They Alpert explained that Mobile Commons has partcan use their mobile device to share their personal nered with the National Cancer Institute, The New health records with a provider. They have a digital ID York Department of Health, The California Departcard as a way to essentially remove the plastic from ment of Health, Planned Parenthood, The American their pocket and provide information at a point of Diabetes Association and a number of national care.” hospital groups. ITriage is another popular app that has over 8 Jed Alpert “We always want to have the technology that million registered downloads. ITriage tracks the the maximum amount of people are using, and user’s health, identifies symptoms and provides the [want] to be able to communicate in a secure way user with potential causes for their symptoms. about things that are of immediate need to them With CarePass, Aetna engages with an open digiwith regard to maintaining their own health,” said tal platform. “Open is a fairly new concept within the Alpert. health care space, but not really anywhere outside Diversinet is another company that is confrontthe health care space, although it’s been around for ing the rising cost of health care by introducing its a few years now,” said Brostek. “We’re looking for own mobile app. Their solution is the mobiHealth opportunities to create this platform that will allow Wallet. This application leverages the power of two users to sync—based upon their permissioning— other Diversinet technologies known as mobiSecure their different mobile health applications. Fitness and mobiPublisher. applications, nutrition applications, on down the Dr. Hon Pak “MobiSecure is a security product that enables line, [can be] linked to their CarePass account and clients to secure mobile applications, secure data be able to, with permission, transition that data back on the device and secure transactions with the device,” said Dr. and forth.” Hon Pak, chief executive officer of Diversnet. “MobiPublisher is an On December 13, 2012, the health/wellness technology firm enterprise solution to a secure agile development of mobile apps BettrLife announced that it would be a partner on Aetna’s CarePass using a unique ‘configure once, deploy many’ methodology.” application. The mobiHealth Wallet acts as a personalized container for “BettrLife is introducing a new segment called Mobile Health downloading, storing, managing and sharing health data securely. Coaching, which provides innovation and depth to existing wellness “The wallet provides for easy Blue Button downloads. Designed platforms,” said Don Schoen, chief executive officer of BettrLife. for web and mobile devices, it has a configurable module for col“The aim is to empower consumers to be proactive about their own lecting profile, preferences and determinants of health, which can health care, ultimately reducing health care costs.” be tied to specific care plan interventions and patient adherence When asked to summarize Aetna’s future developments in outcomes,” said Pak. mobile health platforms, Brostek had the following remarks: “We Ultimately, as health care costs continue to rise, mobile health are continuing to spend a lot of time exploring what it means to technologies will continue their debut on the world stage as create a multi-channel experience for our members and consumers systems for tracking one’s health care and maintaining wellness at large. A lot of times people want to talk about mobile because it is within the civilian and military populations. O the biggest and quickest growing channel that’s out there.” Brostek added, “I think more and more what we’re realizing For more information, contact M2VA Editor Chris McCoy is that it’s not going to replace these channels that have been at or search our here for years; it is just going to be the next channel. It’s become online archives for related stories at an interesting channel that’s led to people to rethink the other 22 | M2VA 17.4

The ascent of the patient-centered medical home in the M ilitary H ealth S ystem . By Regina Julian, M.H.A., M.B.A., FACHE In December 2008, the Military Health System (MHS) adopted the patient-centered medical home (PCMH) model of care for implementation in its Army, Navy, Air Force and Marine military treatment facilities (MTFs). These MTFs deliver health care to over 3 million enrollees. Since 2008, the MHS has been transforming all MTF family medicine, internal medicine, pediatrics and general primary care practices into PCMHs. These actions were taken to improve health care quality, access, care coordination, satisfaction and safety for the nation’s military, retired personnel and their families. The PCMH model is designed to improve the overall health of enrolled beneficiaries by addressing or preventing underlying causes of disease. PCMHs support a positive patient experience with high-quality, accessible, evidence-based, personalized, coordinated and integrated health care. PCMHs also more efficiently and effectively use resources and lower per capita costs, primarily through reduced hospitalizations and reduced emergency care utilization. The PCMH model also strengthens the relationship between the patient, primary care manager (PCM) and health care team. The model is endorsed by major stakeholders across the United States and worldwide. These stakeholders include the American Academy of Family Medicine, American Academy of Pediatrics and the American College of Physicians, as well as employer groups and major health care insurance companies The MHS’s initial goals for PCMH were, in part, informed by what MTF beneficiaries reported they wanted. Specifically, patients reported they wanted better continuity of care from providers that they knew and who knew them and their medical histories. Patients also reported that they wanted better access to care,

especially acute care within 24 hours, and assistance in coordinating their primary and specialty care. As a result, MHS’s first steps were to set goals to increase PCM continuity, enhance availability of and access to health care, and train health care teams to address and help coordinate patients’ primary and specialty care referrals. To further improve the MTF primary care system, the MHS set goals for improving patient health outcomes by screening for and addressing key components of health during patient visits. This was accomplished through the standardized use of evidence-based medicine and by enhancing access to preventive health care tests. PCMHs have also helped the MHS reduce the growth of health care costs by recapturing care to the MTFs through increased enrollment and reduced private sector care costs due to unnecessary emergency room/urgent care utilization. The MHS wanted to ensure its primary care practices not only were consistent across the uniformed services but were also meeting the same standards as in the civilian sector. As a result, the MHS selected the National Center for Quality Assurance (NCQA) to formally recognize the MTFs’ 435 primary care practices and to drive consistent implementation of the PCMH principles of coordinated, integrated and continuous primary care across the uniformed services. Currently, 171 primary care practices are NCQA-recognized PCMHs. Over 92 percent of these PCMHs are recognized as NCQA’s highest Level 3 PCMHs. Since feedback from patients and staff in the transformed clinics has been so positive, the uniformed services accelerated PCMH implementation and NCQA recognition. By the end of calendar year (CY) 2013, an additional 158 PCMHs will achieve NCQA recognition for a total of 80 percent practice recognition across all uniformed services. All M2VA  17.4 | 23

435 current primary care practices will achieve NCQA recognition by December 2014. This is four years ahead of schedule. Exceeding even the MHS’ high expectations, the MTF PCMHs recognized by NCQA in CY12 had the highest average score of all practices seeking NCQA recognition in the United States, with an average score of 91 percent versus 84 percent nationally. At this time, 158 or 92 percent of MTF formally recognized PCMHs have been recognized as NCQA’s highest Level 3 PCMHs, a higher rate than in the civilian sector. The success of MTF PCMH implementation efforts is due to the incredible commitment of the MTF leadership and the primary care staff members to their patients. The MHS’ PCMH model of care differs from the traditional primary care model in several ways. In order to more fully address the patient’s health care needs, the MTF PCMHs integrated disease and case management support. The MHS model also includes internal behavioral health specialists, who work in the primary care clinics to address patients’ behavioral health needs. These specialists identify and treat depression while assisting the patient in setting personal health and wellness goals. In addition, physicians and other health care team members designed a tri-service workflow (TSWF) suite of forms in the MHS’ electronic health record. This drives evidence-based health care and is used to screen patients for height, weight, activity, depression, alcohol use, smoking and a general sense of health. Currently, clinical practice guidelines (CPGs) for a variety of common, chronic health care conditions are embedded in the TSWF core forms. Additional specialty TSWF forms with embedded CPGs are under development or in pilot testing to enhance the quality of care for MTF beneficiaries. The TSWF forms help ensure the patient’s health care team and PCM pay attention to key, evidence-based issues that may impact the patient’s overall health. Between December 2012 and March 2013, the percentage of patients screened for depression increased from 29 percent to almost 90 percent in pilot testing at select PCMHs. TSWF forms also help the health care team in knowing the patient’s relevant medical history. TRICARE Management Activity’s patient satisfaction survey results demonstrate that the percentage of MTF patients who believe their PCMs knows their important medical history is 29 percent higher than the national civilian benchmark. The MHS is committed to enhancing further the use of evidence-based tools to identify health issues, to prevent or treat health problems and to help patients and their PCMs work together to develop a care plan supporting good health. Patients also need to be able to contact their PCM or team directly. As a result, the MHS is implementing a reliable, commercial secure messaging system at all MTF primary care practices. As of April 2013, almost 500,000 MTF beneficiaries were enrolled in secure messaging with almost 40,000 patients joining each month. Secure messaging is expected to be implemented at all MTFs in the continental United States by October 2013 and at all overseas MTFs by December 2013. Secure messaging allows MTF beneficiaries to send an email to their PCM 24 hours a day to obtain health advice, request appointments, review results and participate in “virtual” appointments. Secure messaging also is used by the extended MTF health care team to coordinate patient care. In the future, the MHS hopes patients will be able to use the MHS secure messaging system to share their important medical information and communicate with specialty providers in the civilian network where they may be referred. MHS secure messaging has high patient and staff satisfaction, twice the rate of civilian 24 | M2VA 17.4

adoption, and has decreased appointment demand by managing more care virtually. The MHS expects the percentage of virtual appointments to increase as more MTF beneficiaries are enrolled in and use secure messaging. Patients interested in enrolling in secure messaging should inquire at their local MTF PCMH or look for the link on their local MTF’s webpage. To further support beneficiaries, the MHS is implementing a 24-7 Nurse Advice Line (NAL) to provide health advice and health care access in order to lower unnecessary emergency and urgent care utilization. The line will be accessed by calling 1-800-TRICARE and will be available to all MHS beneficiaries. In addition to self-care advice from health care professionals, patients enrolled to MTFs will be able to schedule same-day or next-day appointments in the MTF enrollee’s PCMH or receive urgent care authorizations, if clinically indicated. Within 24 hours, MTF enrollees’ PCMs will receive a report outlining the reason for and the result of any calls. PCMs and PCMH teams will review the report and if clinically indicated, will contact patients for follow-ups. MHS beneficiaries enrolled to the private sector also will receive self-care advice or urgent care authorizations. MHS beneficiaries using the TRICARE Standard Option will receive self-care advice and information on where to seek urgent care from providers accepting TRICARE. The MHS expects the NAL to be fully operational by the end of FY13. The MHS also is interested in encouraging the PCMH model of care for prime beneficiaries enrolled to the private sector. The MHS is participating in a private sector care demonstration to see if the PCMH model of care will reduce health care costs and improve health. The MHS is exploring participation in other private sector PCMH demonstrations, as well. The MHS’s mature NCQA-recognized PCMHs continue to demonstrate a trend of above average performance compared to overall MHS performance in key performance measures. For example, PCM continuity exceeds the MHS’s goal and has increased over 45 percent since August 2010. In addition, MTFs with mature PCMHs have improved access to care, reduced unnecessary emergency room utilization and decreased primary care delivered by other than the beneficiaries’ health care teams. PCMHs also have higher patient and staff satisfaction. To further capitalize on the improvements so far, the MHS is identifying best performing MTF PCMH operations in order to spread their successes across the MHS’ entire direct care system. The MHS is firmly committed to the health of its beneficiaries and the PCMH model of care is a critical element to the MHS’s transformation from a health care system to a system supporting health. Eligible beneficiaries who are interested in enrolling in a PCMH should contact their local MTF for more information. O

Regina Julian is currently the director of the Military Health System PCMH division at the Office of the Assistant Secretary of Defense for Health Affairs/TRICARE Management Activity. Julian leads Tri-Service collaboration with the Army, Navy and Air Force to transform over 435 military treatment facility primary care practices into the PCMH model of care.

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

A new position is created at U.S. Army Dental Command. By Colonel Daniel P. Lavin

The next few years hold great promise for the introduction of a DoD electronic dental health record (DHR). This article discusses the tremendously positive impact of the role of a chief dental informatics officer (CDIO) in this process. For the U.S. Army Dental Command (USA DENCOM), the newly created position of CDIO fills a critical void for military dentistry that will be felt across DoD. The field of informatics deals with the resources, devices and methods required to optimize the acquisition, storage, retrieval and use of information in health and biomedicine. Dental informatics specifically applies informatics to the field of dentistry. Virtually all hospitals and large health care organizations have a chief medical informatics officer (CMIO) who ensures that the interests of providers are well represented

in decisions involving technology that is to be used by the provider. The CMIO is the clinical subject matter expert who represents the medical clinician in the planning, development and implementation of medical health care related technology. The unique mission of the dental community is best served by having a CDIO assume the dentist equivalent role. Prior to the development of the CDIO position at Dental Command, it was difficult for coders and developers of the DENCOM information systems to obtain input from the functional community as systems were being developed and tested. Inevitably, those technicians writing code and developing information systems would have to search for any available clinician to offer input from their perspective relative to the program. Since different clinicians

were consulted over the course of development of an initiative, conflicting input occasionally occurred on the same project. Having a dedicated CDIO allows developers and business analysts to consistently leverage a single functional community dental provider’s clinical knowledge to enhance the development, acquisition, storage, retrieval and use of information related to the field of dentistry. A major responsibility of the CDIO is to lead the acquisition, development and implementation of services that are important to providers. An abundance of technological products are introduced annually in dentistry, many of which are appealing due to their unique capabilities. However, not all products present true value to the organization. Therefore, it is important for a CDIO to scrutinize mission-focused M2VA  17.4 | 25

products and services that are likely to have a positive impact on the ability of providers to deliver more efficient and effective dental care for patients. Other responsibilities of the CDIO include: ensuring that the automation improves clinical practices; assisting in the development of training programs for dental providers who use the clinical systems; meeting and managing the expectations of clinical end users; ensuring clinician input regarding technology development; helping drive the development of new technology to improve clinical outcomes; and optimizing data standards and clinical architecture. One of the primary duties of the DENCOM CDIO revolves around the functional requirements of a suite of programs known as Corporate Dental Systems (CDS). Developed in 2000 by DENCOM, CDS is the USA’s enterprise solution for collecting, processing, presenting and archiving dental data (scheduling, workload and readiness). CDS is a suite of 19 stand-alone and Web-based applications that share a common database of information, used by both USA and U.S. Air Force (USAF) dental providers in the support of the oral health of their patient populations. Originally known as Corporate Dental Application (CDA), the system was designed and built in 2000 by DENCOM program developers. CDA was initially an appointment scheduler and workload entry module. Digital radiography was added as a separate application in 2003, the same year that the USAF began using CDA as their scheduler and workload entry module. The USAF retired their legacy system of reporting in 2011, and has used multiple applications of CDS since that time. In 2010 a web-based CDA scheduler replaced the previous clientbased version. A plan is in place for the U.S. Navy (USN) to begin utilization of CDS in the very near future. As an agile system, CDS contains modules that can be customized to meet the mission-specific requirements of each of the three federal services. For example, CDS will be structured differently when in use by the USN for land-based dental treatment facilities (DTFs) versus ship-based DTFs. Currently, CDS applications and modules are in use at over 132 USA and 143 USAF DTFs in both the continental United States and outside continental United States locations. CDS applications and modules schedule over 12,000 daily and 300,000 monthly patient appointments, and allow for the 26 | M2VA 17.4

addition of over 2 million patient workload entries each fiscal year. Paper DHRs are currently used by all three branches of the armed services. Paper records present a myriad of problems and expenses. A conservative estimate for the cost to produce a dental health record is $6.33 each. The expense of maintaining, storing and retrieving the record in subsequent years is estimated to be $3.33 per record. Added to this expense is the time lost searching for misplaced records and creating duplicate or temporary records. Paper records are not sent with soldiers when they deploy to a wartime environment, thus no prior dental health information is available and treatment rendered when the servicemember is seen in the deployed environment cannot be reliably documented. In addition, paper records are not patient-centric. No capability exists to add dental treatment completed prior to entry on active duty to the paper record. Likewise, when the servicemember leaves the military, there is no reliable, automated method to transfer information to the patient’s next dental provider, whether that provider is in a private practice or a Veterans Health Administration (VHA) dental service setting. The electronic DHR should remedy these shortcomings. Information management projects that are developed without consistent input and feedback from clinical providers frequently do not meet the needs of the clinicians who will ultimately use them. Program developers are experts in their field, and clinical providers are the experts in their field. As the functional users of clinical programs, the providers’ needs and requirements must be understood and met. Providers will not welcome a newly introduced program if it does not provide value to them, or if it causes an inordinate amount of disruption to the clinical workflow. It is imperative that the programs meet the providers’ usability requirements so that they can enthusiastically embrace the programs that are introduced. Electronic medical and dental health records enable access to a tremendous amount of patient data. This data includes demographic information, medical history, past dental history and radiographic images. DoD is making progress toward a tri-service interim electronic DHR. Once a tri-service DHR is fully developed, it will be possible to analyze clinical outcomes related to multiple variables such as: the specific tooth

treated; the areas of the tooth involved; the diagnosis related to a specific diagnostic code set; the material(s) used; and whether the treatment was delivered in a garrison environment, a land-based deployed environment, or onboard a ship. Ultimately, the goal is to have a tri-service electronic DHR that will readily share information with the VHA’s electronic DHR. By leveraging data, variance in techniques and procedures will be reduced, thereby consistently improving the quality of care. This will greatly facilitate the establishment of evidence-based best practices and clinical practice guidelines. DENCOM recognizes the importance of the CDIO to the Army Dental Care System, and offers dental informatics residency training to dental providers who have attained board certification in a dental specialty. Although numerous universities offer training at the certificate, master’s and doctoral level in health informatics, only one dental school offers a degree specifically in dental informatics. One other dental school offers a master’s degree program in medical informatics with a concentration in dentistry. The future is now, and in the spirit of seeking a solution for a DoD integrated electronic health record, the positive impact of a trained dental officer filling the role of chief dental informatics officer will ensure dental functional community representation and user interaction with the technicians developing the program for DENCOM. Since the DENCOM program has been identified as a solution agreed upon by all three services as a potential way ahead, the position of CDIO fills a critical void for military dentistry and will be felt across DoD. O Colonel Daniel P. Lavin is the chief dental informatics officer at U.S. Army Dental Command, Headquarters, Joint Base San Antonio-Fort Sam Houston & Lackland Air Force Base. The appearance of this article in Military Medical & Veterans Affairs Forum does not constitute endorsement by the U.S. Army Dental Command, the Department of the Army, Department of Defense or the U.S. government of the information, products or services contained therein.

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

The advertisers index is provided as a service to our readers. KMI cannot be held responsible for discrepancies due to last-minute changes or alterations.

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Rob Lamb began his medical career as a paramedic in Sydney, Australia, then became a rescue officer, an intensive care flight paramedic and helicopter rescue crewman. After reaching the top of his field in Australia, he headed to Iraq and Afghanistan. While working as a contractor in volatile areas in Iraq, Lamb observed shortfalls in medical services, which led him to establish his own fully integrated medical services and emergency response company. Founded in 2006, RMSI currently serves governments, non-government organizations and corporate clients across the globe with ground operations focused on Afghanistan and Iraq. It has also operated as far afield as Sudan, Libya, Liberia, Somalia and Pakistan. Lamb has successfully led multiple life-saving medevac missions and regularly travels to RMSI field operations based in hostile territories with his simple philosophy: A leader must have been where he expects his team to go, and must have done what he expects his team to do.

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Q: How does RMSI’s infrastructure support military readiness and changes in deployment? A: RMSI has a robust capability in each of the countries and territories in which it operates. The in-country team is comprised of former active duty personnel who know and understand the dynamic needs of a military organization. This team is backed by dedicated resources such as air ambulances and rapid deployment

teams who are responsive to any urgent requirements that may arise. The organic resources are then further enhanced by an extensive provider network, ensuring additional capacity and redundancy in the system. All operations are overseen and coordinated by the 24/7 mission response center that provides the communication, satellite tracking and medical oversight that are vital components for mission success. Q: How can RMSI assist the DoD and overseas military in patient movement and urgent care? A: The key to success is the seamless coordination of all personnel and assets under one unified operating entity. The RMSI clinicians are able to link in with RMSI ground and air ambulances and have this all coordinated by the RMSI mission response center. There are very real operational efficiencies in having every step of the medical chain operating according to the same guidelines and protocols. This integrated system ensures patients receive the best possible care, as they have an RMSI clinician with them on every step throughout the journey until the patient is safely admitted into the nearest center of medical excellence. Regardless of the patient’s location, whether Mogadishu, Baghdad or Kandahar, the RMSI team has proven experience in evacuating critically ill patients from medical treatment facilities and casualty staging units to support both tactical and strategic medevac missions, thus ensuring they have the best chance of recovery. O


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Features: Asthma

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